INSTRUCTIONS: ALABAMA APPLICATION AS UTILIZATION REVIEW ENTITY (Form WC 50)

The form discussed in this article is used to screen applicants applying for utilization review entity as part of the workers' compensation process. This document can be obtained from the website maintained by the Alabama Department of Labor.

Alabama Application As Utilization Review Entity WC 50 Step 1: Part 1 concerns general information. Enter your agency name on the first blank line.

Alabama Application As Utilization Review Entity WC 50 Step 2: Enter your agency address on the second blank line.

Alabama Application As Utilization Review Entity WC 50 Step 3: Enter your agency telephone number, including the area code, on the third blank line.

Alabama Application As Utilization Review Entity WC 50 Step 4: Enter your agency toll-free telephone number, including the area code, on the fourth blank line.

Alabama Application As Utilization Review Entity WC 50 Step 5: Enter the name of a contact person and their title on the fifth blank line.

Alabama Application As Utilization Review Entity WC 50 Step 6: Enter a contact email address on the sixth blank line.

Alabama Application As Utilization Review Entity WC 50 Step 7: Part 2 concerns certifications already held. Indicate whether you have the certifications listed by checking "Yes" or "No" as applicable. If the answer to either listed, you are not required to complete the remainder of the form.

Alabama Application As Utilization Review Entity WC 50 Step 8: Part 3 concerns the purpose for this application. Part I of this section concerns applications for limited certification as a utilization review entity for performance of approvals only. Complete this section as directed.

Alabama Application As Utilization Review Entity WC 50 Step 9: Part II concerns applications for full certification as a utilization review entity. Complete this section as directed.

Alabama Application As Utilization Review Entity WC 50 Step 10: The fourth page contains a statement of certification. On the first blank line, enter the name of the agency on behalf of which you are filing.

Alabama Application As Utilization Review Entity WC 50 Step 11: On the second blank line, enter the name of the company.

Alabama Application As Utilization Review Entity WC 50 Step 12: Enter your signature, name and title on the last three blank lines. Have the form certified by a notary public.

INSTRUCTIONS: ARIZONA APPLICATION FOR SPECIAL BONUS GAME (Form 71-5411)

In Arizona, a form 71-5411 is used to request permission to conduct a special bonus game when administering bingo games. This document can be obtained from the website of the Arizona Department of Revenue.

Arizona Application For Special Bonus Game 71-5411 Step 1: On line 1, enter your name and license number, if known.

Arizona Application For Special Bonus Game 71-5411 Step 2: On line 2, enter your address.

Arizona Application For Special Bonus Game 71-5411 Step 3: On line 3, enter the days and times of the week during which special bonus games will be played.

Arizona Application For Special Bonus Game 71-5411 Step 4: On line 4, enter the pattern required to accomplish bingo.

Arizona Application For Special Bonus Game 71-5411 Step 5: On line 5, enter the number of calls within which a bingo must be accomplished.

Arizona Application For Special Bonus Game 71-5411 Step 6: On line 6, enter the amount of the designated prize.

Arizona Application For Special Bonus Game 71-5411 Step 7: On line 7, enter the type of card to be used.

Arizona Application For Special Bonus Game 71-5411 Step 8: On line 8, enter the cost of a card to the player.

Arizona Application For Special Bonus Game 71-5411 Step 9: On line 9, enter the game number.

Arizona Application For Special Bonus Game 71-5411 Step 10: On line 10, enter how much of the $12,000 prize amount available in the quarter will be guaranteed, if any.

Arizona Application For Special Bonus Game 71-5411 Step 11: On line 11, describe how the special bonus game program will be conducted and the total prize amount offered per quarter.

Arizona Application For Special Bonus Game 71-5411 Step 12: On the next blank line, enter your name.

Arizona Application For Special Bonus Game 71-5411 Step 13: On the last blank line, enter your signature.

Arizona Application For Special Bonus Game 71-5411 Step 14: Mail the form to the Arizona Department of Revenue, whose website can be obtained from their address. 

Arizona Application For Special Bonus Game 71-5411 Step 15: Approval of your application expires at the end of each licensing period. It must be renewed prior to that time in order to allow the continuance of special bonus games.

INSTRUCTIONS: CONNECTICUT MEDICAL DISCOUNT PLAN (MDP) LICENSE RENEWAL 

To apply for a renewal of a Connecticut medical discount plan (MDP) license, use the form discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Medical Discount Plan (MDP) License Renewal Step 1: The first page contains general instructions.

