You must verify that the client is cooperating with the work requirements of this program. 2.7962 2.7525 Td Unless questionable, a verbal statement from the client meets the verification requirement. 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. hbbd```b``"wH`j 0000006411 00000 n endstream endobj 426 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream If the injury/disability is temporary, new verification will be needed if the injury/disability extends past the anticipated end date. See all sections of 0016 (Income from People Not in the Unit), 0017 (Determining Gross Income) for more information. 0000007179 00000 n Document in MAXIS CASE/NOTEs the identity information obtained from SOLQ as a "Verify MN interface". Paperwork can also be submitted by email to EADocs@co.anoka.mn.us. Do not verify earned income of a child under age 6. 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). The advanced tools of the editor will guide you through the editable PDF template. /S 38 f If the exemptions are not listed below, they do not need to be verified unless questionable. in general provisions updates the name and hyperlink for the Verification Request Form (DHS-2919). (4) Tj - This form is used to designate an authorized representative of your choosing who can communicate with Economic Assistance. in general provisions in the 2nd paragraph in the 3rd bullet adds and deletes information. endstream endobj 440 0 obj <>/Subtype/Form/Type/XObject>>stream /Tx BMC << endstream endobj 437 0 obj <>/Subtype/Form/Type/XObject>>stream Human services xD(@, When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. 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. 2.7962 2.7525 Td in SNAP deletes to verify disability exemption from work registration. Select the link to download, print or save to your computer. endstream endobj 423 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Counted TLR months used in another state. GEN 335 General Assistance Advanced Age Form - This form is used to verify a person meets the advanced age guidelines for General Assistance. ET W /ZaDb 5.0258 Tf Get the documents for Minnesota Employment verification you need with an user-interface developed for straightforwardness and organization. Show details How it works Open the mn employment verification and follow the instructions Easily sign the minnesota employment verification form with your finger q When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. 0000022117 00000 n DHS-4034-ENG Minnesota's Diversionary Work Program Applications/Reporting DHS-3550-ENG Minnesota Child Care Assistance Application DHS-5223-ENG MDHS Combined Application Form DHS-2120-ENG Household Report Form DHS-3336-ENG Self-Employment Report Form DHS-2402-ENG Change Report Form Consent/Release DHS-2114-ENG MDHS Request for Medical Opinion Removed WB. 37 0 obj in SNAP adds a cross-reference to 0028.30.09 (Refusing or Terminating Employment). Verify only counted income. >> The participant's last day of employment was 01/13 and received the last check 1/13. f %PDF-1.6 % . 0028.06.12 (Who Is Exempt From SNAP Work Registration). endstream endstream endobj 442 0 obj <>/Subtype/Form/Type/XObject>>stream /Type /Catalog 1 1 9.04 9.4 re Hennepin County 0026.12.12 - WHEN NOT TO GIVE ADDITIONAL NOTICE, 0026.12.15 - WHEN TO GIVE RETROACTIVE OR NO NOTICE, 0026.12.21 - VOLUNTARY REQUEST FOR CLOSURE NOTICE, 0026.15 - NOTICE OF DENIAL, TERMINATION, OR SUSPENSION, 0026.21 - NOTICE OF CHANGE IN ISSUANCE METHOD, 0026.24 - NOTICE OF RELATIVE CONTRIBUTION. DHS 3418-ENG Minnesota Health Care Programs Renewal FormThis is the annual renewal form for all of the Minnesota Health Care Programs except Minnesota Family Planning and Breast and Cervical Cancer. We would like to show you a description here but the site won't allow us. 4.9716 TL @4z$]aAhBK503Ix7$&xv;le|Jn+TjeP-4TS Z 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. 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.. EMC . << 0000006624 00000 n Truework allows you to complete employee, employment and income verifications faster. /ZaDb 5.1626 Tf n /F1 10 0 R 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. Verification is needed when a client is injured/incapacitated and the injury cannot be observed. q 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. q See 0007.03 (Monthly Reporting - Cash), 0007.03.02 (Six-Month Reporting), 0007.15 (Unscheduled Reporting of Changes - Cash), 0007.15.03 (Unscheduled Reporting of Changes - SNAP), 0009 (Recertification). Termination of Employment Verification - Section 8/236 Rev. endstream endobj 438 0 obj <>/Subtype/Form/Type/XObject>>stream Please see your child support/EA paperwork for service by mail directions regarding legal proceedings. 0000025773 00000 n ]J}5vZZc}s?W0\(+X DHS 6165A Application for Certificate of Clearance for Medical Assistance Claims - Decree of Descent (PDF)Opens a New Window. /Marked true 4.9716 TL /Tx BMC SERV. Residency in Minnesota, unless verification cannot be obtained because the people are homeless, migrant farmworkers, or newly arrived in Minnesota. 