INSTRUCTIONS: CONNECTICUT STV/SCHOOL BUS/PUBLIC SERVICE VEHICLE BRAKE INSPECTION REPORT (Form R-380)

A form R-380 is used to document a brake inspection conducted on a Connecticut STV, school bus or public service vehicle. This document can be obtained from the website of the government of Connecticut.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 1: Enter the carrier name in the first blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 2: Enter the carrier address in the second blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 3: Enter the vehicle make in the third blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 4: Enter the vehicle model in the fourth blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 5: Enter the unit number in the fifth blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 6: Enter the vehicle year in the sixth blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 7: Enter the plate number in the seventh blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 8: Enter the vehicle identification number in the eighth blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 9: Enter the vehicle mileage in the ninth blank box.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 10: Indicate whether the front brakes are air brakes by circling "yes" or "no."

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 11: Enter the left and right drum max diameter or rotor thickness OEM discard value of the front brakes on the first line and the actual measured value on the second line. Enter the front brake lining thickness for the inner/upper and outer/lower left and right front brakes on the third line.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 12: Record the same measures for the rear brakes where indicated.

Connecticut STV/School Bus/Public Service Vehicle Brake Inspection Report R-380 Step 13: Enter the name, phone number and address of the repair facility. The mechanic should print and sign their name, as well as entering the date.

INSTRUCTIONS: CONNECTICUT PUBLIC SERVICE VEHICLE LICENSED DEALER/REPAIRER INSPECTOR REPORT (Form R-361)

A Connecticut licensed dealer or repairer uses a form R-361 to document their inspection of a service bus or taxicab motor vehicle. This document can be obtained from the website of the government of the state of Connecticut.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 1: Section A must be completed by the vehicle owner. Enter the carrier name in the first blank box.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 2: Enter your phone number in the second blank box.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 3: Enter your street address in the third blank box.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 4: Enter your town or city in the fourth blank box.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 5: Enter your state in the fifth blank box.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 6: Enter your zip code in the sixth blank box.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 7: Enter the marker plate number in the seventh blank box. 

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 8: In the next four blank boxes, enter the vehicle year, make, model and body style.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 9: Indicate whether the vehicle is a taxi or a service bus with a check mark.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 10: Enter the vehicle identification number, manufacturer's seating capacity and GVWR.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 11: The remainder of the form must be completed by the dealer or repairer. In Section B, they should provide the name of the repairer or garage, the phone number, street address, city, state, zip code, principal, and dealer or repairer license number.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 12: Section C is used to document the results of the inspection.

Connecticut Public Service Vehicle Licensed Dealer/Repairer Inspector Report R-361 Step 13: The dealer or repairer should sign and date Section D.

INSTRUCTIONS: CONNECTICUT USE TAX EXEMPTION ON MOTOR VEHICLES OR VESSELS SOLD TO OR BY BUSINESSES (Form Q 20)

To document an exemption on Connecticut use tax for motor vehicles or vessels sold to or by businesses, file a form Q 20. This document can be obtained from the website of the government of Connecticut.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 1: If applicable, enter the name of the corporation, partnership or LLC on the first blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 2: If applicable, enter the name of the stockholder, partner or member completing this form on the second blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 3: Enter the address of the corporation, partnership or LLC on the third blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 4: Enter the address of the stockholder, partner or member on the fourth blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 5: Enter the year of the motor vehicle or vessel on the fifth blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 6: Enter the make of the motor vehicle or vessel on the sixth blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 7: Enter the model of the motor vehicle or vessel on the seventh blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 8: Enter the VIN or HULL number of the motor vehicle or vessel on the eighth blank line.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 9: Indicate with a check mark whether this is a sale to a corporation, partnership or LLc, or to a stockholder, partner or member.

Connecticut Use Tax Exemption On Motor Vehicles Or Vessels Sold To Or By Businesses Q 20 Step 10: Complete the rest of the form as instructed.

INSTRUCTIONS: ALABAMA PHYSICIAN ASSISTANT JOB DESCRIPTION

As part of the process of registering Alabama physician assistants, this job description form should be filed. This document can be obtained from the website maintained by the Alabama Board of Medical Examiners.

Alabama Physician Assistant Job Description Step 1: On the first blank line, enter the name of the physician assistant.

Alabama Physician Assistant Job Description Step 2: On the second blank line, enter the name of the primary supervising physician.

