DHS 2120 Household Report Form - This form is for people currently open on Cash or SNAP programs that need to complete a monthly household report form. SERVICES SANCTIONS, 0028.30.04.03 - POST 60-MONTH SANCTIONS: 2-PARENT PROVISIONS, 0028.30.06 - SANCTIONS FOR NOT MEETING SNAP WORK RULE, 0028.30.09 - REFUSING OR TERMINATING EMPLOYMENT, 0028.30.12 - SANCTION NOTICE FOR MINOR CAREGIVER, 0028.33 - EMPLOYMENT SERVICES/SNAP E&T NOTICE REQUIREMENTS, 0029.03.06 - FAMILY SUPPORT GRANT PROGRAM, 0029.03.09 - CONSUMER SUPPORT GRANT PROGRAM, 0029.03.18 - RELATIVE CUSTODY ASSISTANCE PROGRAM, 0029.06.03 - SUPPLEMENTAL SECURITY INCOME PROGRAM, 0029.06.06 - RETIREMENT, SURVIVORS AND DISABILITY INSURANCE, 0029.06.21 - UNITED STATES REPATRIATION PROGRAM, 0029.06.24.03 - TRIBAL TANF - MILLE LACS BAND OF OJIBWE, 0029.06.24.06 - TRIBAL TANF - RED LAKE BAND OF CHIPPEWA INDIANS, 0029.07.03 - MINNESOTA STATE FOOD BENEFITS, 0029.07.09 - WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM, 0029.07.12 - COMMODITY SUPPLEMENTAL FOOD PROGRAM, 0029.07.15 FOOD DISTRIBUTION PROGRAM-INDIAN RESERVATION, 0029.20.09 - FAMILY HOMELESS PREVENTION ASSISTANCE, 0029.27 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM, 0029.31 - CHILD CARE RESOURCE AND REFERRAL, 0030.03.01.01 - INELIGIBLE FOR OTHER CASH PROGRAMS, 0030.03.09 - DETERMINING RCA GROSS INCOME, 0030.03.16 - PROCESSING REPORTED CHANGES - RCA, 0030.03.18 - RCA OVERPAYMENTS AND UNDERPAYMENTS, 0030.12.03 - RCA POST-SECONDARY EDUCATION/TRAINING, 0030.12.06 - RCA EMPLOYMENT SERVICES GOOD CAUSE CLAIMS. See 0017.15.15 (Income of Minor Child/Caregiver Under 20). /Filter /FlateDecode %%EOF DHS-2146 Authorization for Release of Employment Information - This form is completed by an employer to verify employment start, stop, or wage change. Verify the following for all programs: Inconsistent information. q This program was suspended 12/1/14. If the injury/disability is expected to last indefinitely, verification is only needed once. The verification requirements are as follows: trailer 0016 (Income from People Not in the Unit), Combined Six-Month Review (DHS-5576) (PDF), 0022.03.01.03 (Prospective Budgeting - SNAP Provisions), 0017.15.36 (Student Financial Aid Income), 0017.15.15 (Income of Minor Child/Caregiver Unde. Counted TLR months used in another state. 1 1 7.96 7 re This can be obtained by contacting the client's Employment Services Provider. The way to fill out the DSS stop work form online: To get started on the blank, use the Fill camp; Sign Online button or tick the preview image of the document. _ ! endstream endobj startxref The number of hours of employment or work program activities. (4) Tj TO: (Name& Addressof Employer) FROM: RE Forms - Minneapolis Public Housing Authority n GEN 262 Special Diets - This form is used to provide information regarding diets prescribed by a doctor. 