Connecticut Medical Discount Plan (MDP) License Renewal Step 2: On the first blank line of the second page, enter the calendar year for which you are filing.

Connecticut Medical Discount Plan (MDP) License Renewal Step 3: On the second blank line, enter the name of the MDP.

Connecticut Medical Discount Plan (MDP) License Renewal Step 4: On the third blank line, enter all names used to market the MDP plan.

Connecticut Medical Discount Plan (MDP) License Renewal Step 5: On the fourth blank line, enter the MDP connecticut license number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 6: On the fifth blank line, enter the MDP tax identification number or federal employer identification number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 7: On the next three blank lines, enter the business address of the MDP.

Connecticut Medical Discount Plan (MDP) License Renewal Step 8: If your mailing address is different from your business address, enter it on the next two blank lines.

Connecticut Medical Discount Plan (MDP) License Renewal Step 9: On the eleventh blank line, enter the MDP phone number.

Connecticut Medical Discount Plan (MDP) License Renewal Step 10: Indicate with a check mark whether any suspension, sanction or disciplinary action has been taken against the MDP in any state. If yes, explain.

Connecticut Medical Discount Plan (MDP) License Renewal Step 11: Indicate with a check mark whether any suspension, sanction or disciplinary action has been taken against the controlling company or organization in any state. If yes, explain.

Connecticut Medical Discount Plan (MDP) License Renewal Step 12: At the top of the third page, enter the total number of enrollees served by the plan both nationwide and in Connecticut.

Connecticut Medical Discount Plan (MDP) License Renewal Step 13: List all provider networks with which the MDP has contracts or agreements to provide discounted health services to Connecticut enrollees.

Connecticut Medical Discount Plan (MDP) License Renewal Step 14: Complete the rest of the form as instructed.

INSTRUCTIONS: CONNECTICUT AFFIDAVIT OF COMPLAINT STATE ELECTIONS ENFORCEMENT COMMISSION

To file a complaint regarding an election violation in Connecticut, use the affidavit discussed in this article. This document can be obtained from the website of the government of Connecticut.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 1: Section I concerns the identity of the complainants. Enter their name, address, home, work and cell telephone numbers and email address. You may document up to three complainants in this section.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 2: Section II concerns the identity of the respondents. You may document up to three respondents on the page provided. Enter the name, address, home phone number, work phone number, cell phone number and email address of each respondent. Should you require additional space to document all respondents, attach additional copies of this page. Check the box where indicated and enter the number of additional pages attached.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 3: Section III concerns the violations being alleged. Enter the date or dates of the alleged violations, if known, where indicated.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 4: In the space provided, provide a concise statement of the facts of these alleged violations.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 5: Section IV concerns witnesses to these alleged violations. For each witness, enter their name, address, work phone number, home phone number, cell phone number, and email address.

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 6: Section V concerns evidence of these alleged violations. For each evidentiary attachment, enter the title of the document, the number of pages, the author, the date of publication, how you acquired this evidence, and the date of your acquisition. 

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 7: If there is not enough space provided for documentation of all evidentiary attachments, complete additional pages. Check the box where indicated and write how many additional pages are attached. 

Connecticut Affidavit Of Complaint State Elections Enforcement Commission Step 8: Section VI concerns certification of your statement. The complainant should sign and date the form where indicated in the presence of a notary public, justice of the peace, town clerk or a similarly authorized official. 

INSTRUCTIONS: CONNECTICUT PROPERTY EXECUTION PROCEEDINGS APPLICATION, ORDER, EXECUTION (Form JD-CV-5)

When a Connecticut case has resulted in a judgment against the debtor but full or partial payment has not been made as ordered, the judgment creditor should complete a form JD-CV-5 to request enforcement of the ruling. This document can be found on the website of the Connecticut Judicial Branch.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 1: The application section should be completed by the judgment creditor or their attorney. In the first blank box, enter the address of the court and indicate with a check mark whether it is a geographical area, judicial district or housing session court.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 2: In the second blank box, enter the date of judgment.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 3: In the third blank box, enter the docket number.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 4: In the fourth blank box, enter the name and address of the judgment creditor or creditors making this application.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 5: In the fifth blank box, enter the name and address of the judgment debtor or debtors.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 6: In box 1, enter the amount of judgment.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 7: In box 2, enter the amount of costs and fees.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 8: In box 3, enter the total of the judgment amount, costs and fees.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 9: In box 4, enter the total amount paid, if any.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 10: In box 5, enter the total amount unpaid by subtracting box 4 from box 3.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 11: In box 6, enter the application fee for property execution if not waived by the court. Add boxes 5 and 6 and enter the resulting sum in box 7.