Alabama Physician Assistant Job Description Step 3: On the third blank line, enter the principal practice location address of the physician.

Alabama Physician Assistant Job Description Step 4: On the fourth blank line, enter the location's telephone number, including the area code.

Alabama Physician Assistant Job Description Step 5: On the fifth blank line, enter the medical specialty of the primary supervising physician.

Alabama Physician Assistant Job Description Step 6: The rest of the first page, the entirety of the second page, and the top of the third page outline the standard responsibilities of a physician assistant. 

Alabama Physician Assistant Job Description Step 7: If requesting additional duties for the physician assistant, describe these in section 2k at the top of the third page.

Alabama Physician Assistant Job Description Step 8: In section 3, list each practice site where this job description will be utilized, including the address and phone number.

Alabama Physician Assistant Job Description Step 9; In section 4, list the name and designated working hours of each physician assistant at each practice site where this job description will be utilized. 

Alabama Physician Assistant Job Description Step 10: In section 5, indicate with a check mark whether there is a request for the applying physician assistant to practice in a remote site. If yes, attach a letter from the physician requesting approval to utilize the assistant at a remote site and provide all information requested.

Alabama Physician Assistant Job Description Step 11: In section 6, provide a written plan for review of medical records and patient outcomes.

Alabama Physician Assistant Job Description Step 12: In section 7, indicate with a check mark whether the physician assistant will be authorized to have prescriptive privileges. In section 8, indicate whether they will be authorized to have prescriptive privileges for controlled substances. The supervising physician and physician assistant should both print and sign their names at the bottom of the fourth page. 

INSTRUCTIONS: ALABAMA STATE EMPLOYEES' HEALTH INSURANCE PLAN ANNUAL TOBACCO USER PREMIUM DISCOUNT APPLICATION (Form IB06)

Alabama state employees apply for a tobacco user premium discount application using a form IB06. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 1: Enter the name of the contract holder in the first blank box.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 2: Enter your contract number in the second blank box.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 3: Check the first statement if you have used tobacco products in the last 12 months.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 4: Check the second statement if your spouse has used tobacco products in the last 12 months.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 5: Check the third statement if you have completed an SEIB approved tobacco cessation program and attach verification.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 6: Check the fourth statement if your spouse has completed an SEIB approved tobacco cessation program and attach verification.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 7: Check the fifth statement if you cannot stop using tobacco products as advised by your physician because it would be unreasonably difficult due to a medical condition. Attach a statement from your physician.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 8: Check the sixth statement if your spouse cannot stop using tobacco products as advised by your physician because it would be unreasonably difficult due to a medical condition. Attach a statement from your physician.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 9: Enter your signature, date and daytime phone number where indicated.

Alabama State Employees' Health Insurance Plan Annual Tobacco User Premium Discount Application IB06 Step 10: Sign and date the authorization portion of the form and enter the name and telephone number of your primary care physician. If applicable, your spouse should do the same.

INSTRUCTIONS: ALABAMA SUPPLEMENTARY REPORT (WC Form 3)

As part of the process of paying workers' compensation in Alabama after an on-the-job injury, employers may be required to complete the form discussed in this article. This document can be obtained from the website of the Alabama Department of Labor.

Alabama Supplementary Report WC Form 3 Step 1: Indicate whether this form documents a first payment, reinstatement or is amended with a check mark.

Alabama Supplementary Report WC Form 3 Step 2: Enter the employee's name on line 1.

Alabama Supplementary Report WC Form 3 Step 3: Enter the employee's Social Security number on line 2.

Alabama Supplementary Report WC Form 3 Step 4: Enter the name of the employer on line 3.

Alabama Supplementary Report WC Form 3 Step 5: Enter the unemployment compensation number on line 4.

Alabama Supplementary Report WC Form 3 Step 6: Enter the date of the injury on line 5.

Alabama Supplementary Report WC Form 3 Step 7: Enter the date the disability began this period on line 6.

Alabama Supplementary Report WC Form 3 Step 8: Enter the name of the insurance carrier on line 7.

Alabama Supplementary Report WC Form 3 Step 9: Enter the claim number and service number on line 8.

Alabama Supplementary Report WC Form 3 Step 10: Enter the name, address, telephone number, and extension of the office filing this report on line 9.

Alabama Supplementary Report WC Form 3 Step 11: If payment was made, on line A, enter the date of the first check on the first blank line.

Alabama Supplementary Report WC Form 3 Step 12: Enter the amount of the first check on the second blank line.

