INSTRUCTIONS: ALABAMA COBRA EMPLOYER NOTICE MEMO (Form IB11)

Alabama state employers notify the State Employees' Insurance Board of various changes in the status of an employee under the provisions of COBRA who is enrolled in SEHIP by filing form IB11. This document can be obtained from the website maintained by the Alabama State Employee's Insurance Board. Alternately, you may choose to file form 11 to notify the State Employees' Insurance Board of these changes in status.

Alabama COBRA Employer Notice Memo IB11 Step 1: Enter the name of the employee on the first blank line.

Alabama COBRA Employer Notice Memo IB11 Step 2: Enter the social Security number of the employee on the second blank line.

Alabama COBRA Employer Notice Memo IB11 Step 3: Enter the street number or P.O. box number of the employee on the third blank line.

Alabama COBRA Employer Notice Memo IB11 Step 4: Enter the employee's city, state and zip code on the fourth blank line.

Alabama COBRA Employer Notice Memo IB11 Step 5: Enter the name of the employer on the fifth blank line.

Alabama COBRA Employer Notice Memo IB11 Step 6: Place a check mark on line 1 if the employee has been terminated for any reason other than gross misconduct. Enter the date of their termination.

Alabama COBRA Employer Notice Memo IB11 Step 7: Place a check mark on line 2 if the employee has had a reduction in the hours of employment, including taking leave without pay. Enter the date of this reduction.

Alabama COBRA Employer Notice Memo IB11 Step 8: Place a check mark on line 3 if the employee has died. Enter the date of death.

Alabama COBRA Employer Notice Memo IB11 Step 9: Place a check mark on line 4 if the employee has become eligible for Medicare. Enter the date on which they became eligible.

Alabama COBRA Employer Notice Memo IB11 Step 10: Enter the date on the next blank line.

Alabama COBRA Employer Notice Memo IB11 Step 11: The employer should enter their signature on the next blank line.

Alabama COBRA Employer Notice Memo IB11 Step 12: File the form by mailing it to the address given at the bottom of the page. Further assistance in completing this form can also be obtained by calling the phone numbers given here.

INSTRUCTIONS: ALABAMA MEDICATION REQUEST FORM (MRF)

Participating physicians and providers treating an Alabama public employee and obtaining coverage for a Prior Authorization drug for which there is no available suitable alternative use the medication request form discussed in this article. This website can be found on the website maintained by the Retirement Systems of Alabama.

Alabama Medication Request Form (MRF) Step 1: Enter the patient name in the first blank box.

Alabama Medication Request Form (MRF) Step 2: Enter the patient insurance company and contract number in the second blank box.

Alabama Medication Request Form (MRF) Step 3: Enter the patient date of birth in the third blank box.

Alabama Medication Request Form (MRF) Step 4: Enter the diagnosis in the fourth blank box.

Alabama Medication Request Form (MRF) Step 5: Enter the physician's name and their specialty in the fifth blank box.

Alabama Medication Request Form (MRF) Step 6: Enter the physician's telephone number in the sixth blank box.

Alabama Medication Request Form (MRF) Step 7: Enter the physician's DEA number in the seventh blank box.

Alabama Medication Request Form (MRF) Step 8: Enter the physician's fax number in the eighth blank box.

Alabama Medication Request Form (MRF) Step 9: Enter the pharmacy used by the patient in the ninth blank box.

Alabama Medication Request Form (MRF) Step 10: Enter the pharmacy telephone number in the tenth blank box.

Alabama Medication Request Form (MRF) Step 11: Enter the drug requested in the eleventh blank box.

Alabama Medication Request Form (MRF) Step 12: Enter the quantity per month in the twelfth blank box.

Alabama Medication Request Form (MRF) Step 13: Enter the dose in the thirteenth blank box.

Alabama Medication Request Form (MRF) Step 14: Enter the length of treatment in the fourteenth blank box.

Alabama Medication Request Form (MRF) Step 15: Enter the drug strength in the fifteenth blank box.

