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KEEP THIS BOOKLET FOR YOUR RECORDS Assistance Application

Information Booklet
Welcome to the State of Michigan Department of Human Services (DHS)
We have programs to help you and/or your household (everyone living in your home) with food, medical care, child care, cash and emergencies. We can also tell you about other programs and resources that may help meet your needs. We look forward to helping you and your household. If you need help with reading, writing, hearing, etc., please tell us. If you need an interpreter, we will provide one or you may bring your own.

Steps to Assistance
- Apply online for assistance programs at www.michigan.gov/mibridges. You may bring, mail or fax your assistance application to the DHS ofﬁce in your area. You can ﬁnd the address and phone number to the ofﬁce in your area in your phone book under the state government section, or online at www.michigan.gov/dhs-countyofﬁces. 2 - Read this booklet and keep it. It tells you about our programs and has important information. When you sign the assistance application, you agree to the rules in this booklet. 3 - Answer the questions on the assistance application. We need your answers to decide what help you may receive. You can apply for all or some of our programs. 4 - For some programs we may need to ask for more information (proof). We will let you know what we need. 5 - We will send you a letter in the mail telling you if you are approved or denied. Keep this letter. It has important information including the name, phone number and email address of your DHS specialist. You have the right to apply for help today. The date DHS receives your assistance application or ﬁling form may affect the date your beneﬁts start. Exception: If you are applying for Supplemental Security Income and food assistance beneﬁts before being released from an institution, the ﬁling date for your beneﬁts will be the date you get out of the facility. If you cannot ﬁnish the whole assistance application today, you may either complete the ﬁling form (available at the end of this booklet or online at www.michigan.gov/dhs-forms) or you may turn in your incomplete assistance application. It must have your: • Name • Date of birth (not needed for food assistance) • Address (unless homeless) • Signature or your representative’s signature (someone ﬁling for you). Before you can be Services (DHS) will not discriminate against any individual or group application. Department of Human approved for help, you must complete the assistance because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS ofﬁce in your area. Department of Human Services (DHS) no discrimina contra ningún individuo o grupo a causa de su raza, religión, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, sexo, orientación sexual, identidad de sexo o expresión, creencias políticas o incapacidad. Si usted necesita ayuda para leer, escribir, oír, etc., bajo la Acta de Americanos con Incapacidades, usted está invitado a hacer saber sus necesidades a una oﬁcina de DHS en su área.

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Local ofﬁce address

DHS specialist name, phone number and email address

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 1

Timely Decisions
We must make timely decisions to approve or deny your application for assistance. Below are the program standards we follow: Program Symbols DHS Programs Standards 7 days 30 days 45 days 90 days 15 days 30 days 45 days 45 days 30 days 60 days 10 days Food Assistance (FAP) • Expedited (seven-day processing) ................................. • Food Assistance Program ............................................. Medical Assistance (MA) .................................................. • With a medical decision on disability .............................. • For pregnant women ...................................................... • Refugee Medical Assistance (RMA) ............................... Child Development and Care (CDC) ................................ Cash Assistance • Family Independence Program (FIP) ............................. • Refugee Cash Assistance (RCA) ................................... • State Disability Assistance (SDA)................................... State Emergency Relief (SER) .........................................

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Expedited Food Assistance Program (Seven-Day Processing)
Your household may qualify for seven-day processing of your food assistance application if: • If your household qualiﬁes for seven-day processing you must:

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You have less than $150 in monthly gross • Participate in an interview, and income and $100 or less in liquid assets • Provide proof of your identity, and (cash on hand, checking or savings accounts, • Complete the entire application form. savings certiﬁcates), or To continue receiving food assistance beneﬁts, Your combined gross income and liquid you will be asked to provide proof of other assets are less than your monthly rent and/or information (like income, residency, etc.). If you mortgage payment plus heat and utilities, or provide the proof when you apply, you may be You are a destitute* migrant or seasonal given a longer food assistance beneﬁt period. farmworker with $100 or less in liquid assets. * Destitute means that your income stopped before the date you applied, or your income has started but you expect to receive no more than $25 within the next 10 days.

Food Assistance Program (FAP) Interviews
Most FAP interviews are held by telephone. However, you may request an in-person interview. If you are also applying for cash assistance, you may be scheduled for an in-person interview.

We May Need Proof
For most programs, DHS will need proof of your household’s income. If you have proof, send or bring it with your assistance application. Some ways to prove income are:  Check stubs  Child support receipts  Social Security award letter  Self-employment records of income and expenses If we need proof, we will send you a list of what we need. For some programs, we MAY need proof of:  Age and/or identity  Immigration status  U.S. citizenship  Pregnancy  Current medical insurance card  School enrollment, anyone age 6-49  Income that recently started or stopped  Assets (for example, cash on hand, checking/ savings accounts, credit union accounts, etc.) If you need help getting proof, ask your DHS specialist.

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 2

TABLE OF CONTENTS
Programs Food Assistance Program (FAP) ..................................................................................................... 4 Adult Medical Program (AMP)......................................................................................................... 4 Resident County Hospitalization (RCH) .......................................................................................... 4 Medical Assistance (MA) ................................................................................................................. 5 Child Development And Care (CDC)............................................................................................... 6 Family Independence Program (FIP)/Refugee Cash Assistance (RCA) ......................................... 7 State Disability Assistance (SDA) ................................................................................................... 7 State Emergency Relief (SER)........................................................................................................ 8 Child Support Services.................................................................................................................... 8 Early On® ....................................................................................................................................... 8 Low Income Home Energy Assistance Program (LIHEAP)............................................................. 9 - Home Heating Credit (HHC) ........................................................................................... 9 - Weatherization Assistance Program (WAP) ................................................................... 9 Things You Must Do Give Correct Information and Report Changes (All Programs) ....................................................... 9 Repay Extra Beneﬁts (All Programs) ............................................................................................ 10 Provide Social Security Numbers (Most Programs) ...................................................................... 10 Pursue Other Beneﬁts (Most Programs) ....................................................................................... 10 Immunize Children Under Age Six - Get Shots (FIP) .................................................................... 10 Child Support Actions (Most Programs) ........................................................................................ 10 Follow Work Rules and Penalties (FIP or RCA and FAP) ............................................................. 11 Work Rule Deferrals and Good Cause (FIP or RCA and FAP) ..................................................... 12 Important Things To Know Penalties, Intentional Program Violation Or Fraud (FAP, FIP, SDA, CDC) .................................... 13 General Complaints ...................................................................................................................... 14 Hearing Rights .............................................................................................................................. 14 If You Think We Discriminate ........................................................................................................ 14 Race and Ethnicity ........................................................................................................................ 14 Citizens and Non-Citizens/Social Security Numbers .................................................................... 14 Welfare Fraud ............................................................................................................................... 15 Persons With Disabilities............................................................................................................... 15 Domestic Violence ........................................................................................................................ 15 If You Receive Tribal Beneﬁts ....................................................................................................... 15 Bridge Card ................................................................................................................................... 15 Repay Agreements Recovery of Medical Costs (MA, AMP) ......................................................................................... 15 Estate Recovery (MA-Long Term Care) ........................................................................................ 16 Lump Sums and Accumulated Beneﬁts (SDA and State-Funded FIP) ......................................... 16 Information About Your Household That Will Be Shared Information DHS Will Get From Others ......................................................................................... 16 Information DHS Will Give To Others ............................................................................................ 17 Coordination of Health Care ......................................................................................................... 17 Web Site References ........................................................................................................................ 17 Publications ...................................................................................................................................... 18 Filing Form ........................................................................................................................................ 19
Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 3

