- Receiving or applying for Unemployment Insurance (UI) and are cooperating with the work requirements. This form reports the verified hours and is adapted for use by unlicensed individuals registered to perform electrical work. Use the Verification Request Form (DHS-2919) (PDF) to request needed verification. in SNAP deletes to verify disability exemption from work registration. Verify at the point of employment termination for participants, and for any employment terminated within 60 days of application for applicants. ET Please seek professional legal advice if you are not sure this is the correct form for your situation. BT in general provisions deletes to verify self-employment expenses if applicable. CASES, 0022.09 - WHEN TO SWITCH BUDGET CYCLES - CASH, 0022.09.03 - WHEN TO SWITCH BUDGET CYCLES - SNAP, 0022.12 - HOW TO CALC. 1 1 7.96 7 re For more information, see 0028.30.09 (Refusing or Terminating Employment). See 0010.18.06 (Verifying Disability/Incapacity - SNAP). - This form is used to designate an authorized representative of your choosing who can communicate with Economic Assistance. 1300.0170 STOP WORK ORDER. << These forms do not need to be verbally reviewed during the interview. The verification requirements are as follows: 0010.18.06 (Verifying Disability/Incapacity - SNAP). EMC - A person subject to and complying with any Employment Services requirement for MFIP and/or DWP. n See 0011.24 (Time-limited SNAP Recipients). in general provisions updates the name and hyperlink for the Verification Request Form (DHS-2919). x]K$ 0zb%Ynl!?$(_)UkggTRHTQ?[LIt_=?I}~J@NxO?3O~CJK? 5}X}t^ x{Jk? WORK VERIFICATION - Page 2. 0.749023 g /GS0 8 0 R /Tx BMC Household Report Form Case number: How to fill out this form: 1. The following list includes the most commonly requested forms. Immigration status, ONLY if the applicant reports a non-citizen status, including non-citizens, naturalized and derived citizen status. (4) Tj See 0010.15 (Verification - Inconsistent Information). If your child support, economic assistance (EA), or property tax paperwork involves a petition or claim to the Anoka County Attorney, those documents MUST be served on the County Attorney. - This form is used to request a Certificate of Clearance when the property was transferred using a Transfer on Death Deed. 3. The verification requirements are as follows: 0.749023 g << n OF MINOR CRGVR, 0016.18.01 - 200 PERCENT OF FEDERAL POVERTY GUIDELINES, 0016.21 - INCOME OF SPONSORS OF IMMIGRANTS WITH I-134, 0016.21.03 - INCOME OF SPONSORS OF LPRS WITH I-864, 0016.27 - INCOME FROM SPOUSES WHO CHOOSE NOT TO APPLY, 0016.33 - INCOME OF INELIGIBLE NON-CITIZENS, 0016.39 - INCOME OF TIME-LIMITED RECIPIENTS, 0017.03 - AVAILABLE OR UNAVAILABLE INCOME, 0017.09 - CONVERTING INCOME TO MONTHLY AMOUNTS, 0017.12 - DETERMINING IF INCOME IS EARNED OR UNEARNED, 0017.15.03 - CHILD AND SPOUSAL SUPPORT INCOME, 0017.15.12 - INFREQUENT, IRREGULAR INCOME, 0017.15.15 - INCOME OF MINOR CHILD/CAREGIVER UNDER 20, 0017.15.18 - EMPLOYMENT, TRAINING, AND NATIONAL SERVICE INCOME, 0017.15.33.03 - SELF-EMPLOYMENT, CONVERT INC. TO MONTHLY AMT, 0017.15.33.24 - SELF-EMPLOYMENT INCOME FROM FARMING, 0017.15.33.27 - SELF-EMPLOYMENT INCOME FROM ROOMER/BOARDER, 0017.15.33.30 - SELF-EMPLOYMENT INCOME FROM RENTAL PROPERTY, 0017.15.36 - STUDENT FINANCIAL AID INCOME, 0017.15.36.03 - WHEN TO