Connecticut Property Execution Proceedings Application, Order, Execution JD-CV-5 Step 12: Complete the rest of Section I as directed. Section II will be completed by the assistant clerk of the court.

INSTRUCTIONS: CONNECTICUT CERTIFICATE OF JUDGMENT STRICT FORECLOSURE (Form JD-CV-47)

When a Connecticut Superior Court issues a judgment of strict foreclosure, this is certified using a form JD-CV-47. This form will be completed by the superior clerk of the court. This document can be obtained from the website maintained by the Connecticut Judicial Branch.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 1: In the first blank box, enter the name of the case.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 2: In the second blank box, enter the docket number.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 3: In the third blank box, enter the judicial district.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 4: In the fourth blank box, enter the address of the court.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 5: In the fifth blank box, enter the return date.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 6: In the sixth blank box, enter the property location.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 7: In the seventh blank box, enter the judgment date.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 8: In the eighth blank box, enter the amount of debt including attorney's fees.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 9: In the ninth blank box, enter the costs, if taxed.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 10: In the tenth blank box, enter the name of the judge.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 11: In the table provided below, the court will provide details for the dates on which redemption must be made to the creditor. In the column on the left, the date on which debtor must redeem their debt will be entered.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 12: In the column on the right, the name of each applicable party will be entered.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 13: On the second page, a detailed legal description of the property will be entered.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 14: In the first blank box at the bottom left of the first page, the clerk of the superior court will enter their signature.

Connecticut Certificate Of Judgment Strict Foreclosure JD-CV-47 Step 15: In the second blank box, the date will be entered.

INSTRUCTIONS: CONNECTICUT SCHEDULING ORDER (Form JD-CV-71)

During a Connecticut foreclosure trial, you will be told by the court when you are required to complete a scheduling order. This form JD-CV-71 can be found on the website of the Connecticut Judicial Branch.

Connecticut Scheduling Order JD-CV-71 Step 1: Enter the name of the judicial district in the first blank box.

Connecticut Scheduling Order JD-CV-71 Step 2: Enter the conference date, if known, in the second blank box.

Connecticut Scheduling Order JD-CV-71 Step 3: Enter the docket number in the third blank box.

Connecticut Scheduling Order JD-CV-71 Step 4: Enter the name of the case in the fourth blank box.

Connecticut Scheduling Order JD-CV-71 Step 5: The next five questions concern alternate dispute resolution (ADR). The first question asks whether the parties involved have discussed ADR methods including court-annexed mediation, binding arbitration and private mediation. Check "yes" or "no" as appropriate.

Connecticut Scheduling Order JD-CV-71 Step 6: The next question asks whether all parties are willing to refer the case to private ADR. Check "yes" or "no" as appropriate.

Connecticut Scheduling Order JD-CV-71 Step 7: The next question asks whether there is any reason the case should be referred to the complex litigation docket. Check "yes" or "no" as appropriate.

Connecticut Scheduling Order JD-CV-71 Step 8: The next question asks whether the parties in a court case are willing to try the case before an attorney trial referee. Check "yes" or "no" as appropriate.

Connecticut Scheduling Order JD-CV-71 Step 9: The next question asks whether the parties in a jury case are willing to try the case before a judge trial referee. Check "yes" or "no" as appropriate.

Connecticut Scheduling Order JD-CV-71 Step 10: The next section concerns the discovery order which is entered by order of the presiding judge and will be completed under their supervision. Failure to follow the conditions of this order may result in a fine, having proposed evidence being excluded at trial, having the case dismissed, being dismissed, or other sanctions. Complete this section as directed.

Connecticut Scheduling Order JD-CV-71 Step 11: On the second page, all involved attorneys or self-represented parties in this scheduling order must enter their names. One must sign the document.

Connecticut Scheduling Order JD-CV-71 Step 12: The last section concerns certification that copies of this form have been mailed to all involved attorneys and self-represented parties.