0000024944 00000 n See 0010.18.01 (Mandatory Verifications - Cash Assistance). W GEN 205 Emergency Programs Release Form - This form is used to allow Economic Assistance to contact landlords and utility companies in order to complete our Emergency Assistance or Emergency General Assistance application. /N 1 /ZaDb 5.1626 Tf 0000000025 00000 n 0.749023 g Choose My Signature. 2023 Minnesota Department of Human Services, 0007.15 (Unscheduled Reporting of Changes - Cash), Verification Request Form (DHS-2919) (PDF), 0010.15 (Verification - Inconsistent Information), 0010.18.11 (Verifying Citizenship and Immigration Status), 0010.18.11.03 (Systematic Alien Verification (SAVE)), 0011.03.27 (Undocumented and Non-Immigrant People), (Mandatory Verifications - Cash Assistance). Stop Work Form Hennepin County - Fill and Sign Printable Template Online 0000005978 00000 n in SNAP deletes all policy about non-mandatory verifications and moves it to 0010.18.02.03 (Non-Mandatory Verifications SNAP) and adds a cross-reference to 0010.18.02.03 (Non-Mandatory Verifications SNAP). iin SNAP adds to document in MAXIS CASE/NOTEs the identity information obtained from SOLQ as a "Verify MN interface" for clarity. If there is not enough room on the form to answer a question, attach your own pages. in SNAP in the 2nd paragraph in the 1st bullet adds and deletes information about allowing housing costs as a deduction for applications and recertifications. Human services e-forms | Hennepin County /ProcSet [/PDF] >> US Legal Forms is definitely the industry leader in affordable access to state-specific form templates. W Minnesota Employment Verification Form Use a minnesota employment verification template to make your document workflow more streamlined. /Marked true Q 3. SNAP: Removed WB. Employment verification Forms for Minnesota - US Legal Forms To learn more about what might be personally identifiable information . name, student ID number, date of birth), we encourage you to submit the completed form by mail or in person. See 0011.24 (Time-limited SNAP Recipients) for more information on counted months used in another state. Social Security numbers of all people applying for assistance. When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. /ExtGState << Applying for MNsure Helpful Information - This document gives you step by step instructions for completing an online MNsure application. endstream endobj 422 0 obj <>/Subtype/Form/Type/XObject>>stream Questions about legal documents can be directed to the County Attorneys Office: 763-324-5550. hb``d``~4YAb,_w400q` 0K* `3.vbwH, ,870c``u@ {@U ,Mf1249 ,0e0Z0Pk 0ahcLwLo0`Nb: m13y e-L}~fd``: If the exemptions are not listed below, they do not need to be verified unless questionable. H BT Hennepin County . SERVICES SANCTIONS, 0028.30.04.03 - POST 60-MONTH SANCTIONS: 2-PARENT PROVISIONS, 0028.30.06 - SANCTIONS FOR NOT MEETING SNAP WORK RULE, 0028.30.09 - REFUSING OR TERMINATING EMPLOYMENT, 0028.30.12 - SANCTION NOTICE FOR MINOR CAREGIVER, 0028.33 - EMPLOYMENT SERVICES/SNAP E&T NOTICE REQUIREMENTS, 0029.03.06 - FAMILY SUPPORT GRANT PROGRAM, 0029.03.09 - CONSUMER SUPPORT GRANT PROGRAM, 