BUDGET STUDENT FINANCIAL AID, 0017.15.36.06 - IDENTIFYING TITLE IV OR FEDERAL STUDENT AID, 0017.15.36.09 - STUDENT FINANCIAL AID DEDUCTIONS, 0017.15.42 - INTEREST AND DIVIDEND INCOME, 0017.15.45.03 - HOW TO DETERMINE GROSS RSDI, 0017.15.48 - DISPLACED HOMEMAKER PROGRAM INCOME, 0017.15.51 - PAYMENTS RESULTING FROM DISASTER DECLARATION, 0017.15.54 - CAPITAL GAINS AND LOSSES AS INCOME, 0017.15.57 - PAYMENTS TO PERSECUTION VICTIMS, 0017.15.63 - RELATIVE CUSTODY ASSISTANCE GRANTS, 0017.15.78 - NATIONAL AND COMMUNITY SERVICE PROGRAMS, 0017.15.84 - CONTRACTS FOR DEED AS INCOME, 0018.06.06 - PLAN TO ACHIEVE SELF-SUPPORT (PASS), 0018.12.03 - ALLOWABLE SNAP MEDICAL EXPENSES, 0018.15.03 - SHELTER DEDUCTION - HOME TEMPORARILY VACATED, 0018.33 - CHILD AND SPOUSAL SUPPORT DEDUCTIONS, 0018.39 - PRIOR AND OTHER INCOME REDUCTIONS, 0018.42 - INCOME UNAVAILABLE IN FIRST MONTH, 0019.03 - GROSS INCOME TEST - WHAT INCOME TO USE, 0019.09 - GIT FOR SEPARATE ELDERLY DISABLED UNITS, 0020.03 - PEOPLE EXEMPT FROM NET INCOME LIMITS, 0020.06 - CHOOSING THE ASSISTANCE STANDARD TABLE, 0022 - BUDGETING AND BENEFIT DETERMINATION, 0022.03 - HOW AND WHEN TO USE PROSPECTIVE BUDGETING, 0022.03.01 - PROSPECTIVE BUDGETING - PROGRAM PROVISIONS, 0022.03.01.03 - PROSPECTIVE BUDGETING - SNAP PROVISIONS, 0022.03.03 - INELIGIBILITY IN A PROSPECTIVE MONTH - CASH, 0022.03.04 - INELIGIBILITY IN A PROSPECTIVE MONTH - SNAP, 0022.06 - HOW AND WHEN TO USE RETROSPECTIVE BUDGETING, 0022.06.03 - WHEN NOT TO BUDGET INCOME IN RETRO. l(i`_Vh5F,mXB7sJK~A."ak&MaWtyB\"#upI7HD6 .Qpfv \#ba=Jzc0%FFA(=Z(pK4V:pT"#nQ $F_Mq~$\b7 .QpQ $FF#Lzup! Q Verify additional eligibility factors required by each program as noted in the specific program provisions in 0004.12 (Verification Requirements for Emergency Aid), 0010.18.01 (Mandatory Verifications - Cash Assistance), 0010.18.02 (Mandatory Verifications - SNAP). 0 0 9.96 9 re 0 0 9.96 9 re SNAP: n In the first, the county agency received a stop - work verification on 4/13. EDAK 0058B Start and Stop Verification . Share your form with others Send it via email, link, or fax. To learn more about what might be personally identifiable information . Removed WB. > Fill out and return this form or your benefits may be late or stop. AREP Authorization form for SNAP, CASH, Medical (DOC), DHS 2243 Authorization for Release of Information about Assets, DHS 2952 Authorization for Release of Information About Residence and Shelter Expenses, DHS 3549 General Consent/Authorization for Release of Information (PDF), DHS 7823 Authorization to Obtain Information from AVS, DHS-2146 Authorization for Release of Employment Information, GEN 335 General Assistance Advanced Age Form, DHS 5893 Application for Certificate of Clearance for Medical Assistance Claim - Transfer on Death Deed (PDF), DHS 6165A Application for Certificate of Clearance for Medical Assistance Claims - Decree of Descent (PDF), DHS 3543 Request for Payment of Long Term Care Services, Minnesota Department of Human Services Website, Supplemental Nutrition Assistance Program, Medical Assistance Certificate of Clearance, Medical Assistance Claim/Probate Payments. 0000019329 00000 n 7V,%2EPEr_:b9~*x8|s.R&"WN,I# /|!