Programs
Food Assistance Program (FAP)
FAP provides beneﬁts that can be used to buy food (including seeds and plants to grow your own food) for your household. People of all ages may receive FAP. You may be eligible for FAP beneﬁts if you have either: • Low/no income. • Low/no assets. Income FAP eligibility and beneﬁt amounts are based on your household income and the number of people in your FAP group. When we look at your income, we make some deductions and consider allowable expenses (see below). Deductions from countable income: • 20 percent of earned income, and • A standard deduction based on the number of people in your FAP group. Allowable expenses: • Medical expenses over $35 a month not paid by a third party (for persons age 60 or older, veteran with a disability or a person with a disability). • • •

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Some housing and utility costs. Some child care costs and costs for care of persons with disabilities. Court-ordered child support paid to a nonhousehold member.

I understand that failure to report or verify any listed expenses will be seen as a statement by me that I do not want to receive a deduction for the unreported or unveriﬁed expenses. Veriﬁcations must be received within 10 days. If your heat is included in your rent, and you receive or expect to receive the Home Heating Credit, tell us on your assistance application. If you do not tell us about the credit, we will assume you do not want to receive a deduction for heat expenses. Program requirements: • • • Follow Work Rules and Penalties - see page 11. Child Support Services - see page 8. Child Support Actions - see pages 10, 11.

Adult Medical Program (AMP)
AMP helps pay for basic medical care for lowincome adults. Additional services may be available through a county health plan. You may be eligible for AMP if you are not eligible for Medicaid and you have: • Cash assets of $3,000 or less, and • Low income.

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Limited enrollment. We limit the number of people who can receive AMP in Michigan. When we reach the limit, we must deny your application, even if you meet the eligibility rules.

Resident County Hospitalization (RCH)
RCH helps individuals with low income who cannot pay for medical care when they are in the hospital overnight. You may be eligible for RCH if you: • • Have low income, and Are not eligible for Medicaid, and • Do not have other insurance to pay for inpatient hospital care.

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Each county sets its own ﬁnancial eligibility rules. For more information, contact the DHS ofﬁce in your area.

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 4

Medical Assistance (MA)
We have many MA programs for children, families and adults. Our goal is to make essential health care services, including Medicare premiums, available to people who cannot pay for them. Asset and income rules are different for different MA groups and programs. If you have other health insurance or coverage, you may still qualify. Your medical providers (doctors, hospitals, etc.) will have to bill the other insurance ﬁrst. You may be eligible for MA when you are: • A Supplemental Security Income (SSI) recipient. • Financially eligible, and: – Under age 21. – Age 65 or older. – Pregnant. – Blind or disabled. – A parent or close relative living with and acting as a parent for a child. – Refugee in the country less than 8 months. Assets are counted for some programs. Many children and pregnant women can get MA with no limit on assets. For persons age 19 and older (except for pregnant women), your assets must be below the limit for at least one day in the month that you ask for medical help. You must provide proof of your assets. If you are over the asset limit, you may be able to get help if you use the excess assets to pay bills. We may ask for proof of how you used excess assets. Income. Each Medicaid program has income limits. The limits depend on the program, who lives with you, and where you live. If your income is over the limit: • You may still get help if you give us proof of your medical expenses. • We may give you MA with a deductible. Getting your medical bills paid. Choose a provider who will accept Medicaid – not all providers do. If you are applying for MA, tell your medical providers (doctors, hospital, pharmacy, etc.) before you receive any medical services.

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If you are eligible for help, you will be sent a mihealth card. Each eligible person in your family will get his/her own card. Do not throw this card away. If your mihealth card is lost, stolen or damaged, call: 1-800-642-3195. Give your medical providers a copy of your mihealth card as soon as you receive it. This information is needed to bill Medicaid for your covered services. Your providers must bill Medicaid within 12 months from the date you received their services, even if you gave the bill to DHS. If your providers miss the 12-month limit, the bill may not be paid unless the delay is because you asked for a hearing to get MA. DHS determines your eligibility but the Department of Community Health (MDCH) pays for the services covered by Medicaid. MDCH may refund your money if you pay for an MA-covered service between the date your hearing request is received by DHS after an incorrect denial of MA and the date your MA is approved as a result of your hearing. Help for past months. We may approve MA for up to three months before the month you applied. If we do, ask your providers to bill Medicaid for services you received before we approved your application. If you pay for services before your application is approved, ask your health providers to refund your money and bill Medicaid. Providers do not have to give refunds, but some will. The provider must bill Medicaid even if you gave the bill to DHS. Program requirements: • Child Support Services - see page 8. • Child Support Actions - see pages 10, 11. Healthy lifestyles. We want all MA clients to live healthy lifestyles. This might include making a commitment to: attend all medical appointments, exercise regularly, not smoke or use illegal drugs, and keep children’s shots up-to-date. For more information on living a healthy lifestyle, you may visit the Michigan Department of Community Health (MDCH) Web site at: www. michiganstepsup.org or call the following numbers: • 1-877-422-4244 - healthy eating habits and tips. • 1-877-422-4244 - free Make Health Your Choice booklet. • 1-800-480-7848 - quit smoking.

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 5

Child Development And Care (CDC)
CDC helps pay for the cost of child care. You may be eligible if you are: • • • • A family with low income. A licensed foster parent requesting care for foster children. A member of a DHS protective services case participating in a treatment plan. A FIP/Extended Family Independence Program (EFIP) or Supplemental Security Income (SSI) recipient. A FIP applicant doing a required work participation program activity. Work. High school completion classes (including general equivalency diploma, adult basic education, and English as a second language). Approved education or training. Approved treatment activities for a health or social condition.

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are eligible without an income determination. Eligibility for all other families is based on gross monthly income. Use the table below to get an idea if you may be eligible. Family Group Size 1&2 3 4 5 6 7 8 9 10+ What does DHS pay? CDC Payment The actual CDC payment amount may not cover all child care expenses. The Department pays part of the cost of child care for approved families. This part is the Department Pay Percent (DP %). The DP % can be from 70% to 100% of CDC reimbursement rate. Current reimbursement rates are available online at www.michigan.gov/childcare. You are responsible for any child care costs not covered by the CDC program. Program requirements: • • • Child Support Services - see page 8. Child Support Actions - see pages 10, 11. More information about the CDC program may be obtained online at: www.michigan.gov/childcare If you need help ﬁnding an eligible child care provider, contact your Great Start to Quality Resource Center at 1-877-614-7328 or visit www.greatstartconnect.com. Gross Monthly Income $0-1607 $0-1990 $0-2367 $0-2746 $0-3123 $0-3500 $0-3877 $0-4254 $0-4634

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You must have a child care need because of: • •

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The child care must be provided in Michigan by a: • • • • Licensed child care center. Licensed group child care home. Registered family child care home. DHS-enrolled* unlicensed child care provider who has completed the Great Start to Quality Orientation and: - provides care in the child’s home, or - is related by blood, marriage or adoption as a grandparent/great-grandparent, aunt/ great-aunt, uncle/great-uncle, or sibling and provides care in his/her own home. * Enrollment is not allowed if the provider, or an adult household member age 18 and older, living with the provider, is: • • Convicted of certain crimes. On the central registry for child abuse or neglect.