0029.03.18 - RELATIVE CUSTODY ASSISTANCE PROGRAM, 0029.06.03 - SUPPLEMENTAL SECURITY INCOME PROGRAM, 0029.06.06 - RETIREMENT, SURVIVORS AND DISABILITY INSURANCE, 0029.06.21 - UNITED STATES REPATRIATION PROGRAM, 0029.06.24.03 - TRIBAL TANF - MILLE LACS BAND OF OJIBWE, 0029.06.24.06 - TRIBAL TANF - RED LAKE BAND OF CHIPPEWA INDIANS, 0029.07.03 - MINNESOTA STATE FOOD BENEFITS, 0029.07.09 - WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM, 0029.07.12 - COMMODITY SUPPLEMENTAL FOOD PROGRAM, 0029.07.15 FOOD DISTRIBUTION PROGRAM-INDIAN RESERVATION, 0029.20.09 - FAMILY HOMELESS PREVENTION ASSISTANCE, 0029.27 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM, 0029.31 - CHILD CARE RESOURCE AND REFERRAL, 0030.03.01.01 - INELIGIBLE FOR OTHER CASH PROGRAMS, 0030.03.09 - DETERMINING RCA GROSS INCOME, 0030.03.16 - PROCESSING REPORTED CHANGES - RCA, 0030.03.18 - RCA OVERPAYMENTS AND UNDERPAYMENTS, 0030.12.03 - RCA POST-SECONDARY EDUCATION/TRAINING, 0030.12.06 - RCA EMPLOYMENT SERVICES GOOD CAUSE CLAIMS. /F7 23 0 R >> Minnesota Department of Labor & Industry Construction Codes and Licensing Division Licensing and Certification Services 443 Lafayette Road North St. Paul, MN 55155 Mailing Address: PO Box 64217 St. Paul, MN 55164-0217 Phone: 651.284.5031 Email: dli.exam@state.mn.us Web site: www.dli.mn.gov . f Student course of study if attending a post-secondary institution. MFIP, DWP: It also in the 4th paragraph adds tribe language. 0 0 9.96 9 re See 0011.18 (Students). in SNAP in 2nd paragraph adds "lives with a natural, adoptive, or stepparent or is under the parental control of a household member other than a parent" for not requesting verification of earned income of an elementary, secondary, or GED student. 4.9716 TL Select the link to download, print or save to your computer. x]K$ 0zb%Ynl!?$(_)UkggTRHTQ?[LIt_=?I}~J@NxO?3O~CJK? 5}X}t^ x{Jk? Q Find the Stop Work Form Hennepin County you require. SNAP Application Packet - This packet provides SNAP program information to people applying for SNAP benefits. /ZaDb 7.6247 Tf 0 /GS0 8 0 R Verify the exemptions listed below at application time and/or when a change occurs. in SNAP in the 2nd paragraph clarifies to allow the listed verifications only if an applicant/participant wants a deduction from their income for them. Household Report Form - Fill Out and Sign Printable PDF Template | signNow This is valid for 1 year or when I withdraw it in writing. 2.7962 2.7525 Td Human services e-forms. << You must verify that the client is cooperating with the work requirements of this program. A verbal client statement indicating residency in Minnesota meets the verification requirement. For more information about running SAVE, see 0010.18.11.03 (Systematic Alien Verification (SAVE)). >> /Tx BMC 0002.05 - GLOSSARY: ASSISTANCE STANDARD 0002.17 - GLOSSARY: DISPLACED HOMEMAKER 0002.41 - GLOSSARY: MEDICALLY NECESSARY 0003 - CLIENT RESPONSIBILITIES AND RIGHTS, 0003.03 - CLIENT RESPONSIBILITIES - GENERAL, 0003.06 - CLIENT RESPONSIBILITIES - QUALITY CONTROL, 0003.09.03 - CLIENT RIGHTS - CIVIL RIGHTS, 0003.09.06 - CLIENT RIGHTS - DATA PRIVACY PRACTICES, 0003.09.09 - CLIENT RIGHTS, PRIVATE AND CONFIDENTIAL DATA, 0003.09.12 - CLIENT RIGHTS - LIMITED ENGLISH PROFICIENCY, 0004.01 - EMERGENCIES - PROGRAM PROVISIONS, 0004.03 - EMERGENCY AID ELIGIBILITY - CASH ASSISTANCE, 0004.04 - EMERGENCY AID ELIGIBILITY--SNAP/EXPEDITED FOOD, 0004.06 - EMERGENCIES - 1ST MONTH PROCESSING, 0004.09 - EMERGENCIES - 2ND AND 3RD MONTH PROCESSING, 0004.12 - VERIFICATION REQUIREMENTS FOR EMERGENCY AID, 0004.15 - EMERGENCIES - POSTPONED VERIFICATION NOTICE, 0004.18 - DETERMINING THE AMOUNT OF EMERGENCY AID, 0004.48 - DESTITUTE UNITS--MIGRANT/SEASONAL FARMWORKER, 0004.51 - DESTITUTE UNITS, ELIGIBILITY AND BENEFITS, 0005.06.03 - WHO CAN/CANNOT BE AUTHORIZED REPRESENTATIVES, 0005.06.06 - DISQUALIFYING AUTHORIZED REPRESENTATIVES, 0005.09 - COMBINED APPLICATION FORM (CAF), 0005.09.03 - WHEN PEOPLE MUST COMPLETE AN APPLICATION, 0005.09.06 - WHEN NOT TO REQUIRE COMPLETION OF AN APPLICATION, 0005.09.09 - WHEN TO USE AN ADDENDUM TO AN APPLICATION, 0005.09.15 - EMERGENCY ASSISTANCE AND APPLICATIONS, 0005.10 - MINNESOTA TRANSITION APPLICATION FORM (MTAF), 0005.12 - ACCEPTING AND PROCESSING APPLICATIONS, 0005.12.03 - WHAT IS A COMPLETE APPLICATION, 0005.12.12.01 - FORMS/HANDOUTS FOR APPLICANTS, 0005.12.12.06 - ORIENTATION TO FINANCIAL SERVICES, 0005.12.12.09 - FAMILY VIOLENCE PROVISIONS/REFERRALS, 0005.12.15 - APPLICATION PROCESSING STANDARDS, 0005.12.15.01 - PROCESSING SNAP APPLICATION NON-MANDATORY VERIFICATION, 0005.12.15.03 - DELAYS IN PROCESSING APPLICATIONS, 0005.12.15.06 - DETERMINING WHO CAUSED THE DELAY, 0005.12.15.09 - DELAYS CAUSED BY THE APPLICANT HOUSEHOLD, 0005.12.15.12 - DELAYS CAUSED BY THE AGENCY, 0005.12.15.15 - DELAYS CAUSED BY THE AGENCY AND APPLICANT, 0005.12.21 - REINSTATING A WITHDRAWN APPLICATION, 06 - DETERMINING FINANCIAL RESPONSIBILITY, 0006 - DETERMINING FINANCIAL RESPONSIBILITY, 0006.06 - MOVING BETWEEN COUNTIES - PARTICIPANTS, 0006.09 - MOVING BETWEEN COUNTIES - MINOR CHILDREN, 0006.12 - ASSISTANCE TERMINATED WITHIN LAST 30 DAYS, 0006.15 - MULTIPLE COUNTY FINANCIAL RESPONSIBILITY, 0006.18 - EXCLUDED TIME FACILITIES AND SERVICES, 0006.21 - TRANSFERRING RESPONSIBILITY - OLD COUNTY, 0006.24 - TRANSFERRING RESPONSIBILITY - NEW COUNTY, 0006.27 - COUNTY FINANCIAL RESPONSIBILITY DISPUTES, 0006.30 - STATE FINANCIAL RESPONSIBILITY DISPUTES, 0007.03.01 - MONTHLY REPORTING - UNCLE HARRY FS, 0007.03.04 - SIX-MONTH REPORTING DEADLINES, 0007.03.07 - PROCESSING A LATE COMBINED SIX-MONTH REPORT, 0007.12 - AGENCY RESPONSIBILITIES FOR CLIENT REPORTING, 0007.15 - UNSCHEDULED REPORTING OF CHANGES - CASH, 0007.15.03 - UNSCHEDULED REPORTING OF CHANGES - SNAP, 0008.03 - CHANGES - OBTAINING INFORMATION, 0008.06 - IMPLEMENTING CHANGES - GENERAL PROVISIONS, 0008.06.01 - IMPLEMENTING CHANGES - PROGRAM PROVISIONS, 0008.06.03 - CHANGE IN BASIS OF ELIGIBILITY, 0008.06.06 - ADDING A PERSON TO THE UNIT - CASH, 0008.06.07 - ADDING