(C4YhB##v4 4kec$%:E>E7 ,)`) %bi,rKh,a% yi z.3~@m&wWs3)/Rn%p 0000020677 00000 n @ @3Nd&` ` xP /Tx BMC Work verification is what employers conduct to see the work history and eligibility of both current and potential employees. endstream endobj 435 0 obj <>/Subtype/Form/Type/XObject>>stream The participant's last day of employment was 01/13 and received the last check 1/13. EDAK 0058BEmployment Start and Stop Verification Authorization form allowing release of employment information required for the determination of eligibility for assistance.EDAK 3239Taxi/Limo Driver Income and Expense ReportReport used by participants who are self-employed to report income and expenses each month. When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. 2 36 endstream endobj 422 0 obj <>/Subtype/Form/Type/XObject>>stream If no other form of verification is available or if the client chooses to use a form to verify residence or shelter expenses, you may use the Authorization for Release of Information About Residence and . MFIP, DWP: 0.749023 g This program was suspended 12/1/14. Q q endstream endobj 431 0 obj <>/Subtype/Form/Type/XObject>>stream Date and reason of employment termination, and date last paid. endstream endobj 442 0 obj <>/Subtype/Form/Type/XObject>>stream Follow the step-by-step instructions below to design your hennepin county household report form: Select the document you want to sign and click Upload. <1b285431b6d97f0b3d25c629171a4448>] See 0017.15.15 (Income of Minor Child/Caregiver Under 20). n RESPONSIBILITIES, 0028.03.01 - COUNTY AND TRIBAL NATION SNAP E&T RESPONSIBILITIES, 0028.03.02 - ES PROVIDER RESPONSIBILITIES - SNAP E&T, 0028.03.03 - EMPLOYMENT SERVICES/SNAP E&T REQUIRED COMPONENTS, 0028.03.06 - DETERMINING SNAP PRINCIPAL WAGE EARNER, 0028.03.09 - REPORTING CHANGES TO JOB COUNSELOR, 0028.06.02 - UNIVERSAL PARTICIPATION PROVISIONS, 0028.06.03 - WHO MUST PARTICIPATE IN EMPL. Enter your official identification and contact details. When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. Do not verify earned income of a child age 6 or older who has verified they are enrolled in school full-time in elementary, secondary, or GED. For more information about running SAVE, see 0010.18.11.03 (Systematic Alien Verification (SAVE)). - Medically certified as pregnant. DHS 3336-ENG Self-Employment Report FormReport used by participants who are self-employed to report income and expenses each month. Set yourself up for success and utilize the online library to download samples and turn them into . endstream endobj 433 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj startxref Please enable scripts and reload this page. 2.7962 2.7525 Td Follow general provisions. endstream endobj 425 0 obj <>/Subtype/Form/Type/XObject>>stream ET /Resources 5 0 R MSA, GA, GRH: ^ey$>PzVjP~64$b*a`?H"4{p1 j X %PDF-1.6 % EMC Accessibility|Privacy|Open Government| Copyright document.write(new Date().getFullYear()); Application for payment of long-term care services, Authorization to obtain or release information/records, Child care assistance program (CCAP) Change Report, Combined annual renewal for certain populations, Minnesota health care programs (MHCP) Application for certain populations, Minnesota health care programs (MHCP) Renewal for people receiving long-term care services, MNsure Application for health coverage and help paying costs. GEN 335 General Assistance Advanced Age Form - This form is used to verify a person meets the advanced age guidelines for General Assistance. Please seek professional