Resources:

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How much money can you make and still be eligible? FIP/EFIP, SSI recipients, licensed foster parents, and children’s protective services families

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 6

Family Independence Program (FIP) Refugee Cash Assistance (RCA)
The main goal of cash assistance programs is to help families become self-supporting and independent. • FIP is temporary cash assistance for low-income families with minor children. • RCA is temporary cash assistance for persons recently admitted into the U.S. as refugees. To qualify for FIP or RCA, you must have: • • Low income, and Cash assets less than $3,000 and property assets less than $500,000. You may be eligible for FIP if you are not receiving cash beneﬁts from another state and you are either: • • Pregnant. A parent, legal guardian, or relative acting as a parent for a child under the age of 18 (or a high school student age 18). Children ages 6-18 must attend school full time. You may be eligible for RCA if you are: •

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A refugee (or someone treated as a refugee) as determined by the United States Citizenship and Immigration Services (USCIS). Within eight months of date of entry to the U.S., and Not eligible for FIP. Number of people in your household group. Court-ordered child support expenses paid by your household. Total income.

The FIP or RCA grant amount is based on:

48-month lifetime limit: You cannot receive FIP for more than 48 months in your lifetime unless you qualify for an exception month. This includes any cash assistance you may have received in another state. Months you receive EFIP may count toward your time limit. It is prohibited to use FIP or RCA to purchase lottery tickets, alcohol, or tobacco or for gambling, illegal activities, massage parlors, spas, tattoo shops, bail-bond activities, adult entertainment, cruise ships, or other nonessential items.

Child support payments. Each month you are on FIP, current support we collect on your order is kept by the state. If you get support in a month when you are getting FIP, you must report it to your local DHS ofﬁce, and you may need to repay it. If the support we collect is more than your FIP grant for at least two months, we may close your FIP case so you can get the child support payments directly. Program requirements: • • • • Follow Work Rules and Penalties - see pages 11, 12, 13. Child Support Services - see page 8. Child Support Actions - see pages 10, 11. Immunize Children Under Age Six - Get Shots (FIP) - see page 10.

State Disability Assistance (SDA)
SDA provides cash assistance to meet the basic needs of a person with a disability, a person caring for a person with a disability, or persons in a special living arrangement. It is prohibited to use SDA to purchase lottery tickets, alcohol, or tobacco or for gambling, illegal activities, massage parlors, spas, tattoo shops, bail-bond activities, adult entertainment, cruise ships, or other nonessential items. A person is considered disabled if (s)he is one of the following (reasons for disability may change): • Age 65 or older. • Unable to work for 90 days or more because of a medical condition. • Receiving Supplemental Security Income (SSI) or Social Security disability beneﬁts. • Receiving medical assistance based on disability or blindness. • • • •

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Receiving special education services. Receiving Michigan Rehabilitation Services. Diagnosed as having AIDS. Living in an adult foster care home, a home for the aged, a county inﬁrmary or a substance abuse treatment center. You may be eligible for SDA if you are not eligible for FIP and you are any of the following (reasons for disability may change): • 65 or older. • Permanently or temporarily disabled. • Taking care of a person with a disability who lives with you. AND you have: • Cash assets less than $3,000 and property assets less than $500,000 and • Low income (different limits for single and married persons). Read this information booklet before you sign the assistance application.
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DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete.

State Emergency Relief (SER)
SER provides limited help to households with low income who have an emergency. SER helps prevent serious harm to individuals and families who have an emergency that threatens their health or safety. You may be eligible for SER if: • You have low income and limited assets. • The emergency situation is not likely to happen again (example: for help with rent or house payments, you must show you have enough income to pay your housing costs in the future). • You have made certain required payments on your shelter, heat, electric and/or utility bills. • The amount you need is within our limits. Covered services include: •

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Relocation payments to avoid or eliminate homelessness.* • Mortgage, insurance and/or property tax payment, to stop forfeiture, foreclosure or tax sale.* • Limited home repairs. • Home heating, electric and utility bills. • Burial costs. * DHS works with the Salvation Army to provide emergency shelter statewide. The amount of help you may receive depends on the number of people in your household, income, assets, type of service requested and other factors.

Child Support Services
The Ofﬁce of Child Support (OCS) is part of DHS and is responsible for the child support program in Michigan. OCS works with the Prosecuting Attorney (PA), Friend of the Court (FOC) and agencies in other states. The goal of OCS is to ensure that children are supported by their parents. Child support may include: • Cash for everyday living. • Health and/or educational beneﬁts. • Payment for child care costs. Child support services can help: • Locate a child’s parent(s). • Establish a child’s legal father by: - Voluntary paternity papers. - Court action for paternity. • Establish a court order to support the child’s ﬁnancial and medical needs. Child support services are available if: • One or both of the child’s parents do not live in the home with the child. • You receive child care services, food, cash or medical assistance from DHS. You do not have to receive help from DHS to apply for child support services. To apply for services, complete the IV-D Child Support Services Application/Referral (DHS-1201): • Print a DHS-1201 from the DHS public Web site at www.michigan.gov/dhs-forms. • Call OCS at 1-866-540-0008 or 1-866-661-0005. • Send a written request to: Ofﬁce of Child Support Case Management Unit PO Box 30750 Lansing, MI 48909-8250 Return the completed DHS-1201 to the DHS in your area, the local PA or FOC, or the address above.

Early On®
Early On coordinates services for families who have a child age zero (birth) to age three with a disability, developmental delay or a related medical condition. To ﬁnd out if your child is eligible, call Early On at 1-800-EarlyOn (327-5966) or online at www.1800earlyon.org. An Early On coordinator in your county will: • Let you know if your child is eligible. • Help you decide if you want Early On services for your child.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 8

There is no cost for an evaluation of Early On eligibility. Early On services can include: • assessment services • audiology • diagnostic medical services • early identiﬁcation • family skills training • health services • home visits • nursing services• nutritional counseling • occupational therapy• pathology • psychological services • screening • service coordination • social work services • special equipment • special instruction • speech • transportation • counseling (family, group, individual) • vision services.

Read this information booklet before you sign the assistance application.