Alabama Medication Request Form (MRF) Step 16: Enter the dosage form in the sixteenth blank box.

Alabama Medication Request Form (MRF) Step 17: Enter the reason for the medication request in the seventeenth blank box.

Alabama Medication Request Form (MRF) Step 18: Enter other medications tried and/or failed where indicated, as well as other pertinent history bearing on your request.

Alabama Medication Request Form (MRF) Step 19: Fax the form to the number at the top of the page.

INSTRUCTIONS: ARIZONA APPLICATION FOR BINGO LICENSE (Form 71-1010)

To apply for an Arizona bingo license, file a form 71-1010. This document can be obtained from the website of the Arizona Department of Revenue.

Arizona Application For Bingo License 71-1010 Step 1: In boxes 1 through 4b, enter your name, telephone number, administrative office location and mailing address.

Arizona Application For Bingo License 71-1010 Step 2: Lines 5 through 11 should only be completed with check marks by Class B and Class C license applicants.

Arizona Application For Bingo License 71-1010 Step 3: On line 12, give the name, title and address of one or two persons who will serve as managers.

Arizona Application For Bingo License 71-1010 Step 4: On line 13, give the name, title and address of the person designated as proceeds coordinator.

Arizona Application For Bingo License 71-1010 Step 5: On line 14, enter the names, titles and address of up to four people who will serve as supervisors.

Arizona Application For Bingo License 71-1010 Step 6: On line 15, enter the names of up to eight people who will serve as assistants.

Arizona Application For Bingo License 71-1010 Step 7: On line 16, give the street address of the physical location where bingo will be played.

Arizona Application For Bingo License 71-1010 Step 8: On line 17, enter the hours during which bingo will be played on each line.

Arizona Application For Bingo License 71-1010 Step 9: On line 18, list the dates of proposed game cancellation, if any.

Arizona Application For Bingo License 71-1010 Step 10: On line 19, provide all information requested about the type of premises where bingo will be played.

Arizona Application For Bingo License 71-1010 Step 11: On line 20, list up to two bingo licensees who are or will be conducting bingo in the same premises as you or those who are located within 1,000 feet of your premises.

Arizona Application For Bingo License 71-1010 Step 12: In section 21, document your expected bingo expenses as instructed.

Arizona Application For Bingo License 71-1010 Step 13: In section 22, briefly state the specific projected use of net proceeds from games of bingo.

Arizona Application For Bingo License 71-1010 Step 14: In the last section, print your name, enter your signature, the date and your title.

INSTRUCTIONS: CONNECTICUT REQUEST FOR RESCISSION, CANCELLATION OR LIMITATION OF A HEALTH INSURANCE POLICY

To request the rescission, cancellation or limitation of a Connecticut health insurance policy administered by the state's insurance department, the form discussed in this article should be submitted. This document can be obtained from the website of the government of Connecticut.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 1: Enter the name of the insurance carrier or health care center on the first blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 2: Enter the NAIC number of the insurance carrier or health care center on the second blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 3: Enter the address of the insurance carrier or health care center on the third and fourth blank lines.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 4: Enter the name of a contact person for the insurance carrier or health care center on the fifth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 5: Enter the telephone number of the insurance carrier or health care center on the sixth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 6: Enter the name of the insured on the seventh blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 7: Enter the department name which employs the insured on the eighth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 8: Enter the address of the insured on the ninth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 9: Enter the insurance identification number of the insured on the tenth blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 10: Indicate whether this is a group policy or an individual policy by circling the appropriate statement.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 11: Enter the insurance policy number on the eleventh blank line.

Connecticut Request For Rescission, Cancellation Or Limitation Of A Health Insurance Policy Step 12: Enter the effective date of the policy on the twelfth blank line.