legal advice if you are not sure this is the correct form for your situation. It also adds appropriate cross-references. CASES, 0022.09 - WHEN TO SWITCH BUDGET CYCLES - CASH, 0022.09.03 - WHEN TO SWITCH BUDGET CYCLES - SNAP, 0022.12 - HOW TO CALC. 0 0 11.04 11.4 re Q 2023 Minnesota Department of Human Services, 0010.18.03 (Verifying Social Security Numbers), 0010.18.11.03 (Systematic Alien Verification (SAVE)), 0010.18.11 (Verifying Citizenship and Immigration Status), 0011.03.27 (Undocumented and Non-Immigrant People). /ZaDb 5.1626 Tf . endobj Verifiers love Truework because it's never been easier and more streamlined to verify an employee, learn more here. If DHS does not provide a form for a given purpose, the county or tribe may develop their own form; however, the form must meet the requirements in TEMP Manual TE12.02.01 (County Designed Forms). EMC /Tx BMC DHS 8107 Household Update Form - This form is for people currently open on Cash or SNAP programs that need to complete a review following the COVID emergency. 0 0 9.96 8.88 re 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. "Verify MN" is another name for the area within SOLQ that provides Social Security information. Decide on what kind of signature to create. 0026.06 - NOTICE - APPROVAL OF APPLICATION OR RECERT. in SNAP under sub-heading ABAWDs in the 3rd bullet adds and deletes language and cross-references for clarity. Non-Mandatory Verifications endobj BT 0000021969 00000 n /ZaDb 5.1626 Tf Unit Member Information. 0000006411 00000 n Social Security numbers of all people applying for assistance. 2 0 obj You may also mail any paperwork to our mailing address listed on this page. EMC << Stop Work Verification accap.org Details File Format PDF Size: 358 KB Download What Is a Work Verification Form? For more information on work rules and exemptions, see 0011.24 (Time-limited Recipients), 0028.06.12 (Who Is Exempt From SNAP Work Registration), 0028.07 (General Work Rules for SNAP). Applying for MNsure Helpful Information - This document gives you step by step instructions for completing an online MNsure application. name, student ID number, date of birth), we encourage you to submit the completed form by mail or in person. /StructTreeRoot 32 0 R Registered unlicensed individuals, as part of renewing their registration, must provide verification of their employment by a licensed contractor or registered employer during the registration period. For budgeting information see 0022.03.01.03 (Prospective Budgeting - SNAP Provisions). n The advanced tools of the editor will direct you through the editable PDF template. EMC There are three variants; a typed, drawn or uploaded signature. .x\m|W8p~Z3SlHI`tQ.T$[}62Glp6p6p68eV6a-{. endstream endobj 417 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 4.9716 TL 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. If you are submitting a PDF form that contains personally identifiable information (i.e. DHS 3543 Request for Payment of Long Term Care Services - This form is for people currently open on Medical Assistance (MA) that need waiver services, assisted living services, or nursing home services paid. Enter your official contact and identification details. endstream endobj 436 0 obj <>/Subtype/Form/Type/XObject>>stream Answer Yes or No to each question. 