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. << stream SERV. Verification of participation is required every 12 months or when there is a change in the clients participation, whichever comes first. You must verify that the client is complying with Refugee Employment Services. Minnesota Employment Verification Form Use a minnesota employment verification template to make your document workflow more streamlined. Disability status may be need to be verified. H > BT n endstream endobj 417 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream (4) Tj Work verification form (DOC) MFIP exemption - caring for a child under the age of 12 months; State. EMC DHS 3418-ENG Minnesota Health Care Programs Renewal Form 481 0 obj <>/Filter/FlateDecode/ID[<6D1378B16692F9479C354AD2C049B183>]/Index[409 149]/Info 408 0 R/Length 206/Prev 521012/Root 410 0 R/Size 558/Type/XRef/W[1 3 1]>>stream 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. Stop Work Verification accap.org Details File Format PDF Size: 358 KB Download What Is a Work Verification Form? For more information about running SAVE, see 0010.18.11.03 (Systematic Alien Verification (SAVE)). 0000019554 00000 n DHS 2120-ENG Household Report Form for MFIP/DWPReporting form used by clients to report income, asset and circumstance changes usually on a scheduled basis. If there is not enough room on the form to answer a question, attach your own pages. DHS 2952 Authorization for Release of Information About Residence and Shelter Expenses - This form is used to allow a landlord or homeowner information about your shelter expense. endstream endobj 428 0 obj <>/Subtype/Form/Type/XObject>>stream MSA, GA, GRH: The following list includes the most commonly requested forms. hb``d``~4YAb,_w400q` 0K* `3.vbwH, ,870c``u@ {@U ,Mf1249 ,0e0Z0Pk 0ahcLwLo0`Nb: m13y e-L}~fd``: 7V,%2EPEr_:b9~*x8|s.R&"WN,I# /|!(C4YhB##v4 4kec$%:E>E7 ,)`) %bi,rKh,a% yi z.3~@m&wWs3)/Rn%p AREP Authorization form for SNAP, CASH, Medical (DOC)Opens a New Window. _ ! for additional MFIP provisions relating to citizenship and immigration status. 0000007708 00000 n CASES, 0022.09 - WHEN TO SWITCH BUDGET CYCLES - CASH, 0022.09.03 - WHEN TO SWITCH BUDGET CYCLES - SNAP, 0022.12 - HOW TO CALC. These forms do not need to be verbally reviewed during the interview. @4z$]aAhBK503Ix7$&xv;le|Jn+TjeP-4TS Z 3) Workforce and Utilization Analysis. In addition it is allowable to use SOLQ-I as verification of identity. (4) Tj West St. Paul, MN 55118-4765. endstream endobj 439 0 obj <>/Subtype/Form/Type/XObject>>stream H {e.2J0+z0.lG%12 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. See 0010.18.06 (Verifying Disability/Incapacity - SNAP). endobj You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank. GEN 262 Special Diets - This form is used to provide information regarding diets prescribed by a doctor. << /Tx BMC Q Employment and Earnings Statement. MFIP, DWP, MSA, GA, GRH: 0000005955 00000 n Do not verify earned income of a caregiver under 20 who has verified they are enrolled at least half-time in an approved school. This form reports the verified hours and is adapted for use by unlicensed individuals registered to perform electrical work. Verify at the point of employment termination for participants, and for any employment terminated within 60 days of application for applicants. Enter your official contact and identification details. Employment & Economic Assistance651-554-5611. EMC It also in the 4th paragraph adds tribe language. endstream endobj 414 0 obj <>/Subtype/Form/Type/XObject>>stream Enter your official identification and contact details. @~bJmmv6. X^'=sAb7:7f]l}`d1f7eB\w w= 0000021946 00000 n 4.9716 TL in SNAP adds that identity may be verified through a document, collateral contact or SOLQ-I. in SNAP adds in the last paragraph that unless questionable, a verbal statement from the client meets the school attendance verification requirement. If the injury/disability is temporary, new verification will be needed if the injury/disability extends past the anticipated end date. See 0010.18.06 (Verifying Disability/Incapacity SNAP). The advanced tools of the editor will direct you through the editable PDF template. <1b285431b6d97f0b3d25c629171a4448>] 0000001677 00000 n If the exemptions are not listed below, they do not need to be verified unless questionable. If there is student income, also give the Financial Aid Information Form (DHS-2646) (PDF). Items required to be verified at application, recertification and when changes occur are listed below. SERVICES/SNAP E&T, 0028.06.12 - WHO IS EXEMPT FROM SNAP WORK REGISTRATION, 0028.09 - ES OVERVIEW/SNAP E&T ORIENTATION, 0028.09.06 - EXEMPTIONS FROM ES OVERVIEW/SNAP E&T ORIENTATION, 0028.18 - GOOD CAUSE FOR NON-COMPLIANCE--MFIP/DWP, 0028.18.01 - MFIP GOOD CAUSE--CAREGIVERS UNDER 20, 0028.21 - GOOD CAUSE NON-COMPLIANCE - SNAP/MSA/GA/GRH, 0028.30 - SANCTIONS FOR FAILURE TO COMPLY - CASH, 0028.30.03 - PRE 60-MONTH TYPE/LENGTH OF ES SANCTIONS, 0028.30.04 - POST 60-MONTH EMPL. CASES, 0022.09 - WHEN TO SWITCH BUDGET CYCLES - CASH, 0022.09.03 - WHEN TO SWITCH BUDGET CYCLES - SNAP, 0022.12 - HOW TO CALC. for more information on counted months used in another state. Click Done after twice-checking all the data. n 0000021550 00000 n endstream endobj 415 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream endstream endobj 436 0 obj <>/Subtype/Form/Type/XObject>>stream 0 0 9.96 8.88 re There are three variants; a typed, drawn or uploaded signature. H, 0 0 Td /Pages 1 0 R See 0010.15 (Verification - Inconsistent Information). f The process is simple and automated, and most employees are verified within 24 hours. endobj 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. /Font << Q endstream endobj 427 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Household Report Form Case number: How to fill out this form: 1. 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 - MANDATORY VERIFICATIONS - SNAP, 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.
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