Low Income Home Energy Assistance Program (LIHEAP)
LIHEAP consists of federal money given to each state to help low-income individuals and families with heating costs. In Michigan, this money is used for the following programs: • Home Heating Credit (HHC). • State Emergency Relief (SER) - see page 8. • Weatherization Assistance Program (WAP). There is no separate application for LIHEAP. Home Heating Credit (HHC) The HHC is available to all low-income households including those with rent that includes heat. The Michigan Department of Treasury determines eligibility and makes the payments. Applications for the HHC are available at the Department of Treasury and wherever tax forms are available (online at www.michigan.gov/treasury, select Income Tax Forms from the Treasury Quick List on the home page). You do not need to ﬁle a state income tax return to receive the HHC. Eligibility is based on income, number of tax exemptions and household heating costs. Weatherization Assistance Program (WAP) WAP is a federally funded, low-income residential energy conservation program available to low-income Michigan homeowners and renters. These services reduce energy use and lower utility bills. Services may include: • Attic insulation and ventilation. • Wall insulation. • Foundation insulation. • Smoke detectors. • Dryer venting. • Air leakage reduction. Applications for WAP are available at your local weatherization operator. Resources: • LIHEAP - call the toll-free DHS Assistance hotline at 855-275-6424 (855-ASK-MICH). • HHC - www.michigan.gov/heatingassistance or call the Michigan Department of Treasury at 517-636-4486. • Weatherization www.michigan.gov/dhs-womap.

Things You Must Do
By signing the assistance application, you agree to do these things.

Give Correct Information and Report Changes (All Programs)
Correct information. You must give DHS correct and complete information about you and everyone in your household. If you give us incorrect or incomplete information on purpose, or you do not report a change, you may be prosecuted for perjury or fraud, or denied beneﬁts. (See “Penalties for Intentional Program Violation Or Fraud” for more information.) Reporting changes. Tell your DHS specialist about changes or report changes online within 10 days of the change.* If you have any doubt about whether to report a change, contact your DHS specialist. Your DHS specialist will tell you if different reporting rules apply to you. If you ﬁle for bankruptcy, you shall send a copy of the ofﬁcial bankruptcy notice to: DHS, Legal Services, 235 S. Grand Ave., #715, Lansing, MI 48933. The types of changes you must report are: • Employment starts, stops (within 10 days of receiving your ﬁrst/last payment) or changes. • • • • • Change in rate of pay (within 10 days of receiving the ﬁrst payment reﬂecting the change). Bank accounts (opening/changes/closures), sale/ purchase of property, etc. Change of hours worked by more than ﬁve hours per week, if it will last more than one month. Unearned income starts or stops (like Social Security, unemployment or retirement beneﬁts, etc.). Unearned income changes by more than: - $50 per month for most programs. - $25 per month for most MA programs. Change in assets. Change of address. Housing or utility cost stops, starts or changes. Anyone moving in or out of your home. Changes in child care need, cost or provider. Changes in child support amount paid out or received. Health or medical insurance premiums or change in coverage. Changes in a child’s school attendance.

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*Exception: For FIP only, you must report a child leaving your home within 5 days of the date you know they will be absent for 30 days or more. Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 9

Things You Must Do (continued)
Repay Extra Beneﬁts (All Programs)
If you or anyone in your household receives beneﬁts they are not eligible for, the adults in the household must repay the extra beneﬁts. The beneﬁts must be repaid even if there was no fraud. If DHS makes an error, the adults in the household must repay the extra beneﬁts except in medical assistance cases. For FAP, an authorized representative (someone with access to your food beneﬁts who can shop for you) may also be responsible for repayment of any extra FAP beneﬁts. For most programs, under federal law 42 USC 1320b-7, you must provide Social Security numbers for everyone applying. Exceptions include: • When applying for child care only, you do not have to provide a Social Security number for adults or children who do not need child care. • Non-citizens who cannot get a Social Security number may still qualify for medical assistance for emergency services, pregnancy and childbirth. (See “Citizens and Non-Citizens.”) • Persons not applying for FAP are not required to provide a Social Security number. You must apply for other beneﬁts you may qualify for, such as: • • Unemployment beneﬁts. Social Security and Supplemental Security Income (SSI) beneﬁts. Recoupment. DHS may keep part of your future beneﬁts as repayment for extra beneﬁts you received. Trafﬁcking. FAP beneﬁts that are sold or traded are treated as extra beneﬁts and must be repaid. Release of information. If you or anyone in your household received extra beneﬁts, the information on your assistance application, including Social Security numbers, may be given to federal, state and private agencies to help with collection. FAP clients are excused from providing and obtaining a Social Security number based on religious grounds. DHS will help you apply for Social Security numbers. Give DHS the Social Security number as soon as you receive it. If you do not, your beneﬁts may be reduced or denied. You may have to repay an overpayment. DHS will use Social Security numbers to check whether you are eligible and receiving the correct beneﬁts. DHS uses Social Security numbers to check information with other agencies. (See “Information About Your Household That Will Be Shared.”) •

*Provide Social Security Numbers (Most Programs)

Pursue Other Beneﬁts (Most Programs)
• Veterans Administration beneﬁts. DHS will tell you if you need to apply for beneﬁts. If you do not pursue beneﬁts when required, your DHS beneﬁts may be reduced, closed or denied.

Immunize Children Under Age Six - Get Shots (FIP)
Children under age six must be immunized as recommended by the Michigan Department of Community Health. Your cash beneﬁts may be reduced by $25 per month until your children are up-to-date on their immunizations. You will receive a letter about the child support program if: • You receive FIP, FAP, MA or CDC; and • One or more of the child’s parents do not live with the child. You must contact the support specialist when you receive the letter and provide additional information about yourself, the minor child, and the parent(s) of the minor child. A child is exempt from the immunization requirement if: • (S)he is under two months of age. • Immunizations are medically inappropriate for the child. • Immunizations are against the family’s religious beliefs.

Child Support Actions (Most Programs)
To claim good cause, tell your DHS specialist and ask for the “Claim of Good Cause” (DHS-2168) form. You may be asked to provide proof. If you do not cooperate with child support actions when required, and do not have a good-cause reason, DHS will do all of the following for at least one month: • Remove the food assistance beneﬁts of the person not cooperating. While you receive beneﬁts from FIP, FAP, MA or CDC, you • Deny or stop your medical beneﬁts. We will not deny must keep working with the Ofﬁce of Child Support, the or stop Medicaid for children or pregnant women. Prosecuting Attorney and Friend of the Court to pursue • Deny or stop your child care beneﬁts. paternity and/or support. • Deny or stop cash assistance for your entire household. Good cause. DHS will not require you to pursue paternity • Deny SER for failure to comply with a requirement of or support if you have good cause. FIP. *See pages C-H of this booklet. Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 10

Assistance Application
Michigan Department of Human Services (DHS) Instructions
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If you answer all the questions on the assistance application, we can determine if you are eligible for ALL programs. Please print your answers. Check ALL programs you are applying for. The program symbols below will appear in each section of questions on the application. These symbols tell you which questions you must answer for each program. For more information about programs, see the Information Booklet.

    

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Food Assistance Program (FAP). Medical Assistance (MA, AMP) (doctor or hospital bills, prescriptions, Medicare premiums). Retroactive Medical - Do you, or anyone in your household, have paid or unpaid medical expenses in the last three months?  Yes  No Child Development and Care (CDC) (help with child care costs). Cash Assistance (FIP - Family Independence Program, RCA - Refugee Cash Assistance, SDA State Disability Assistance) (help with cash for pregnant women, families with children, refugees, adults with disabilities, live-in caretakers of adults with disabilities or residents of special living arrangements). State Emergency Relief (SER) (utility shut-off, eviction notice, burial or other emergency). NOTE: You must complete both the assistance application and SER supplemental application (DHS-1514) available from the DHS office in your area or you may also apply online at www.michigan.gov/dhs-forms.