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. f 1 1 7.96 7 re q /F6 14 0 R 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. 4.9716 TL 4.8399 TL Click Done after twice-checking all the data. hbbd```b``"wH`j In addition it is allowable to use SOLQ-I as verification of identity. If the building official finds any work regulated by the code being performed in a manner contrary to the provisions of the code or in a dangerous or unsafe manner, the building official is authorized to issue a stop work order or a notice or order pursuant to part 1300.0110, subpart 4.. 3) Workforce and Utilization Analysis. MFIP, DWP, MSA, GA, GRH: Document this verbal statement in CASE/NOTEs. /Outlines 33 0 R 0026.30 - NOTICE, DISQUALIFICATION OF AUTHORIZED REP. 0026.33 - NOTICE, DENYING GOOD CAUSE FOR IV-D NON-COOP, 0026.39 - NOTICE OF OVERPAYMENT AND RECOUPMENT, 0026.42 - NOTICE OF INCOMPLETE OR MISSING REPORT FORM, 0026.51 - NOTICES - CHEMICAL USE ASSESSMENT, 0027.12.03 - APPEAL HEARING EXPENSE REIMBURSEMENT, 0028.03 - COUNTY AGENCY EMPL. Go to the Department of Human Services' (DHS) e-Docs site and search for the form by entering the DHS form number. 0000024944 00000 n 0000005978 00000 n ET H "H`DH.~ "9H0:@X,r,bb{5 I& |##(9$L @/b /Size 38 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). RESPONSIBILITIES, 0028.03.01 - COUNTY AND TRIBAL NATION SNAP E&T RESPONSIBILITIES, 0028.03.02 - ES PROVIDER RESPONSIBILITIES - SNAP E&T, 0028.03.03 - EMPLOYMENT SERVICES/SNAP E&T REQUIRED COMPONENTS, 0028.03.06 - DETERMINING SNAP PRINCIPAL WAGE EARNER, 0028.03.09 - REPORTING CHANGES TO JOB COUNSELOR, 0028.06.02 - UNIVERSAL PARTICIPATION PROVISIONS, 0028.06.03 - WHO MUST PARTICIPATE IN EMPL. 0000019554 00000 n 0000001524 00000 n This form is for clients who have a six-month renewal for health care eligibility or a six-month report for the Supplemental Nutrition Assistance Program (SNAP) due. 2.2948 3.1191 Td July 2, 2019 General Phone 651-554-5611 . f 1 1 9.04 9.4 re 0 0 9.96 9 re 0000001233 00000 n 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. Unless questionable, a verbal statement from the client meets the verification requirement. DHS-2146 Authorization for Release of Employment Information - This form is completed by an employer to verify employment start, stop, or wage change. 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. /Contents 6 0 R >> 0000021946 00000 n endstream endobj 428 0 obj <>/Subtype/Form/Type/XObject>>stream % << Identity of the applicant and the authorized representative if the authorized representative is applying for the applicant. for additional MFIP provisions relating to citizenship and immigration status. Do not verify earned income of a caregiver under 20 who has verified they are enrolled at least half-time in an approved school. breaks MFIP, DWP into their own provisions and adds when not to request verification of school attendance. Verify the exemptions listed below at application time and/or when a change occurs. QD~bJmb}`!lsUJ3>11g.x z;eY#\. Counties and tribes must use forms developed by DHS for the purposes of informing and advising clients about their rights and responsibilities, the status of an application or recertification, and ongoing eligibility for assistance. {e.2J0+z0.lG%12 EMC W in general provisions in the 2nd bullet deletes reference to self-employment deductions and adds to verify self-employment expenses if applicable. 