Please note: this is not the most recent revision of this document.

All links to other documents have been disabled, as they may be out of date. This document is presented for historical purposes only.

Combined Manual


FORMS/HANDOUTS FOR APPLICANTS

ISSUE DATE: 08/2014
Revision #19

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).

A cover letter including the following:

-

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

-

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

-

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).

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

Do you have a disability? (DHS-4133). 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), Combined Six-Month Report (CSR) (DHS-5576), or Change Report Form (DHS-2402). 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), 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).

Notice of Privacy Practices (DHS-3979). See 0003.09.06 (Client Rights - Data Privacy Practices).

Work Benefit Program Information (DHS-5837).

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



ApplyMN applicants have access via a link to the Program information brochure for cash, food, child care and health care programs (DHS-2920) and Do you have a disability? (DHS-4133). 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).

Client Responsibilities and Rights (DHS-4163).

Authorization for Sharing Information and Medical Assignment of Benefits.

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

Penalty Warnings.

Employment Services Registration.

Domestic Violence Information (DHS-3477).



Give the following forms/handouts based on the programs applied for and the circumstances in the case. Check the cross-referenced sections for procedures for each form/handout listed.


MFIP:

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

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

-

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

-

Referral to Support and Collections (DHS-3163B). (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).

-

Cooperation with Child Support Enforcement (DHS-2338). 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). 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) and Graduate to Independence - MFIP Teen Parent Informational Brochure (DHS-2887). If there is a custodial parent under age 18, the MFIP for Minor Caregivers (DHS-3238) 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) and Domestic Violence Information (DHS-3477).

Important Information about the MFIP Family CAP (DHS-4198).

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



WB:

No provisions.


DWP:

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


SNAP:

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

If you know there is student income, the Financial Aid Information Form (DHS-2646). 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). See 0028.30.09 (Refusing or Terminating Employment).



MSA:

SSI Interim Assistance Authorization (DHS-1795).

Interim Assistance Agreement (DHS-1795A), do not use for SSI. See 0012.12 (Applying for Other Benefits), 0012.12.03 (Interim Assistance Agreements).



GA:

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

.

SSI Interim Assistance Authorization (DHS-1795), Interim Assistance Agreement (DHS-1795A) (Do not use for SSI), if appropriate. See 0012.12 (Applying for Other Benefits), 0012.12.03 (Interim Assistance Agreements).



GRH:

For participants who are aged, blind, or disabled and over 18, follow MSA. For all other participants, follow GA.


© 2018 Minnesota Department of Human Services
Updated: 8/1/14 6:45 AM