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Minnesota Department of Human Services Combined Manual
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FORMS/HANDOUTS FOR APPLICANTS

ISSUE DATE: 04/2018

Give the forms/handouts listed in this section to applicants at the interview or send them with the application packet if you are aware of the specific programs for which the applicants will apply.

The following are required to be included in the application packet:

Combined Application Form (CAF) (DHS-5223) (PDF). Attached to the CAF are the following:

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Notice of Privacy Practices (DHS-3979) (PDF).

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Client Responsibilities and Rights (DHS-4163) (PDF).

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Notice About Income and Eligibility Verification System and Work Reporting System (DHS-2759) (PDF).

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Important Information (DHS-3353) (PDF).

A cover letter including the following:

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The county agency address, office hours, and phone number.

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The importance of returning page number 1 of the CAF as soon as possible.

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Information about the interview and returning the remainder of the CAF.

Program information brochure for cash, food, child care and health care programs (DHS-2920) (PDF).

Domestic Violence Information (DHS-3477) (PDF). See 0029.36 (Domestic Violence Brochure).

Do you have a disability? (DHS-4133) (PDF). Also see 0003.09.03 (Clients Rights - Civil Rights).


The following may also be included in the application packet or handed out at the interview as appropriate:

Household Report Form (DHS-2120) (PDF), Combined Six-Month Report (CSR) (DHS-5576) (PDF), or Change Report Form (DHS-2402) (PDF). See 0007 (Reporting), 0007.12 (Agency Responsibilities for Client Reporting), 0007.15 (Unscheduled Reporting of Changes - Cash), 0007.15.03 (Unscheduled Reporting of Changes - SNAP).

Authorization for Release of Information About Residence and Shelter Expenses (DHS-2952) (PDF), if appropriate. See 0010.18 (Mandatory Verifications).

Application for Social Security number (SS-5), if needed. See 0010.18.03 (Verifying Social Security Numbers), 0012.03 (Providing/Applying for an SSN).



ApplyMN applicants have access via a link to the Program information brochure for cash, food, child care and health care programs (DHS-2920) (PDF) and Do you have a disability? (DHS-4133) (PDF). The following forms are disclosures all cash and/or SNAP ApplyMN applicants must review and agree to by checking a box in front of the form before the ApplyMN application may be submitted:

Notice of Privacy Practices (DHS-3979) (PDF).

Client Responsibilities and Rights (DHS-4163) (PDF).

Authorization for Sharing Information and Assignment of Benefits.

Notice About Income and Eligibility Verification System and Work Reporting System (DHS-2759) (PDF).

Important Information (DHS-3353) (PDF).

Additional Important Information.

Penalty Warnings.

Employment Services Registration.

Domestic Violence Information (DHS-3477) (PDF).

Do you have a disability? (DHS-4133) (PDF).

How to Use Your Minnesota EBT Card (DHS-3315A) (PDF).

Civil Rights Notice.



Give the following forms/handouts based on the programs applied for and the circumstances in the case at the interview or send them out if the interview is conducted over the phone. Check the cross-referenced sections for procedures for each form/handout listed.


MFIP:

Reporting Responsibilities for MFIP Households (DHS-2647) (PDF). See 0007.12 (Agency Responsibilities for Client Reporting).

In cases where there is at least 1 non-custodial parent:

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Understanding Child Support - A Handbook for Parents (DHS-3393) (PDF).

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Referral to Support and Collections (DHS-3163B) (PDF). (This is in addition to the Combined Application Form or ApplyMN application, for EACH non-custodial parent). See 0012.21.03 (Support From Non-Custodial Parents).

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Cooperation with Child Support Enforcement (DHS-2338) (PDF). See 0012.21.06 (Child Support Good Cause Exemptions).

NOTE: This does not apply to a married parent who is out of the home on military duty when there is no breakdown in the marital relationship.

Notice of Requirement to Attend MFIP Overview (DHS-2929) (PDF). See 0028.09 (ES Overview/SNAP E&T Orientation).

If there is a custodial parent under 20, the Notice of Requirement to Attend School (DHS-2961) (PDF) and Graduate to Independence - MFIP Teen Parent Informational Brochure (DHS-2887) (PDF). If there is a custodial parent under age 18, the MFIP for Minor Caregivers (DHS-3238) (PDF) brochure. See 0012.06 (Requirements for Caregivers Under 20), 0028.06.03 (Who Must Participate in Empl. Services/SNAP E&T), 0028.12 (Education Requirements).

Family Violence Referral (DHS-3323) (PDF) and Domestic Violence Information (DHS-3477) (PDF).

If a non-parental caregiver applies, MFIP Child Only Assistance (DHS-5561) (PDF).

For all applicants, How to Use Your Minnesota EBT Card (DHS-3315A) (PDF).



DWP:

Follow MFIP, EXCEPT do not give the Notice of Requirement to Attend MFIP Overview (DHS-2929) (PDF) to the applicants. Instead, give the applicant the Minnesota’s Diversionary Work Program-DWP (DHS-4034) (PDF).


SNAP:

Supplemental Nutrition Assistance Program Reporting Responsibilities (DHS-2625) (PDF). See 0007.12 (Agency Responsibilities for Client Reporting).

If you know there is student income, the Financial Aid Information Form (DHS-2646) (PDF). See 0010.18.30 (Verifying Student Income and Expenses).

For all applicants, the Facts on Voluntarily Quitting Your Job If You Are on the Supplemental Nutrition Assistance Program (SNAP) (DHS-2707) (PDF). See 0028.30.09 (Refusing or Terminating Employment).

For all applicants, How to Use Your Minnesota EBT Card (DHS-3315A) (PDF).

For all applicants, Work registration notice (DHS-7635) (PDF).



MSA, GA, GRH:

SSI Interim Assistance Authorization (DHS-1795) (PDF) and/or Interim Assistance Agreement (DHS-1795A) (PDF), if appropriate. See 0012.12 (Applying for Other Benefits), 0012.12.03 (Interim Assistance Agreements).

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