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If you cannot complete this application now, you may complete the ﬁling form on the last page of the information booklet or online at www.michigan.gov/dhs-forms. The date DHS receives your assistance application or ﬁling form may affect the date your beneﬁts start. DHS will still need to receive your completed assistance application before any beneﬁts can be approved. If you need help filling out this application, DHS must help you. If you are refused help, you may call (855) 275-6424. 1. If you do not speak English or you have a disability, how can we help you?  Interpreter  Sign language  Assisted listening device (ALD)  Other ___________________ 2. If you do not speak English, what language do you speak? _________________________________________ Si usted necesita ayuda llenando esta solicitud, DHS debe ayudarle. Si ellos se niegan ayuda, usted puede llamar a (855) 275-6424. 1. ¿Si usted no habla inglés o tiene una incapacidad, como podemos ayudarle?  Intérprete  Dactilología  Dispositivo vivo asistido (ALD)  Otro ________________________ 2. ¿Si usted no habla inglés, qué idoma habla? ____________________________________________________

For ofﬁce use only

Date application received in local ofﬁce

Case name Application number Specialist name Specialist phone Specialist email Fax Case number

This form is issued under authority of the Code of Federal Regulations (CFR) 42 CFR 435.907; 7 CFR 273.2(d); and Sections 25 and 59 of Act 280 of the Public Acts of 1939, as amended, and Public Act 280 of 1939. You must complete this form if you want the department to consider your application for ﬁnancial, medical or food assistance or for child care services.

DHS-1171 (Rev. 11-12) Previous edition obsolete.

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A. Address Information
1. Check where you live:  House/apartment/mobile home

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 Homeless  Other ___________________  Hospital  County inﬁrmary  Nursing facility  Mental health or psychiatric facility  Jail/prison  Emergency  housing/shelter  Drug or alcohol treatment center  Juvenile residential facility  Community justice center  Domestic violence shelter  Halfway house  Assisted living  Date unknown  Does not apply

If you live in a facility or special living arrangement, or have lived in one in the last three months, check what type below:  Home for the aged  Children’s group home  Adult foster care home  Commercial boarding  house

 What date do you expect to leave, or what date did you leave the facility?

Name of facility __________________________________________________________________________ 2. Address where you live, or address of facility (number, street, rural route, apartment/lot number)

City

State

ZIP code

County

3. Mailing address (if different from above, or PO box)

City 4. Home phone

State Cell phone

ZIP code

County Work phone

Phone number where we can leave a message Telephone Typewriter (TTY) number

Whose number is it? (name/relationship) Email address  Yes  No

5. Have you moved from, or received assistance from another state any time after August 1996? If yes, what state? _____________________________

What county?_____________________________

Date(s) received assistance from another state. ____________ What type of assistance _________________ Date you moved to Michigan (MI) What was your caseworker’s name? Caseworker phone number

6. Do you and your household intend to remain in MI?  Yes  No 7. Did you or someone in your household come to MI with a job commitment or looking for work?  Yes 8. If you are a migrant or seasonal farmworker, list your permanent mailing address below. Permanent mailing address (number, street, rural route, apartment/lot number, PO box)

 No

City

State

ZIP code

County

DHS-1171 (Rev. 11-12) Previous edition obsolete.

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B. Food Assistance Information

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1. Does everyone in the household buy and ﬁx food together?  Yes  No If no, list who does not ______________________________________________________________________ 2. How much are the total cash assets belonging to your household? (Include cash, savings, checking, savings bonds, etc.) $ ________________________________________ 3. How much is the total monthly gross income (before any deductions) for your household? (Include earnings, unemployment beneﬁts, child support, Social Security beneﬁts, etc.) $ _________________ 4. Does anyone in your household receive tribal food distribution beneﬁts?  Yes  No If yes, list who ____________________________________________________________________________ 5. If attending college, university, etc., do you live in a dorm or have a meal plan?  Yes  No

C. Information About You and Your Household

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• Answer for ALL persons in your household (everyone living in your home). Include persons who are not there all the time, even if you are not applying for them. LIST YOURSELF FIRST.

• If you are an alien with a sponsor who has agreed to ﬁnancially support you, even if (s)he is not doing so, include your sponsor’s information in one of the boxes below.

• If you are ﬁlling out the application for a patient in a nursing facility, list:
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The patient ﬁrst.

- The patient’s spouse.

- Any dependents living at home.

• Spaces for ﬁve more persons in your household are available on the next ﬁve pages.
Do you need more household pages?  Yes  No Answer for person 1. Check all boxes that apply. 1. Name (ﬁrst, middle initial, last; birth name, if different) 2. Date of birth __________________________________________________ ___________________ 4.Male  Female 6. Marital status 5. Social Security number*  Never married  Divorced  Widowed  Separated  Married

3. Relationship to you _________________ SELF

7. Is this person a U.S. citizen?  Yes  No **If no, and you are a documented alien, what is your date of entry: ___________ Mother’s Maiden Name ______________________ Place of Birth
(county, city, state)

8. Pregnant now/last three months  Yes  No If yes,Due date/pregnancy end date Number expected/had  One  Twins  Triplets  Other ________________  Full-time Half-time 10. In school now?  Yes  No If yes,School name________________________  Less than half-time   K-12  GED  College  Trade school  University  Vocational  Other 11. Ethnicity (optional)  Hispanic/Latino  Not Hispanic/Latino 12.   13.   14. 15. Race (optional)  American Indian/Alaska Native – Enter tribe name _______________________________  Asian  Black/African American  Native Hawaiian/Other Paciﬁc Islander  White Is this person any of the following? (check all that apply)  Refugee  Sponsor of an alien  Migrant farmworker  Foster child  Foster parent  Temporarily absent (college, military, etc.)  Seasonal farmworker  Adopted child  Non-parent caregiver  None apply to this person If this person is currently away from the home Why? ______________ Expected return date ___________ How many days each month does this person stay at the application address? at another address? Other address ___________________________________________________________________________
(number, street, rural route, apartment/lot number, city, state, zip code)

9. Highest grade completed in school ____________

 Received GED

16. What kind of help does this person need? Food  Medical  Emergency help   Family Planning Services  Child care Cash assistance  None (not applying) * Optional if applying ONLY for child care or emergency medical services. **Applies to FIP, MA, RCA and FAP applicants only.
*/**For FAP, see pages 10 and 14 of this booklet. DHS-1171 (Rev. 11-12) Previous edition obsolete. C

Answer for person 2. Check all boxes that apply.
1. Name (first, middle initial, last; birth name, if different) ______________________________________________________ 4. c Male c Female 5. Social Security number* c Never married c Divorced c Widowed
(county, city, state)