A PERSON TO THE UNIT - SNAP, 0008.06.09 - REMOVING A PERSON FROM THE UNIT, 0008.06.12.09 - CONVERTING A PREGNANT WOMAN CASE, 0008.06.15 - REMOVING OR RECALCULATING INCOME, 0008.06.21 - CHANGE IN COUNTY OF RESIDENCE, 0008.06.24 - DWP CONVERSION OR REFERRAL TO MFIP, 0009.03 - LENGTH OF RECERTIFICATION PERIODS, 0009.03.03 - WHEN TO ADJUST THE LENGTH OF CERTIFICATION, 0009.06.03 - RECERTIFICATION PROCESSING STANDARDS, 0009.06.03.03 - PROCESSING SNAP RECERTIFICATION NON-MANDATORY VERIFICATION, 0010.03 - VERIFICATION - COOPERATION AND CONSENT, 0010.06 - SOURCES OF VERIFICATION - DOCUMENTS, 0010.09 - SOURCES OF VERIFICATION, COLLATERAL CONTACTS, 0010.12 - SOURCES OF VERIFICATION - HOME VISITS, 0010.15 - VERIFICATION - INCONSISTENT INFORMATION, 0010.18.01 - MANDATORY VERIFICATIONS - CASH ASSISTANCE, 0010.18.02.03 - NON-MANDATORY VERIFICATIONS - SNAP, 0010.18.03 - VERIFYING SOCIAL SECURITY NUMBERS, 0010.18.03.03 - VERIFYING SOCIAL SECURITY NUMBERS - NEWBORNS, 0010.18.05 - VERIFYING DISABILITY/INCAPACITY - CASH, 0010.18.06 - VERIFYING DISABILITY/INCAPACITY - SNAP, 0010.18.08 - VERIFYING STATE RESIDENCE - CASH, 0010.18.09 - VERIFYING SELF-EMPLOYMENT INCOME, 0010.18.11 - VERIFYING CITIZENSHIP AND IMMIGRATION STATUS, 0010.18.11.03 - SYSTEMATIC ALIEN VERIFICATION (SAVE), 0010.18.12 - VERIFYING LAWFUL TEMPORARY RESIDENCE, 0010.18.15 - VERIFYING LAWFUL PERMANENT RESIDENCE, 0010.18.15.03 - LAWFUL PERMANENT RESIDENT: USCIS CLASS CODES, 0010.18.15.06 - VERIFYING SOCIAL SECURITY CREDITS, 0010.18.18 - VERIFYING SPONSOR INFORMATION, 0010.18.21 - IDENTIFY NON-IMMIGRANT OR UNDOCUMENTED PEOPLE, 0010.18.21.03 - NON-IMMIGRANT PEOPLE: USCIS CLASS CODES, 0010.18.30 - VERIFYING STUDENT INCOME AND EXPENSES, 0010.24 - INCOME AND ELIGIBILITY VERIFICATION SYSTEM, 0010.24.03 - IEVS MATCH TYPE AND FREQUENCY, 0010.24.09 - PROCESSING IEVS MATCHES TIMELY, 0010.24.12 - DETERMINING IEVS EFFECT ON ELIGIBILITY, 0010.24.15 - RECORDING IEVS RESOLUTION FINDINGS, 0010.24.18 - CLIENT COOPERATION WITH IEVS, 0010.24.21 - IEVS SAFEGUARDING RESPONSIBILITIES, 0010.24.24 - IEVS NON-DISCLOSURE AND EMPLOYEE AWARENESS, 0011.03 - CITIZENSHIP AND IMMIGRATION STATUS, 0011.03.03 - NON-CITIZENS - MFIP/DWP CASH, 0011.03.06 - NON-CITIZENS - MFIP FOOD PORTION, 0011.03.09 - NON-CITIZENS - SNAP/MSA/GA/GRH, 0011.03.12 - NON-CITIZENS - LAWFUL PERMANENT RESIDENTS, 0011.03.12.03 - NON-CITIZENS - ADJUSTMENT OF STATUS, 0011.03.15 - NON-CITIZENS - LPR WITH SPONSORS, 0011.03.17 - NON-CITIZENS - PUBLIC CHARGE, 0011.03.18 - NON-CITIZENS - PEOPLE FLEEING PERSECUTION, 0011.03.21 - NON-CITIZENS - VICTIMS OF BATTERY/CRUELTY, 0011.03.24 - NON-CITIZENS - LAWFULLY RESIDING PEOPLE, 0011.03.27 - UNDOCUMENTED AND NON-IMMIGRANT PEOPLE, 0011.03.27.01 - NON-CITIZENS - CITIZENS OF PALAU, THE FEDERATED STATES OF MICRONESIA, AND THE REPUBLIC OF THE MARSHALL ISLANDS, 0011.03.27.03 - PROTOCOLS FOR REPORTING UNDOCUMENTED PEOPLE, 0011.03.30 - NON-CITIZENS - TRAFFICKING VICTIMS, 0011.03.33 - NON-CITIZENS - IMMIGRATION COURT ORDERS, 0011.06.03 - STATE