INSTRUCTIONS: CONNECTICUT APPLICATION FOR WITHHOLDING OF RESIDENT ADDRESS (Form E-224)

Connecticut residents who work in an official capacity for the state use a form E-224 to request that their residential address be withheld from a motor vehicle or vessel license. This document can be obtained from the website of the government of Connecticut.

Connecticut Application For Withholding Of Resident Address E-224 Step 1: Indicate with a check mark whether this application is new, documents a change or if you no longer qualify for withholding of your residential address.

Connecticut Application For Withholding Of Resident Address E-224 Step 2: If this is an application documenting, enter the nature of the change.

Connecticut Application For Withholding Of Resident Address E-224 Step 3: The next section concerns the applicant. Enter the name of your business organization or department in the first blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 4: Enter your date of birth and business email address in the next two blank boxes.

Connecticut Application For Withholding Of Resident Address E-224 Step 5: Enter the name of the applicant in the next blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 6: Enter your business telephone number in the next blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 7: Enter your complete business address in the next two blank boxes.

Connecticut Application For Withholding Of Resident Address E-224 Step 8: Enter your official title and home phone number in the next two blank boxes.

Connecticut Application For Withholding Of Resident Address E-224 Step 9: Enter your residential address in the next blank box.

Connecticut Application For Withholding Of Resident Address E-224 Step 10: Indicate your official status with a check mark.

Connecticut Application For Withholding Of Resident Address E-224 Step 11: The next section should be completed by your supervisor, who should enter their name, title, signature, the date and their phone number.

Connecticut Application For Withholding Of Resident Address E-224 Step 12: In the next section, enter all applicable vehicle registration plate numbers and registration classes. If applicable, also enter your vessel registration number.

Connecticut Application For Withholding Of Resident Address E-224 Step 13: At the bottom of the form, enter your signature, operator license number, employee or badge number and the date.

INSTRUCTIONS: CONNECTICUT ORTHOPEDIC MEDICAL REPORT (Form P-142OR)

Connecticut drivers involved in an incident in which an orthopedic incident may have caused an accident may be required to have an examination performed by a medical professional. This examination will be documented using a form P-142OR. This document may be obtained from the website maintained by the government of the state of Connecticut.

Connecticut Orthopedic Medical Report P-142OR Step 1: Enter the date of the incident being addressed at the top right-hand corner.

Connecticut Orthopedic Medical Report P-142OR Step 2: The patient should enter their signature and the date in the first two blank boxes, then give the form to the medical professional for completion.

Connecticut Orthopedic Medical Report P-142OR Step 3: Enter the name of the patient in the first blank box, their date of birth in the second blank box and their telephone number in the third blank box.

Connecticut Orthopedic Medical Report P-142OR Step 4: Enter the patient's address in the fourth blank box.

Connecticut Orthopedic Medical Report P-142OR Step 5: Enter the date of the last examination in the fifth blank box.

Connecticut Orthopedic Medical Report P-142OR Step 6: Indicate with a check mark whether this is a progressive illness. If yes, comment as to its progress.

Connecticut Orthopedic Medical Report P-142OR Step 7: Indicate with a check mark whether there are splints or appliances that should be worn while the patient is operating a motor vehicle. If yes, specify.

Connecticut Orthopedic Medical Report P-142OR Step 8: Indicate with a check mark whether you believe the patient understands the potential risk posed by their condition which may affect their ability to operate a motor vehicle. 

Connecticut Orthopedic Medical Report P-142OR Step 9: Indicate with a check mark whether you believe the patient takes medications as prescribed.

Connecticut Orthopedic Medical Report P-142OR Step 10: In the blank space provided, write any abnormalities detected during the orthopedic examination. Indicate with a check mark whether there are any other conditions that should be evaluated by another specialist. If so, provide an explanation.

Connecticut Orthopedic Medical Report P-142OR Step 11: Answer the next four questions by checking "yes" or "no" as appropriate. In response to the last question, indicate what types of restrictions would make it appropriate for the patient to operate a vehicle safely. Sign and date the form and provide all identifying information requested.