2. Date of birth 3. Relationship to you _____________________ ___________________ c Separated

6. Marital status

c Married

7. Is this person a U.S. citizen? c Yes c No **If no, and you are a documented alien, what is your date of entry: ___________ Mother’s Maiden Name Place of Birth 8. Pregnant now/last three months Number expected/had c Yes c No If yes,4 Due date/pregnancy end date c Twins c Triplets c One c Other __________________

c Full-time c Half-time 9. Highest grade completed in school ________________ c Received GED 10. In school now? c Yes c No If yes,4School name ____________________________ c Less than half-time c K-12 c GED c College c Trade school c University c Vocational c Other 11. Ethnicity (optional) c Hispanic/Latino c Not Hispanic/Latino
12. Race (optional) c Asian c American Indian/Alaska Native – Enter tribe name ______________________________________ c Native Hawaiian/Other Pacific Islander c Black/African American c White

13. Is this person any of the following? (check all that apply) c Refugee c Sponsor of an alien c Migrant farmworker c Foster child c Foster parent c Temporarily absent (college, military, etc.) c Seasonal farmworker c Adopted child c Non-parent caregiver c None apply to this person 14. If this person is currently away from the home 4Why? ____________________ Expected return date _____________ 15. How many days each month does this person stay at the application address? at another address? Other address ____________________________________________________________________________________ (number, street, rural route, apartment/lot number, city, state, zip code)

16. What kind of help does this person need? c Family Planning Services

c Food c Child care

c Medical c Cash Assistance

c Emergency help c None (not applying)

17. If this person is under 22, complete this section: Who paid for this child’s birth expenses c State c Parents c Another person What was the marital status of the mother while pregnant with this child? __________________ If Married or Divorced: Marriage Date __/__/____ Separation Date __/__/____ Divorce Date __/__/____ Order/County/State: ____________________ Order/County/State: ____________________ If single, this child’s Conception Date __/__/____ City: _________________________ State ____ Country __________ Has an Affidavit of Parentage (AOP) or a court order named someone as the father? c Yes c No If Yes, Order/AOP# __________ Date __/__/____ City: ______________________ State ____ Country __________ If No, is there more than one likely father? c Yes c No, If Yes, Stop If not directed to stop, complete the following for each parent: Father Mother Name (first, mi, last) Birthdate SSN Name (first, mi, last) Birthdate SSN ________________ __/__/_____ ________________ ________________ __/__/_____ ________________ Approximate age (if Birthdate not known): __________ Approximate age (if Birthdate not known): __________ Is he in the home? c Yes c No Is she in the home? c Yes c No Is he deceased? c Yes c No Is she deceased? c Yes c No Is he the same father described for a previous child? Is she the same mother described for a previous child? c Yes, name: _______________________ c No c Yes, name: _______________________ c No Is he a single-parent adopter? c Yes c No Is she a single-parent adopter? c Yes c No Has the court terminated his rights? c Yes c No Has the court terminated her rights? c Yes c No If Yes to any of the above, stop. Otherwise: If Yes to any of the above, stop. Otherwise: Is there a support order naming him for this child? Is there a support order naming her for this child? Order # _____ County_____State_____Country_____ Order #_____County_____State_____Country_____ Last known employer & address _________________ Last known employer & address _________________ Month/year last worked __/____ Month/year last worked __/____ Height ___ Weight ___ Hair color ____ Eye Color ____ Height ___ Weight ___ Hair color ____ Eye Color ____ Ethnicity c Hispanic/Latino c Not Hispanic/Latino Ethnicity c Hispanic/Latino c Not Hispanic/Latino Race: c American Indian/Alaska Native (Tribe ______) Race: c American Indian/Alaska Native (Tribe ______) c Asian c Hawaiian Native/Pacific Islander c Asian c Hawaiian Native/Pacific Islander c Black/African American c White c Black/African American c White Father’s health insurance covering this child: Mother’s health insurance covering this child: Carrier _______________ Policy # _______________ Carrier _______________ Policy # _______________
* Optional if applying ONLY for child care or emergency medical services. **Applies to FIP, MA, RCA and FAP applicants only. */**For FAP, see pages 10 and 14 of this booklet. DHS-1171 (Rev. 11-12) Previous edition obsolete. D

Answer for person 3. Check all boxes that apply.
1. Name (ﬁrst, middle initial, last; birth name, if different) ______________________________________________________ 4. Male Female 5. Social Security number*  Never married  Divorced  Widowed  Separated 2. Date of birth 3. Relationship to you _____________________ ___________________

6. Marital status

 Married

7. Is this person a U.S. citizen?  Yes  No **If no, and you are a documented alien, what is your date of entry: ___________ Mother’s Maiden Name Place of Birth
(county, city, state)

8. Pregnant now/last three months Number expected/had 9. 10.  11.

 Yes  No If yes, Due date/pregnancy end date  Twins  Triplets  Other __________________

 One

Highest grade completed in school ________________  Received GED  Full-time Half-time In school now?  Yes  No If yes,School name ____________________________  Less than half-time  K-12  GED  College  Trade school  University  Vocational  Other Ethnicity (optional)  Hispanic/Latino  Not Hispanic/Latino  American Indian/Alaska Native – Enter tribe name ______________________________________  Native Hawaiian/Other Paciﬁc Islander  Black/African American  White

12. Race (optional)   Asian 13.   14. 15.

Is this person any of the following? (check all that apply)  Refugee  Sponsor of an alien  Migrant farmworker  Foster child  Foster parent  Temporarily absent (college, military, etc.)  Seasonal farmworker  Adopted child  Non-parent caregiver  None apply to this person If this person is currently away from the home Why? ____________________ Expected return date _____________ How many days each month does this person stay at the application address? at another address? Other address ____________________________________________________________________________________
(number, street, rural route, apartment/lot number, city, state, zip code)

16. What kind of help does this person need?  Food Medical  Emergency help   Family Planning Services  Child care Cash Assistance  None (not applying) 17. If this person is under 22, complete this section: Who paid for this child’s birth expenses State Parents  Another person What was the marital status of the mother while pregnant with this child? __________________ If Married or Divorced: Marriage Date __/__/____ Separation Date __/__/____ Divorce Date __/__/____ Order/County/State: ____________________ Order/County/State: ____________________ If single, this child’s Conception Date __/__/____ City: _________________________ State ____ Country __________ Has an Afﬁdavit of Parentage (AOP) or a court order named someone as the father? Yes No If Yes, Order/AOP# __________ Date __/__/____ City: ______________________ State ____ Country __________ If No, is there more than one likely father? Yes No, If Yes, Stop If not directed to stop, complete the following for each parent: Father Mother Name (ﬁrst, mi, last) Birthdate SSN Name (ﬁrst, mi, last) Birthdate SSN ________________ __/__/_____ ________________ ________________ __/__/_____ ________________ Approximate age (if Birthdate not known): __________ Approximate age (if Birthdate not known): __________ Is he in the home? Yes No Is she in the home? Yes No Is he deceased? Yes No Is she deceased? Yes No Is he the same father described for a previous child? Is she the same mother described for a previous child? Yes, name: _______________________ No Yes, name: _______________________ No Is he a single-parent adopter? Yes No Is she a single-parent adopter? Yes No Has the court terminated his rights? Yes No Has the court terminated her rights? Yes No If Yes to any of the above, stop. Otherwise: If Yes to any of the above, stop. Otherwise: Is there a support order naming him for this child? Is there a support order naming her for this child? Order # _____ County_____State_____Country_____ Order #_____County_____State_____Country_____ Last known employer & address _________________ Last known employer & address _________________ Month/year last worked __/____ Month/year last worked __/____ Height ___ Weight ___ Hair color ____ Eye Color ____ Height ___ Weight ___ Hair color ____ Eye Color ____ Ethnicity Hispanic/Latino Not Hispanic/Latino Ethnicity Hispanic/Latino Not Hispanic/Latino Race: American Indian/Alaska Native (Tribe ______) Race: American Indian/Alaska Native (Tribe ______) Asian Hawaiian Native/Paciﬁc Islander Asian Hawaiian Native/Paciﬁc Islander Black/African American White Black/African American White Father’s health insurance covering this child: Mother’s health insurance covering this child: Carrier _______________ Policy # _______________ Carrier _______________ Policy # _______________
* Optional if applying ONLY for child care or emergency medical services. **Applies to FIP, MA, RCA and FAP applicants only. */**For FAP, see pages 10 and 14 of this booklet. DHS-1171 (Rev. 11-12) Previous edition obsolete. E