RESIDENCE - EXCLUDED TIME, 0011.06.06 - STATE RESIDENCE - INTERSTATE PLACEMENTS, 0011.06.09 - STATE RESIDENCE - 30-DAY REQUIREMENT, 0011.12.01 - DRUG ADDICTION OR ALCOHOL TREATMENT FACILITY, 0011.12.03 - UNDER CONTROL OF THE PENAL SYSTEM, 0011.30.06 - 180 TO 60 DAYS BEFORE MFIP CLOSES, 0011.33.02 - MFIP HARDSHIP EXTENSIONS - REMOVING 1 PARENT, 0011.33.03 - MFIP EMPLOYED EXTENSION CATEGORY, 0011.33.03.03 - LIMITED WORK DUE TO ILLNESS/DISABILITY, 0011.33.06 - MFIP HARD TO EMPLOY EXTENSION CATEGORY, 0011.33.09 - MFIP ILL/INCAPACITATED EXTENSION CATEGORY, 0012.06 - REQUIREMENTS FOR CAREGIVERS UNDER 20, 0012.12.03 - INTERIM ASSISTANCE AGREEMENTS, 0012.12.06 - SPECIAL SERVICES - APPLYING FOR SOCIAL SECURITY, 0012.15 - INCAPACITY AND DISABILITY DETERMINATIONS, 0012.15.03 - MEDICAL IMPROVEMENT NOT EXPECTED (MINE) LIST, 0012.15.06 - STATE MEDICAL REVIEW TEAM (SMRT), 0012.15.06.03 - SMRT - SPECIFIC PROGRAM REQUIREMENTS, 0012.21 - RESPONSIBLE RELATIVES NOT IN THE HOME, 0012.21.03 - SUPPORT FROM NON-CUSTODIAL PARENTS, 0012.21.06 - CHILD SUPPORT GOOD CAUSE EXEMPTIONS, 0013.03.03 - PREGNANT WOMAN BASIS - MFIP/DWP, 0013.03.06 - MFIP BASIS - STATE-FUNDED CASH PORTION, 0013.06 - SNAP CATEGORICAL ELIGIBILITY/INELIGIBILITY, 0013.09.09 - MSA BASIS - DISABLED AGE 18 AND OLDER, 0013.15.03 - GA BASIS - PERMANENT ILLNESS, 0013.15.06 - GA BASIS - TEMPORARY ILLNESS, 0013.15.09 - GA BASIS - CARING FOR ANOTHER PERSON, 0013.15.12 - GA BASIS - PLACEMENT IN A FACILITY, 0013.15.27 - GA BASIS, SSD/SSI APPLICATION/APPEAL PENDING, 0013.15.33 - GA BASIS - DISPLACED HOMEMAKERS, 0013.15.39 - GA BASIS - PERFORMING COURT ORDERED SERVICES, 0013.15.42 - GA BASIS - LEARNING DISABLED, 0013.15.48 - GA BASIS - ENGLISH NOT PRIMARY LANGUAGE, 0013.15.51 - GA BASIS - PEOPLE UNDER AGE 18, 0013.15.54 - GA BASIS - DRUG/ALCOHOL ADDICTION, 0013.18.09 - GRH BASIS - DISABLED AGE 18 AND OLDER, 0013.18.12 - GRH BASIS - REQUIRES SERVICE IN RESIDENCE, 0013.18.15 - GRH BASIS - PERMANENT ILLNESS, 0013.18.18 - GRH BASIS - TEMPORARY ILLNESS, 0013.18.27 - GRH BASIS - SSD/SSI APPL/APPEAL PEND, 0013.18.33 - GRH BASIS - LEARNING DISABLED, 0013.18.36 - GRH BASIS - DRUG/ALCOHOL ADDICTION, 0013.18.39 - GRH BASIS - TRANSITION FROM RESIDENTIAL TREATMENT, 0014.03 - DETERMINING THE ASSISTANCE UNIT, 0014.03.03 - DETERMINING THE CASH ASSISTANCE UNIT, 0014.03.03.03 - OPTING OUT OF MFIP CASH PORTION, 0014.06 - WHO MUST BE EXCLUDED FROM ASSISTANCE UNIT, 0014.09 - ASSISTANCE UNITS - TEMPORARY ABSENCE, 0014.12 - UNITS FOR PEOPLE WITH MULTIPLE RESIDENCES, 0015.06.03 - AVAILABILITY OF ASSETS WITH MULTIPLE OWNERS, 0015.30 - ASSETS - PAYMENTS UNDER FEDERAL LAW, 0015.48.03 - WHOSE ASSETS TO CONSIDER - SPONSORS W/I-864, 0015.48.06 - WHOSE ASSETS TO CONSIDER - SPONSORS W/I-134, 0015.63 - EVALUATION OF PENSION AND RETIREMENT PLANS, 0015.69.03 - ASSET TRANSFERS FROM SPOUSE TO SPOUSE, 0015.69.09 - IMPROPER TRANSFER INELIGIBILITY, 0015.69.12 - IMPROPER TRANSFERS - ONSET OF INELIGIBILITY, 0016 - INCOME FROM PEOPLE NOT IN THE UNIT, 0016.03 - INCOME FROM