INSTRUCTIONS: CONNECTICUT RECEIVED JUNK VEHICLES REPORT (Form K-174)

Connecticut motor vehicle dealers and repairers with a recycler's license are required to submit a form K-174 to document junk vehicles they have received twice a month. This document can be obtained from the website of the government of the state of Connecticut.

Connecticut Received Junk Vehicles Report K-174 Step 1: Indicate with a check mark whether filing to document the period from the 1st to the 15th of the month or for the period from the 16th to the last day of the month.

Connecticut Received Junk Vehicles Report K-174 Step 2: Enter the month and year for which you are filing.

Connecticut Received Junk Vehicles Report K-174 Step 3: Where indicated, write your business name as it appears on your recycler's license.

Connecticut Received Junk Vehicles Report K-174 Step 4: Enter your business address where indicated.

Connecticut Received Junk Vehicles Report K-174 Step 5: Check the box where indicated if no vehicles were received during this reporting period.

Connecticut Received Junk Vehicles Report K-174 Step 6: Enter your license number where indicated.

Connecticut Received Junk Vehicles Report K-174 Step 7: Enter your telephone number where indicated.

Connecticut Received Junk Vehicles Report K-174 Step 8: The table provided below is for documentation of all received junk vehicles. In the first column, enter the make of each vehicle.

Connecticut Received Junk Vehicles Report K-174 Step 9: In the second column, enter the year of each vehicle.

Connecticut Received Junk Vehicles Report K-174 Step 10: In the third column, enter the engine number, if any, of each vehicle.

Connecticut Received Junk Vehicles Report K-174 Step 11: In the fourth column, enter the vehicle identification number of each vehicle.

Connecticut Received Junk Vehicles Report K-174 Step 12: In the fifth column, enter the ownership document of each vehicle.

Connecticut Received Junk Vehicles Report K-174 Step 13: In the sixth column, enter the state in which each vehicle has been registered.

Connecticut Received Junk Vehicles Report K-174 Step 14: In the first blank box at the bottom of the page, the service manager or their designee should provide their signature.

Connecticut Received Junk Vehicles Report K-174 Step 15: In the second blank box, enter the title of the authorized official signing this form.

Connecticut Received Junk Vehicles Report K-174 Step 16: Enter the date in the third blank box.

INSTRUCTIONS: ALABAMA OFFICE-BASED SURGERY / PROCEDURES PHYSICIAN REGISTRATION FORM

The form discussed in this article is used by Alabama physicians to document their office-based surgery procedures. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 1: Enter your name on the first blank line.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 2: Enter your Alabama license number on the second blank line.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 3: Enter your street address, city, state and zip code on the third blank line.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 4: Indicate with a check mark whether your office performs procedures using moderate sedation analgesia, in which patients are placed into a drug-induced depression of consciousness during which they respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 5: Indicate with a check mark whether your office performs procedures using deep sedation analgesia, in which patients are placed into a drug-induced depression of consciousness during which they cannot be easily aroused but can respond purposefully following repeated or painful stimulation.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 6: Indicate with a check mark whether your office performs procedures using general anesthesia, in which patients are placed into a drug-induced loss of consciousness during which they are not arousable, even by painful stimulation.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 7: Indicate with a check mark whether you as a physician meet the training requirements set forth in the Alabama Board of Medical Examiners' Office-Based Surgery Rules for moderate sedation, deep sedation and general anesthesia.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 8: Indicate with a check mark whether your office is currently accredited by the Accreditation Association for Ambulatory Health Care, the American Association for Accreditation of Ambulatory Surgery Facilities, or the Joint Commission on Accreditation of Healthcare Organizations. Indicate which organization, if applicable, with a check mark.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 9: If not currently accredited, indicate with a check mark whether you plan on obtaining accreditation in the next two years.

Alabama Office-Based Surgery / Procedures Physician Registration Form Step 10: Sign and date the bottom of the form, as well as entering your Alabama medical license number.

INSTRUCTIONS: ALABAMA SOUTHLAND NATIONAL SUPPLEMENTAL VISION INSURANCE ENROLLMENT/CANCELLATION FORM (Form IB20)

Alabama state employees may enroll or cancel their enrollment in supplemental vision insurance administered by Southland National by filing form IB20. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 1: Enter your name in the first blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 2: Enter your sex in the second blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 3: Enter the effective date in the third blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 4: Enter your Social Security number in the fourth blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 5: Enter your date of birth in the fifth blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 6: Enter your mailing address in the sixth blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 7: Enter your city in the seventh blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 8: Enter your state in the eighth blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 9: Enter your zip code in the ninth blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 10: Enter your home telephone number in the tenth blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 11: Enter your work telephone number in the eleventh blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 12: Indicate whether you are enrolling for single coverage, family coverage or are cancelling your enrollment with a check mark.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 13: Enter your email address in the next blank box.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 14: If applicable, document all dependents in the table provided.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 15: Enter your signature on the next blank line.

Alabama Southland National Supplemental Vision Insurance Enrollment/Cancellation Form IB20 Step 16: Enter the date on the last blank line.

INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL ASSISTANCE APPLICATION (FDL) AND CHILDREN'S HEALTH INSURANCE PROGRAM APPLICATION (CHIP) (Form PEEHIP FPL & CHIP)

To apply for federal poverty level assistance or the state administered children's health insurance program while working as an Alabama public education employee, use the application discussed in this article. This document can be obtained from the website of the Retirement Systems of Alabama.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 1: Indicate with a check mark whether you are applying for FDL, CHIP or both.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 2: The first section concerns the public employee subscriber. On the first line, enter your Social Security number, first name, middle name or initial and last name.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 3: On the second line, enter the subscriber's mailing address, city, state and zip code.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 4: On the third line, enter the subscriber's home phone number and work phone number.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 5: Indicate your marital status with a check mark.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 6: The next section is for CHIP applicants. Indicate whether any child is covered under Medicaid with a check mark. If yes, give the names of the eligible children.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 7: Document all household members where indicated. Provide their name, Social Security number, date of birth, age, sex and relationship to you. Enter your information on line A, that of your spouse on line B, and those of all dependents under 19 years of age living in your home on lines C through F.

Alabama Federal Poverty Level Assistance Application (FDL) And Children's Health Insurance Program Application (CHIP) PEEHIP FPL & CHIP Step 8: Answer all remaining questions with check marks, then sign and date the bottom of the page.

INSTRUCTIONS: CONNECTICUT LIFE SETTLEMENT PROVIDER RENEWAL APPLICATION

To renew your license to act as a Connecticut life settlement provider, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Life Settlement Provider Renewal Application Step 1: Enter the name of the life settlement provider on the first blank line.

Connecticut Life Settlement Provider Renewal Application Step 2: Enter the date on which you are sending the form on the second blank line.

Connecticut Life Settlement Provider Renewal Application Step 3: Enter the name of a contact person for further questions or correspondence on the third blank line.

Connecticut Life Settlement Provider Renewal Application Step 4: Enter a contact address on the next two blank lines.

Connecticut Life Settlement Provider Renewal Application Step 5: Enter a contact phone number on the sixth blank line.

Connecticut Life Settlement Provider Renewal Application Step 6: Enter a contact fax number on the seventh blank line.

Connecticut Life Settlement Provider Renewal Application Step 7: Enter a contact email address on the eighth blank line.

Connecticut Life Settlement Provider Renewal Application Step 8: Enter the expiration date of your current license on the ninth blank line.

Connecticut Life Settlement Provider Renewal Application Step 9: The remainder of the first page and the entirety of the second page contains a checklist of documentation that must be attached to your application.

Connecticut Life Settlement Provider Renewal Application Step 10: Enter your signature on the first blank line on the third page.

Connecticut Life Settlement Provider Renewal Application Step 11: Print your name on the second blank line.

Connecticut Life Settlement Provider Renewal Application Step 12: Enter your title on the third blank line.

Connecticut Life Settlement Provider Renewal Application Step 13: The form should then be presented to a notary public, who will sign the document and affix their seal.

Connecticut Life Settlement Provider Renewal Application Step 14: Cut a check for $40. This is the fee for processing of your form. This check should be made out to "Treasurer, State of Connecticut."

Connecticut Life Settlement Provider Renewal Application Step 15: Mail the form to the address given at the top of the first page along with all required supporting documentation and your check. Allow a minimum of 30 days for processing to ensure your license is renewed in a timely fashion.

INSTRUCTIONS: CONNECTICUT CITIZENS' ELECTION PROGRAM – APPLICATION FOR GRANT (SEEC Form CEP 15)

Statewide and general assembly Connecticut candidates may apply for a grant from the citizens' election program by filing a SEEC form CEP 15. This document can be obtained from the website of the government of Connecticut.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 1: Section A concerns identifying information. In box 1, enter the election date.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 2: In box 2, enter the office sought.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 3: In box 3, enter the district number.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 4: In box 4, enter the candidate's name.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 5: In box 5, enter the committee's name.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 6: In box 6, enter the treasurer's name.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 7: In box 7, enter the deputy treasurer's name.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 8: Section B is optional if you wish to request continuation without prejudice.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 9: Section C should be completed by the candidate. The candidate's initials should be placed next to statements 1 through 12.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 10: The candidate should sign and date the bottom of the seventh page.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 11: Section D should be completed by the treasurer. The treasurer's initials should be placed next to statements 1 through 12.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 12: The treasurer should sign and date the bottom of the ninth page.

Connecticut Citizens' Election Program – Application For Grant SEEC Form CEP 15 Step 13: Section E should be completed by the deputy treasurer. Their initials should be placed next to statements 1 through 11. They should also sign and date the bottom of the eleventh page.

INSTRUCTIONS: CONNECTICUT WAGE EXECUTION PROCEEDINGS APPLICATION, ORDER, EXECUTION (Form JD-CV-3)

In Connecticut cases where a judgment creditor has received a ruling in their favor to garnish debtor wages, a form JD-CV-3 is completed and sent to the employer. This document can be obtained from the website maintained by the Connecticut Judicial Department.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 1: The Application section should be completed by the judgment creditor or their attorney. In the first blank box, give the name of the address. Indicate with a check mark whether this is a judicial district, housing session or geographical area court. If the latter, give its number.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 2: In the second blank box, enter the case docket number.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 3: In the third blank box, enter the amount of the weekly, monthly or other payments ordered.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 4: In the fourth blank box, enter the commencement date.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 5: In the fifth blank box, enter the name and address of all judgment creditors.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 6: In the sixth blank box, enter the name and address of all judgment debtors.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 7: In the seventh blank box, if known, enter the name and address of the debtor employer. Enter their telephone number, if known, in the eighth blank box.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 8: In box 1, enter the amount of the judgment. 

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 9: In box 2, enter the amount of costs and fees.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 10: In box 3, enter the total of boxes 1 and 2.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 11: In box 4, enter the total amount paid, if any.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 12: In box 5, enter the total amount unpaid.

Connecticut Wage Execution Proceedings Application, Order, Execution JD-CV-3 Step 13: Complete the remainder of the application as directed and return it to the court.