INSTRUCTIONS: ALABAMA VERIFICATION OF LICENSURE 

This article discusses the form used to verify an Alabama license issued to a professional engineer in the state. This document can be obtained from the website maintained by the Alabama Board of Licensure for Professional Engineers & Land Surveyors.

Alabama Verification Of Licensure Step 1: In the first shaded area, enter the State Board address.

Alabama Verification Of Licensure Step 2: In the second area, enter your name and address.

Alabama Verification Of Licensure Step 3: In the third shaded area, enter the deadline date listed on the website of the Alabama Board of Licensure for Professional Engineers & Land Surveyors.

Alabama Verification Of Licensure Step 4: In the fourth shaded area, enter your social Security number.

Alabama Verification Of Licensure Step 5: Section I concerns the type of license you were issued. Check the first statement if you were issued an Engineer Intern license and enter the license number in the first column.

Alabama Verification Of Licensure Step 6: Check the second statement if you were issued a Professional Engineer license and enter the license number in the first column.

Alabama Verification Of Licensure Step 7: Check the third statement if you were issued a Land Surveyor Intern license and enter the license number in the first column.

Alabama Verification Of Licensure Step 8: Check the fourth statement if you were issued a Professional Land Surveyor license and enter the license number in the first column.

Alabama Verification Of Licensure Step 9: Mail the form to the address given at the top of the page. The remainder of the form will be completed by a member of the Alabama Board of Licensure for Professional Engineers and Land Surveyors. Before mailing, you should check the board to see if a fee is required.

Alabama Verification Of Licensure Step 10: In Section I, the board will enter the date the applicable license was issued in the second column and the until which it is valid in the third column.

Alabama Verification Of Licensure Step 11: In Section II, the board will enter the basis of the licensure.

Alabama Verification Of Licensure Step 12: In Section III, the board will note whether you have ever been disciplined by them or whether disciplinary action is pending. The official completing the form will then sign the bottom and enter their title and the date.

INSTRUCTIONS: ALABAMA FEDERAL POVERTY LEVEL (FPL) DISCOUNT APPLICATION (Form IB12)

To apply for a discount on Alabama state employees' insurance on the basis of being at or below the federal poverty level, file a form IB12. This document can be obtained from the website maintained by the Alabama State Employees' Insurance Board.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 1: Part 1 concerns the employee or retiree. Enter your first, middle and last name in the first blank box and your contract number in the second blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 2: Enter your street address in the third blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 3: Enter your city, state and zip code in the fourth blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 4: Enter your home phone number in the fifth blank box, your work phone number in the sixth blank box, and your cell phone number in the seventh blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 5: Indicate your marital status by circling "Single" or "Married" in the eighth box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 6: Enter your email address in the ninth blank box.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 7: Part 2 concerns your household income. Document household income from all sources listed on lines 1 through 21 of the table provided.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 8: The table provided below is for documentation of household members receiving income. Enter their name in the first column, their source of income in the second column, the current gross monthly amount in the third column, and the projected annual gross amount in the fourth column.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 9: Document all household members in Part 3. Enter their name in the first column, Social Security number in the second column, their relationship to the state employee in the third column, their date of birth in the fourth column, their age in the fifth column and their sex in the sixth column.

Alabama Federal Poverty Level (FPL) Discount Application IB12 Step 10: In Part 4, enter your signature on the first blank line and the date on the second blank line.

INSTRUCTIONS: ALABAMA FLEXIBLE SPENDING ACCOUNT STATUS CHANGE (Form PEEHIP FSA Change)

To document a change in your status as an Alabama public employee enrolled in a flexible spending account administered by BlueCross BlueShield, use a PEEHIP FSA change form. This document can be obtained from the website maintained by BlueCross BlueShield of Alabama.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 1: The first section concerns the subscriber. In the first four blank boxes, enter your Social Security number or PID number, first name, middle name or initial and last name.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 2: In the next four blank boxes, enter your mailing street address, city, state and zip code.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 3: In the next blank box, enter your date of birth.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 4: In the next two blank boxes, enter your home and work phone numbers.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 5: In the next blank box, enter your email address.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 6: Indicate whether you are single, married, divorced, legally separated or widowed with a check mark.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 7: The next reason concerns your reason for the status change. Indicate this with a check mark next to the applicable statement.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 8: Enter the date on which the qualifying event occurred.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 9: The next section concerns your flexible spending account. If making a new annual election amount, check the box where indicated. Enter the monthly and annual amounts.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 10: Check the second box if you wish to stop payroll deductions.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 11: The next section concerns dependant care flexible spending accounts. Indicate with a check mark if you wish to make a new annual election amount or to stop payroll deductions.

Alabama Flexible Spending Account Status Change PEEHIP FSA Change Step 12: Sign and date the form where indicated.

INSTRUCTIONS: CONNECTICUT APPLICATION FOR INDIVIDUAL FRATERNAL LICENSE AGENT/APPOINTMENT

To apply for a Connecticut individual fraternal agent license or appointment, use the form discussed in this article. This document can be obtained from the website maintained by the government of Connecticut.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 1: Enter your Social Security number in box 1. Leave boxes 2 and 3 blank.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 2: Enter your last name, first name, middle name and date of birth in boxes 4 through 7.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 3: Enter your residential street address, P.O. box number, city, state and zip code in boxes 8 through 12.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 4: Enter your home phone number, gender  and indicate your citizenship status with a check mark in boxes 13 through 15.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 5: Enter the business name in box 16.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 6: Enter the business street address, P.O. box number, city, state and zip code in boxes 17 through 21.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 7: Enter the business phone number, fax number, email address and web site address in boxes 22 through 25.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 8: Enter the applicant's mailing address, P.O. box number, city, state and zip code in boxes 26 through 30.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 9: Enter the assumed business name, trade name, or "doing business as" (DBA) name in box 31.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 10: Enter your present occupation and employer on line 31a.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 11: On line 32a, enter the lines of authority being applied for. Indicate with a check mark whether you are seeking a new license, a reinstatement or an amendment.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 12: Answer all questions about your background on the first, second and third pages.

Connecticut Application For Individual Fraternal License Agent/Appointment Step 13: Both the applicant and the fraternal benefit society should sign the third page and provide all certifying information requested.

INSTRUCTIONS: CONNECTICUT THIRD PARTY ADMINISTRATOR (TPA) REGISTRATION

To register as a third party administrator for a Connecticut form, use the document discussed in this article. This application firm can be obtained from the website of the government of Connecticut.

Connecticut Third Party Administrator (TPA) Registration Step 1: Indicate with a check mark whether this is an initial registration or a renewal registration.

Connecticut Third Party Administrator (TPA) Registration Step 2: Indicate whether the entity is a corporation, partnership, association, LLC or other with a check mark.

Connecticut Third Party Administrator (TPA) Registration Step 3: Enter the legal name of the applicant and their federal tax identification number in the first two blank boxes.

Connecticut Third Party Administrator (TPA) Registration Step 4: Enter the last name, first name and middle name of the contact person in the next three blank boxes.

Connecticut Third Party Administrator (TPA) Registration Step 5: In the next four blank boxes, enter your business address, city, state and zip code.

Connecticut Third Party Administrator (TPA) Registration Step 6: In the next four blank boxes, if different from your business address, enter your mailing street address, city, state and zip code.

Connecticut Third Party Administrator (TPA) Registration Step 7: In the next four blank boxes, enter your business telephone number, extension, fax number and state of domicile.

Connecticut Third Party Administrator (TPA) Registration Step 8: In the next three blank boxes, enter the last name, first name and middle name of a complaint contact person.

Connecticut Third Party Administrator (TPA) Registration Step 9: In the next four blank boxes, enter the street address, city, state and zip code of the complaint contact person. If their mailing address is different, enter it in the subsequent four blank boxes.

Connecticut Third Party Administrator (TPA) Registration Step 10: Enter up to two phone numbers, an extension for the first one, and the fax number and email address of the complaint contact person.

Connecticut Third Party Administrator (TPA) Registration Step 11: Give the name and address of all employers to whom your firm provides administrative services, as well as the date the services were initiated.

Connecticut Third Party Administrator (TPA) Registration Step 12: List all states in which each plan is doing business or covers individuals. Select your type of registration with a check mark on the second page and complete the last page as directed.