Answer for person 4. Check all boxes that apply.
1. Name (first, middle initial, last; birth name, if different) ______________________________________________________ 4. c Male c Female 5. Social Security number* c Never married c Divorced c Widowed
(county, city, state)

2. Date of birth 3. Relationship to you _____________________ ___________________ c Separated

6. Marital status

c Married

7. Is this person a U.S. citizen? c Yes c No **If no, and you are a documented alien, what is your date of entry: ___________ Mother’s Maiden Name Place of Birth 8. Pregnant now/last three months Number expected/had c Yes c No If yes,4 Due date/pregnancy end date c Twins c Triplets c One c Other __________________

9. Highest grade completed in school ________________ c Received GED c Full-time c Half-time 10. In school now? c Yes c No If yes,4School name ____________________________ c Less than half-time c K-12 c GED c College c Trade school c University c Vocational c Other 11. Ethnicity (optional) c Hispanic/Latino c Not Hispanic/Latino 12. Race (optional) c Asian c American Indian/Alaska Native – Enter tribe name ______________________________________ c Native Hawaiian/Other Pacific Islander c Black/African American c White

13. Is this person any of the following? (check all that apply) c Refugee c Sponsor of an alien c Migrant farmworker c Foster child c Foster parent c Temporarily absent (college, military, etc.) c Seasonal farmworker c Adopted child c Non-parent caregiver c None apply to this person 14. If this person is currently away from the home 4Why? ____________________ Expected return date _____________ 15. How many days each month does this person stay at the application address? at another address? Other address ____________________________________________________________________________________ (number, street, rural route, apartment/lot number, city, state, zip code)

16. What kind of help does this person need? c Family Planning Services

c Food c Child care

c Medical c Cash Assistance

c Emergency help c None (not applying)

17. If this person is under 22, complete this section: Who paid for this child’s birth expenses c State c Parents c Another person What was the marital status of the mother while pregnant with this child? __________________ If Married or Divorced: Marriage Date __/__/____ Separation Date __/__/____ Divorce Date __/__/____ Order/County/State: ____________________ Order/County/State: ____________________ If single, this child’s Conception Date __/__/____ City: _________________________ State ____ Country __________ Has an Affidavit of Parentage (AOP) or a court order named someone as the father? c Yes c No If Yes, Order/AOP# __________ Date __/__/____ City: ______________________ State ____ Country __________ If No, is there more than one likely father? c Yes c No, If Yes, Stop If not directed to stop, complete the following for each parent: Father Mother Name (first, mi, last) Birthdate SSN Name (first, mi, last) Birthdate SSN ________________ __/__/_____ ________________ ________________ __/__/_____ ________________ Approximate age (if Birthdate not known): __________ Approximate age (if Birthdate not known): __________ Is he in the home? c Yes c No Is she in the home? c Yes c No Is he deceased? c Yes c No Is she deceased? c Yes c No Is he the same father described for a previous child? Is she the same mother described for a previous child? c Yes, name: _______________________ c No c Yes, name: _______________________ c No Is he a single-parent adopter? c Yes c No Is she a single-parent adopter? c Yes c No Has the court terminated his rights? c Yes c No Has the court terminated her rights? c Yes c No If Yes to any of the above, stop. Otherwise: If Yes to any of the above, stop. Otherwise: Is there a support order naming him for this child? Is there a support order naming her for this child? Order # _____ County_____State_____Country_____ Order #_____County_____State_____Country_____ Last known employer & address _________________ Last known employer & address _________________ Month/year last worked __/____ Month/year last worked __/____ Height ___ Weight ___ Hair color ____ Eye Color ____ Height ___ Weight ___ Hair color ____ Eye Color ____ Ethnicity c Hispanic/Latino c Not Hispanic/Latino Ethnicity c Hispanic/Latino c Not Hispanic/Latino Race: c American Indian/Alaska Native (Tribe ______) Race: c American Indian/Alaska Native (Tribe ______) c Asian c Hawaiian Native/Pacific Islander c Asian c Hawaiian Native/Pacific Islander c Black/African American c White c Black/African American c White Father’s health insurance covering this child: Mother’s health insurance covering this child: Carrier _______________ Policy # _______________ Carrier _______________ Policy # _______________
* Optional if applying ONLY for child care or emergency medical services. **Applies to FIP, MA, RCA and FAP applicants only. */**For FAP, see pages 10 and 14 of this booklet. DHS-1171 (Rev. 11-12) Previous edition obsolete. F

Answer for person 5. Check all boxes that apply.
1. Name (ﬁrst, middle initial, last; birth name, if different) ______________________________________________________ 4. Male Female 5. Social Security number*  Never married  Divorced  Widowed  Separated 2. Date of birth 3. Relationship to you _____________________ ___________________

6. Marital status

 Married

7. Is this person a U.S. citizen?  Yes  No **If no, and you are a documented alien, what is your date of entry: ___________ Mother’s Maiden Name Place of Birth
(county, city, state)

8. Pregnant now/last three months Number expected/had 9. 10.  11.

 Yes  No If yes, Due date/pregnancy end date  Twins  Triplets  Other __________________

 One

Highest grade completed in school ________________  Received GED  Full-time Half-time In school now?  Yes  No If yes,School name ____________________________  Less than half-time  K-12  GED  College  Trade school  University  Vocational  Other Ethnicity (optional)  Hispanic/Latino  Not Hispanic/Latino  American Indian/Alaska Native – Enter tribe name ______________________________________  Native Hawaiian/Other Paciﬁc Islander  Black/African American  White

12. Race (optional)   Asian 13.   14. 15.

Is this person any of the following? (check all that apply)  Refugee  Sponsor of an alien  Migrant farmworker  Foster child  Foster parent  Temporarily absent (college, military, etc.)  Seasonal farmworker  Adopted child  Non-parent caregiver  None apply to this person If this person is currently away from the home Why? ____________________ Expected return date _____________ How many days each month does this person stay at the application address? at another address? Other address ____________________________________________________________________________________
(number, street, rural route, apartment/lot number, city, state, zip code)

16. What kind of help does this person need?   Family Planning Services

 Food  Child care

Medical Cash Assistance

 Emergency help  None (not applying)