0028.06.12 (Who Is Exempt From SNAP Work Registration). In the first, the county agency received a stop - work verification on 4/13. (4) Tj DHS 5776-ENG Combined Six-Month Report Form for Medical Assistance and SNAPThis form is for clients who have a six-month renewal for health care eligibility or a six-month report for the Supplemental Nutrition Assistance Program (SNAP) due. 0000021550 00000 n FAX: 612-321-3488. BENEFIT LEVEL - MFIP/DWP/GA, 0022.12.01 - HOW TO CALCULATE BENEFIT LEVEL - SNAP/MSA/GRH, 0022.12.02 - BEGINNING DATE OF ELIGIBILITY, 0022.15.03 - BUDGETING LUMP SUMS IN A PROSPECTIVE MONTH, 0022.15.06 - BUDGETING LUMP SUMS IN A RETROSPECTIVE MONTH, 0022.18.03 - OVERPAYMENTS RELATING TO SUSPENDED CASES, 0022.21 - INCOME OVERPAYMENT RELATING TO BUDGET CYCLE, 0022.24 - UNCLE HARRY FOOD SUPPORT BENEFITS, 0023.09 - HOUSEHOLD FURNISHINGS AND APPLIANCES, 0024.03 - WHEN BENEFITS ARE PAID - MFIP/DWP, 0024.03.03 - WHEN BENEFITS ARE PAID - SNAP/MSA/GA/GRH, 0024.04.03.03 - BENEFIT DELIVERY METHODS--PROGRAM PROVISIONS, 0024.04.04 - CHANGES IN AUTOMATIC BENEFIT DELIVERY METHOD, 0024.06 - PROVISIONS FOR REPLACING BENEFITS, 0024.06.03 - SITUATIONS REQUIRING SNAP BENEFIT REPLACEMENT, 0024.06.03.03 - REPLACING SNAP STOLEN/LOST BEFORE RECEIPT, 0024.06.03.15 - REPLACING FOOD DESTROYED IN A DISASTER, 0024.06.03.18 - REPLACING DAMAGED SNAP CASH-OUT WARRANTS, 0024.09.01 - PROTECTIVE AND VENDOR PAYMENTS-SNAP/MSA/GA/GRH, 0024.09.09 - DISCONTINUING PROTECTIVE AND VENDOR PAYMENTS, 0024.09.12 - PAYMENTS AFTER CHEMICAL USE ASSESSMENT, 0024.12 - ISSUING AND REPLACING IDENTIFICATION CARDS, 0025.03 - DETERMINING INCORRECT PAYMENT AMOUNTS, 0025.06 - MAINTAINING RECORDS OF INCORRECT PAYMENTS, 0025.09.03 - WHERE TO SEND CORRECTIVE PAYMENTS, 0025.12.03 - OVERPAYMENTS EXEMPT FROM RECOVERY, 0025.12.03.03 - SUSPENDING OR TERMINATING RECOVERY, 0025.12.03.09 - CLAIM COMPROMISE & TERMINATION, 0025.12.06 - REPAYING OVERPAYMENTS - PARTICIPANTS, 0025.12.09 - REPAYING OVERPAYMENTS - NON-PARTICIPANTS, 0025.12.12 - ACTION ON OVERPAYMENTS - TIME LIMITS, 0025.15 - ORDER OF RECOVERY - PARTICIPANTS, 0025.18 - ORDER OF RECOVERY - NON-PARTICIPANTS, 0025.21.03 - OVERPAYMENT REPAYMENT AGREEMENT, 0025.24 - FRAUDULENTLY OBTAINING PUBLIC ASSISTANCE, 0025.24.03 - RECOVERING FRAUDULENTLY OBTAINED ASSISTANCE, 0025.24.06.03 - ADMINISTRATIVE DISQUALIFICATION HEARING, 0025.24.07 - DISQUALIFICATION FOR ILLEGAL USE OF SNAP, 0025.24.08 - SNAP ELECTRONIC DISQUALIFIED RECIPIENT SYSTEM, 0025.30 - FINANCIAL RESPONSIBILITY, PEOPLE NOT IN HOME, 0025.30.03 - CONTRIBUTIONS FROM PARENTS NOT IN HOME. f'G!&MCa a@e9\$!E!@m`R`IF\n@ f f endstream endobj 416 0 obj <>/Subtype/Form/Type/XObject>>stream 0000006624 00000 n H$ endstream endobj 430 0 obj <>/Subtype/Form/Type/XObject>>stream AE>-l`.X~JpRMcOxr69_vW61# U3U]30 n0 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). Fill the blank areas; involved parties names, addresses and phone numbers etc. DHS 2402-ENG Change Report FormReporting form used by clients to report income, asset, and circumstance changes usually on a non-scheduled basis. /Type /Page DHS 3163B Referral to Support and CollectionsThis form is used by MinnesotaCare, Medical Assistance and Child Care Assistance recipients for referral to the local child support agency for the purpose of establishing paternity or child support enforcement services.