Alabama Supplementary Report WC Form 3 Step 13: Enter the period covered by the first check on the third blank line.

Alabama Supplementary Report WC Form 3 Step 14: Enter the average weekly wage on the fourth blank line.

Alabama Supplementary Report WC Form 3 Step 15: Enter the compensation rate per week on the fifth blank line.

Alabama Supplementary Report WC Form 3 Step 16: If compensation was not paid within 30 days from the date on which the disability began, complete Part B. Indicate the reason for non-payment on line 13. On line 14, indicate whether compensation was denied and the claimant notified.

INSTRUCTIONS: ARIZONA VERIFICATION RECORD (Form 71-1009)

As part of the bingo licensing process in Arizona, a form 71-1009 is used to document each game. This form can be obtained from the website of the Arizona Department of Revenue.

Arizona Verification Record 71-1009 Step 1: Section A concerns the occasion. Enter the date, the license number, the number of players and the supervisor for the occasion.

Arizona Verification Record 71-1009 Step 2: Section B concerns card sales. For each such transaction, enter the item number, price, number sold, total income and wastage cards. Enter the total card sales at the bottom of the table provided.

Arizona Verification Record 71-1009 Step 3: Section C concerns supply sales. For each dauber, glue stick or other sold, enter the number sold, price and income. Enter the total supply sales at the bottom of the table provided.

Arizona Verification Record 71-1009 Step 4: Section D concerns inducements. Document your giveaways, discounts, admission fees, card sales, supply sales, gross receipts, cash payouts, remaining receipts, beginning cash, cash on hand, cash short or cash over, bank deposit and ending cash as instructed.

Arizona Verification Record 71-1009 Step 5: Section E concerns adjusted gross receipts. Enter your total income on the first blank line and the total prize money on the second blank line.

Arizona Verification Record 71-1009 Step 6: Subtract the second blank line from the first blank line and enter the resulting difference on the third blank line. This is your adjusted income.

Arizona Verification Record 71-1009 Step 7: The supervisor should enter their signature on the first blank line.

Arizona Verification Record 71-1009 Step 8: A witness should enter their signature on the second blank line.

Arizona Verification Record 71-1009 Step 9: The date the form was completed should be entered on the third blank line.

Arizona Verification Record 71-1009 Step 10: Enter any miscellaneous information at the bottom of the first page.

Arizona Verification Record 71-1009 Step 11: The two tables provided at the top of the second page require you to document legend items.

Arizona Verification Record 71-1009 Step 12: The two tables provided at the bottom of the second page are game worksheets. For each game, enter its number, the item number, the cost of each, the number sold, the total income and the prize. 

INSTRUCTIONS: CONNECTICUT INSURANCE PREMIUM FINANCE COMPANY LICENSE RENEWAL APPLICATION

To renew your Connecticut license to act as an insurance premium finance company, you must file the application discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Insurance Premium Finance Company License Renewal Application Step 1: Enter the company name on the first blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 2: Enter the company address on the second blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 3: Enter the name of a contact person on the third blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 4: Enter a contact phone number on the fourth blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 5: Enter the company federal tax identification number on the fifth blank line.

Connecticut Insurance Premium Finance Company License Renewal Application Step 6: On line 1, indicate with a check mark whether the company has employees in Connecticut. If yes, you must attach a current certificate of worker's compensation insurance.

Connecticut Insurance Premium Finance Company License Renewal Application Step 7: Line 2 requires you to make a financial statement about the current financial condition of your company. Enter the date, your assets, liabilities, surplus and the total of your liabilities and surplus where indicated.

Connecticut Insurance Premium Finance Company License Renewal Application Step 8: Line 3 should be completed if your partnership, association or corporation has experienced changes in its partners, members or officers. Enter the full name of each new partner member or officer, their title (if they are an officer), their residential address, their business address and their occupation.

Connecticut Insurance Premium Finance Company License Renewal Application Step 9: Line 4 should completed if your corporation has experienced changes in directors. Enter the full name of each new director, their title (if an officer), their residential address, their business address and their occupation.

Connecticut Insurance Premium Finance Company License Renewal Application Step 10: If you have any new partners, directors, members or officers listed on lines 4 or 5, you must complete a separate biographical affidavit for each one. This is located on the third page.

Connecticut Insurance Premium Finance Company License Renewal Application Step 11: Sign and date the second page before a notary public.