DHHS ITD: Aid to County (ATC) Request Form

Submitted by dlfaison on Wed, 05/19/2021 - 16:57

Indicates required field

Support Type

State User

State User Role Request

State Office Division

County User

County User Role Request

ITD Application Support

ITD Application Support Role Request

User Request

NCID Username

First

Middle Initial

Last

Suffix

Title

Division

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

County

Phone Number

County 2

Are you a member of the Native American Tribe?

Yes