Form Acd 1019 PDF Details

In order to ensure that your tax return is filed accurately, you may need to file Form Acd 1019. This form is used to report any adjustments made to your income that were not reported on your original return. By filing this form, you can avoid potential penalties from the IRS. There are a number of different adjustments that can be made to your income, and each one will have its own set of instructions. Be sure to read through these instructions carefully before filing Form Acd 1019. If you have any questions, don't hesitate to contact the IRS or a qualified tax professional. Filing this form can help you avoid costly mistakes and ensure that your tax return is accurate.

QuestionAnswer
Form NameForm Acd 1019
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesKINSHIP, form 1019, GDC, nyc

Form Preview Example

ACD 1019 (FACE)

 

 

 

 

 

 

 

 

 

 

 

nyc

REV 6/02

 

 

 

 

 

 

 

 

 

 

 

ACS

 

 

 

 

 

 

 

 

 

 

 

NYC Administration for

 

 

SOCIAL SERVICES REFERRAL TO ACD

 

Children’s Services

 

 

 

 

To:

 

 

 

 

 

 

From:

 

 

Date: _____ /_____ /_____

 

 

 

 

 

 

 

 

 

 

 

Director, RA #:

 

 

 

 

 

 

Agency:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Boro:

 

 

 

Zip:

 

Boro:

 

 

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

Day Care Program Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Basic Data

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

First Name:

 

Maiden Name:

 

Tel:

Mother

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

Apt No.

 

Boro:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

First Name:

 

 

 

 

Tel:

Father

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

Apt No.

 

Boro:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name:

 

First Name:

 

Relationship:

 

Tel:

Applicant If

 

 

 

 

 

 

 

 

 

 

 

 

Not Parent

Street Address

 

Apt No.

 

Boro:

 

 

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Children Needing Day Care

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LENGTH OF TIME FOR

NAME

 

SEX

BIRTH

PRIMARY

 

TYPE OF DAY CARE

 

 

WHICH DAY CARE

 

 

 

DATE

LANGUAGE

 

 

 

 

 

 

IS RECOMMENDED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¨ GDC P/S

¨ GDC INF

¨ FDC FT

____ NO. OF MONS.

 

 

 

 

 

 

¨ GDC S/A

¨ GDC SPEC

¨ FDC PT

____ NO. OF YEARS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¨ GDC P/S

¨ GDC INF

¨ FDC FT

____ NO. OF MONS.

 

 

 

 

 

 

¨ GDC S/A

¨ GDC SPEC

¨ FDC PT

____ NO. OF YEARS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

¨ GDC P/S

¨ GDC INF

¨ FDC FT

____ NO. OF MONS.

 

 

 

 

 

 

¨ GDC S/A

¨ GDC SPEC

¨ FDC PT

____ NO. OF YEARS

 

 

 

 

 

 

 

 

 

 

 

 

 

All Other Household Members

NAME

KINSHIP

BIRTH DATE

NAME

KINSHIP

BIRTH DATE

 

 

 

 

 

 

 

 

 

 

 

 

Other Involved Agencies

AGENCY NAME

AGENCY ADDRESS

CONTACT

TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

2. Family Use of Day Care Service

a. Is family in receipt of assistance?PA ¨ Yes ¨ No HA ¨ Yes ¨ No b. If family is not receiving any form of Income Support, does family have the ability to pay day

care, if required?

 

 

 

¨ Yes

¨ No

c. If “yes” is family willing to pay such a fee?

 

 

¨ Yes

¨ No

d. Attitude of Parent/Caretaker toward placement of children in day care:

 

 

¨ Highly Favorable

¨ Favorable

¨ Indifferent

¨ Resistant

¨ Highly Resistant

e. Are there any limitations in transporting child(ren) to and from day care program? ¨ Yes

¨ No

If “yes”, describe: _______________________________________________________________

nyc

ACD 1019 (REVERSE)ACS REV 6/02

NYC Administration for

Children’s Services

3. Reason for Day Care

Explain why day care is needed and how day care will aid the family and/or child(ren). Include service plan for family and/or child(ren). If recertification, update service plan to show progress or current status and explain why day care is still needed. A SERVICE OR TREATMENT PLAN MUST BE INCLUDED WITH THIS REFERRAL. Attach any additional sheets required.

4. Current Family Social Functioning

Give any additional information that might be useful in attempting to make an appropriate day care placement for the child(ren); I . E . , specifics regarding physical or emotional health, family relationships, school problems (for school-age child(ren), etc. Attach additional sheet if necessary.

Referring Person

Name (Print):__________________________________________

Tel. No.: _________________

Signature: ____________________________________________

Date: _____ /______ /_____

 

 

Supervisor

 

 

 

Name (Print):__________________________________________

Tel. No.: _________________

Signature: __________________________________________

Date: _____ /______ /_____

 

 

Form Acd 1019 isn’t the one you’re looking for?

Related Documents