17. If this person is under 22, complete this section: Who paid for this child’s birth expenses State Parents  Another person What was the marital status of the mother while pregnant with this child? __________________ If Married or Divorced: Marriage Date __/__/____ Separation Date __/__/____ Divorce Date __/__/____ Order/County/State: ____________________ Order/County/State: ____________________ If single, this child’s Conception Date __/__/____ City: _________________________ State ____ Country __________ Has an Afﬁdavit of Parentage (AOP) or a court order named someone as the father? Yes No If Yes, Order/AOP# __________ Date __/__/____ City: ______________________ State ____ Country __________ If No, is there more than one likely father? Yes No, If Yes, Stop If not directed to stop, complete the following for each parent: Father Mother Name (ﬁrst, mi, last) Birthdate SSN Name (ﬁrst, mi, last) Birthdate SSN ________________ __/__/_____ ________________ ________________ __/__/_____ ________________ Approximate age (if Birthdate not known): __________ Approximate age (if Birthdate not known): __________ Is he in the home? Yes No Is she in the home? Yes No Is he deceased? Yes No Is she deceased? Yes No Is he the same father described for a previous child? Is she the same mother described for a previous child? Yes, name: _______________________ No Yes, name: _______________________ No Is he a single-parent adopter? Yes No Is she a single-parent adopter? Yes No Has the court terminated his rights? Yes No Has the court terminated her rights? Yes No If Yes to any of the above, stop. Otherwise: If Yes to any of the above, stop. Otherwise: Is there a support order naming him for this child? Is there a support order naming her for this child? Order # _____ County_____State_____Country_____ Order #_____County_____State_____Country_____ Last known employer & address _________________ Last known employer & address _________________ Month/year last worked __/____ Month/year last worked __/____ Height ___ Weight ___ Hair color ____ Eye Color ____ Height ___ Weight ___ Hair color ____ Eye Color ____ Ethnicity Hispanic/Latino Not Hispanic/Latino Ethnicity Hispanic/Latino Not Hispanic/Latino Race: American Indian/Alaska Native (Tribe ______) Race: American Indian/Alaska Native (Tribe ______) Asian Hawaiian Native/Paciﬁc Islander Asian Hawaiian Native/Paciﬁc Islander Black/African American White Black/African American White Father’s health insurance covering this child: Mother’s health insurance covering this child: Carrier _______________ Policy # _______________ Carrier _______________ Policy # _______________
* Optional if applying ONLY for child care or emergency medical services. **Applies to FIP, MA, RCA and FAP applicants only. */**For FAP, see pages 10 and 14 of this booklet. DHS-1171 (Rev. 11-12) Previous edition obsolete. G

Answer for person 6. Check all boxes that apply.
1. Name (ﬁrst, middle initial, last; birth name, if different) ______________________________________________________ 4. Male Female 5. Social Security number*  Never married  Divorced  Widowed  Separated 2. Date of birth 3. Relationship to you _____________________ ___________________

6. Marital status

 Married

7. Is this person a U.S. citizen?  Yes  No **If no, and you are a documented alien, what is your date of entry: ___________ Mother’s Maiden Name Place of Birth
(county, city, state)

8. Pregnant now/last three months Number expected/had 9. 10.  11.

 Yes  No If yes, Due date/pregnancy end date  Twins  Triplets  Other __________________

 One

Highest grade completed in school ________________  Received GED  Full-time Half-time In school now?  Yes  No If yes,School name ____________________________  Less than half-time  K-12  GED  College  Trade school  University  Vocational  Other Ethnicity (optional)  Hispanic/Latino  Not Hispanic/Latino  American Indian/Alaska Native – Enter tribe name ______________________________________  Native Hawaiian/Other Paciﬁc Islander  Black/African American  White

12. Race (optional)   Asian 13.   14. 15.

Is this person any of the following? (check all that apply)  Refugee  Sponsor of an alien  Migrant farmworker  Foster child  Foster parent  Temporarily absent (college, military, etc.)  Seasonal farmworker  Adopted child  Non-parent caregiver  None apply to this person If this person is currently away from the home Why? ____________________ Expected return date _____________ How many days each month does this person stay at the application address? at another address? Other address ____________________________________________________________________________________
(number, street, rural route, apartment/lot number, city, state, zip code)

16. What kind of help does this person need?   Family Planning Services

 Food  Child care

Medical Cash Assistance

 Emergency help  None (not applying)

17. If this person is under 22, complete this section: Who paid for this child’s birth expenses State Parents  Another person What was the marital status of the mother while pregnant with this child? __________________ If Married or Divorced: Marriage Date __/__/____ Separation Date __/__/____ Divorce Date __/__/____ Order/County/State: ____________________ Order/County/State: ____________________ If single, this child’s Conception Date __/__/____ City: _________________________ State ____ Country __________ Has an Afﬁdavit of Parentage (AOP) or a court order named someone as the father? Yes No If Yes, Order/AOP# __________ Date __/__/____ City: ______________________ State ____ Country __________ If No, is there more than one likely father? Yes No, If Yes, Stop If not directed to stop, complete the following for each parent: Father Mother Name (ﬁrst, mi, last) Birthdate SSN Name (ﬁrst, mi, last) Birthdate SSN ________________ __/__/_____ ________________ ________________ __/__/_____ ________________ Approximate age (if Birthdate not known): __________ Approximate age (if Birthdate not known): __________ Is he in the home? Yes No Is she in the home? Yes No Is he deceased? Yes No Is she deceased? Yes No Is he the same father described for a previous child? Is she the same mother described for a previous child? Yes, name: _______________________ No Yes, name: _______________________ No Is he a single-parent adopter? Yes No Is she a single-parent adopter? Yes No Has the court terminated his rights? Yes No Has the court terminated her rights? Yes No If Yes to any of the above, stop. Otherwise: If Yes to any of the above, stop. Otherwise: Is there a support order naming him for this child? Is there a support order naming her for this child? Order # _____ County_____State_____Country_____ Order #_____County_____State_____Country_____ Last known employer & address _________________ Last known employer & address _________________ Month/year last worked __/____ Month/year last worked __/____ Height ___ Weight ___ Hair color ____ Eye Color ____ Height ___ Weight ___ Hair color ____ Eye Color ____ Ethnicity Hispanic/Latino Not Hispanic/Latino Ethnicity Hispanic/Latino Not Hispanic/Latino Race: American Indian/Alaska Native (Tribe ______) Race: American Indian/Alaska Native (Tribe ______) Asian Hawaiian Native/Paciﬁc Islander Asian Hawaiian Native/Paciﬁc Islander Black/African American White Black/African American White Father’s health insurance covering this child: Mother’s health insurance covering this child: Carrier _______________ Policy # _______________ Carrier _______________ Policy # _______________
* Optional if applying ONLY for child care or emergency medical services. **Applies to FIP, MA, RCA and FAP applicants only. */**For FAP, see pages 10 and 14 of this booklet. DHS-1171 (Rev. 11-12) Previous edition obsolete. H

D. Household Members Under Age 22
Do you need more pages? Yes No

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Check box(es) below if: If person under age • Parents were ever 22 does not live married to each other. Check if with a parent, • