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ISSUE DATE: 12/2014

The Combined Application Form (CAF) (DHS-5223) (PDF) allows people to apply for multiple assistance programs on 1 form.

Give the Combined Application Form (CAF) (DHS-5223) (PDF) to people who want to apply for any of the following assistance programs:

Minnesota Family Investment Program (MFIP).

Refugee Cash Assistance (RCA).

Diversionary Work Program (DWP).

General Assistance (GA).

Minnesota Supplemental Aid (MSA).

Group Residential Housing (GRH).

Supplemental Nutrition Assistance Program (SNAP).

Emergency Assistance.

Document on the CAF the date the agency receives the signed page number 1 of the CAF.

Provide people with the CAF, AND the Notice of Privacy Practices (DHS-3979) (PDF). See 0003.09.06 (Client Rights - Data Privacy Practices).

The CAF includes:

Instructions on how to complete the form.

A tear-off page (page number 1) which can be used to set the date of application. See 0005.12.09 (Date of Application), 0004 (Emergencies). This page of the CAF also includes questions to evaluate for emergency need, expedited services, assistance unit composition and size and signature blocks. See 0014 (Assistance Units).

Several pages with Yes/No questions used to determine eligibility. Use the information provided on these pages to establish eligibility factors including:


Client data. See 0010 (Verification), 0013 (Basis of Eligibility), 0014 (Assistance Units).


Basis of eligibility and program coverage. See 0013 (Basis of Eligibility).


Income, asset, and expense data. See 0015 (Assets), 0017 (Determining Gross Income), 0018 (Determining Net Income).


Emergency data. See 0004 (Emergencies).

Client responsibilities and rights are on a tear-off page of the CAF (DHS-5223) (PDF) and should be reviewed with the client during the interview and given to the client for future reference. See 0003 (Client Responsibilities and Rights).

The client fills out the information on the CAF (DHS-5223) (PDF) and is then interviewed for cash and food programs using procedures established by each county.

Review each question on the CAF (DHS-5223) (PDF), even if the client has answered “No” to the question. Additions or changes on the CAF must be initialed and dated by the client.

Check for duplicate program participation through MAXIS Person Search.

For information on application interviews and scheduling appointments, see 0005.12.12 (Application Interviews).

Clients are automatically registered and referred to Employment Services programs by signing page number 1 of the CAF. See 0028 (Employment Services).

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