INSTRUCTIONS: CONNECTICUT POST JUDGMENT REMEDIES INTERROGATORIES (Form JD-CV-23)

In a Connecticut foreclosure or related case, a judgment creditor uses a form JD-CV-23a to require the judgment debtor to answer questions about their financial status. A form JD-CV-23 must be attached to this document, which will be included when the debtor is served with the interrogatories. Both forms can be obtained from the website maintained by the Connecticut Judicial Branch.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 1: In the first blank box, indicate with a check mark whether filing in a judicial district court, a housing session court or a geographical area court. If the latter, give its number. Enter the location of the court.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 2: In the second blank box, enter the case docket number.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 3: In the third blank box, enter the address of the court, including the name and number of the street, the town and the zip code.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 4: In the fourth blank box, enter the date of judgment.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 5: In the fifth blank box, enter the original amount of judgment.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 6: In the sixth blank box, enter the amount due on the judgment.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 7: In the seventh blank box, enter the name of the creditor. 

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 8: In the eighth blank box, enter the address of the creditor.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 9: In the ninth blank box, enter the name of the judgment debtor.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 10: In the tenth blank box, enter the address of the judgment debtor.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 11: In the eleventh blank box, if applicable, enter the name and address of the person believed to have the assets of the judgment debtor.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 12: In the twelfth blank box, enter the date on which the interrogatories were served.

Connecticut Post Judgment Remedies Interrogatories JD-CV-23 Step 13: In the thirteenth blank box, enter the name and address of the person to whom the interrogatories should be returned.

INSTRUCTIONS: CONNECTICUT PETITION FOR EXAMINATION OF JUDGMENT DEBTOR AND NOTICE OF HEARING (Form JD-CV-54)

When judgment is recovered against a debtor in a Connecticut case but they fail to make payment in whole or in part, or, when the debtor fails to respond at all within 30 days of service, a form JD-CV-54 may be filed to request that the debtor be forced to appear in court. This document can be obtained from the website of the Connecticut Judicial Branch.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 1: Enter the docket number of the case in the first blank box.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 2: Enter the number and location of your court and indicate what type of court it is with a check mark in the next blank box.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 3: Enter the name and address of all judgment creditors in the next two blank boxes.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 4: Enter the name and address of the judgment debtor in the next two blank boxes.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 5: Enter the date of judgment in the next blank box.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 6: Enter the amount of damages awarded in the next blank box.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 7: Enter the amount of costs awarded in the next blank box.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 8: Enter the total damages and costs awarded in the next blank box.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 9: Enter the name and address of the judgment creditor's attorney, if applicable, in the next blank box.

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 10: Check the first statement if seeking aid with an unsatisfied judgment. Check the second statement if the debtor has failed to respond within 30 days of service of postjudgment ineterrogatories. 

Connecticut Petition For Examination Of Judgment Debtor And Notice Of Hearing JD-CV-54 Step 11: Sign and date the form where indicated.

INSTRUCTIONS: CONNECTICUT REQUEST FOR ACTION — ADMINISTRATIVE AND TAX APPEALS — NOT FOR USE IN LAND USE APPEALS (Form JD-CV-114)

A form JD-CV-114 should be filed immediately after you have filed an Appearance or motion in an administrative or tax appeal. This document can be obtained from the website maintained by the Connecticut Judicial Branch.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 1: In the first blank box, enter the name of the judicial district.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 2: In the second blank box, enter the name of the case.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 3: In the third blank box, enter the docket number.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 4: In the fourth blank box, enter the title of the motion you want decided.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 5: In the fifth blank box, enter the date of the motion.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 6: In the sixth blank box, enter the motion entry number.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 7: On line 1, indicate whether you are filing this form because you have filed by checking "Yes" or "No." If "no," answer lines 2 through 5.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 8: Answer the questions on lines 2 through 5 by checking "Yes" or "No" as applicable. If you have already filed an objection, enter the date of the objection and the entry number on line 5 where indicated.

Connecticut Request For Action — Administrative And Tax Appeals — Not For Use In Land Use Appeals JD-CV-114 Step 9: Sign and date the bottom of the page to certify that all counsels and self-represented parties have received a copy of this form.