DISQUALIFIED UNIT MEMBERS, 0016.06 - INCOME FROM INELIGIBLE SPOUSE OF UNIT MEMBER, 0016.09 - INCOME FROM INELIGIBLE STEPPARENTS, 0016.12 - INCOME FROM PARENTS OF ADULT GA CHILDREN, 0016.18 - INCOME OF INEL. AE>-l`.X~JpRMcOxr69_vW61# U3U]30 n0 /T 0000025941 Verification is needed that the client is enrolled in the program and can be obtained by contacting your local resettlement agency. PDF Termination of Employment Verification - mnhousing {e.2J0+z0.lG%12 Some Spanish forms are also available. endstream endobj 423 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream If the injury/disability is expected to last indefinitely, verification is only needed once. Each form includes instructions about where and how to turn it in. /Outlines 33 0 R edocs.dhs.state.mn.us These forms do not need to be verbally reviewed during the interview. DOC Hennepin County DHS 6165A Application for Certificate of Clearance for Medical Assistance Claims - Decree of Descent (PDF)Opens a New Window. Verify eligibility factors at initial application. << Please seek professional legal advice if you are not sure this is the correct form for your situation. Employment & Economic Assistance651-554-5611. n Do not verify eligibility factors that are already verified and not subject to change. Sign it in a few clicks Draw your signature, type it, upload its image, or use your mobile device as a signature pad. Document in MAXIS CASE/NOTEs the identity information obtained from SOLQ as a "Verify MN interface". n See 0010.18.06 (Verifying Disability/Incapacity - SNAP). It also adds a new last paragraph with verification requirements. f .lG%12 endstream endobj 421 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0 In addition it is allowable to use SOLQ-I as verification of identity. This change was EFFECTIVE 02/01/16. ET /F6 14 0 R Information that is inconsistent or unclear may need to be verified. Fill out and return this form or your benefits may be late or stop. DHS 3549 General Consent/Authorization for Release of Information (PDF) - This form allows you to give Economic Assistance the authority to share specific information with another person or agency. /Tx BMC Verification must be provided by a medical services provider for a client to meet this exemption. 1300.0170 - MN Rules Part - Minnesota If the injury/disability is temporary, new verification will be needed if the injury/disability extends past the anticipated end date. 02. 1 1 9.04 9.4 re Click on the form to complete and print. BT Share your form with others Send it via email, link, or fax. Q /StructTreeRoot 32 0 R EMC H Unless questionable, a verbal statement from the client meets the verification requirement. PDF DHS-2120-ENG 9-17 Household Report Form - 83rd Minnesota Legislature 7.3425 TL EDAK 3670 Consent for Release Regarding Utility Shutoffs And/Or EvictionAuthorization form allowing Dakota County Employment & Economic Assistance permission to contact utility companies and/or landlord for information required for determination of eligibility for assistance. 0 0 9.96 9 re endstream endobj 436 0 obj <>/Subtype/Form/Type/XObject>>stream DHS 5576 Combined Six Month Report - This form is for people currently open on Cash, SNAP, or Healthcare that are required to complete a six month review. 1 1 7.96 7 re Change the template with exclusive fillable fields. /H [ 0000001041 0000000192] In the first, the county agency received a stop - work verification on 4/13. Dshs Stop Work Form - Fill Out and Sign Printable PDF Template | signNow Earliest date health/dental benefits are available? >> Please see your child support/EA paperwork for service by mail directions regarding legal proceedings. Also see Chapter 8 (Changes in Circumstances) for verifications which may be required when a unit has a change in circumstances. /Size 38 0 0 Td When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. 3 0 obj >> /E 0000027097 Do not request verification of earned income of an elementary, secondary, or GED student IF the student is in school at least half-time, is under age 18, is working, AND lives with a natural, adoptive, or stepparent or is under the parental control of a household member other than a parent. for additional MFIP provisions relating to citizenship and immigration status. Some exemptions from the work rules need to be verified. /Tx BMC /O 4 See 0017.15.36 (Student Financial Aid Income). endstream endobj 431 0 obj <>/Subtype/Form/Type/XObject>>stream ET - Refugees receiving the Matching Grant Program. /MarkInfo << The verification must be in existing files. /Tx BMC EDAK 3641DIAL BrochureBrochure explaining how use the Dakota Information Access Line (DIAL) system. Enter your official identification and contact details. 0000006624 00000 n Document this verbal statement in CASE/NOTEs. Verify the exemptions listed below at application time and/or when a change occurs. BT 0000007708 00000 n DHS 5223C-ENG Combined Application Addendum (Supplemental Nutrition Assistance Program, Cash Assistance, and Health Care Programs)This is an addendum to the Combined Application Form and is used for adding people to existing MFIP and GA assistance units after the initial application has been processed. %%EOF in general provisions deletes to verify self-employment expenses if applicable. For people in the Safe At Home Program, see 0029.29 (Safe At Home Program). See 0010.18.11 (Verifying Citizenship and Immigration Status), 0011.03.27 (Undocumented and Non-Immigrant People). If you are not able to find the form you are looking for, search for additional forms below: Searchable document library (eDocs) / Minnesota Department of Human Services (mn.gov) Contact a human services representative Phone: 612-596-1300 M-F, 8 a.m. to 4:30 p.m. Below is a list of frequently requested Human services forms. in general provisions in the 2nd bullet deletes reference to self-employment deductions and adds to verify self-employment expenses if applicable.
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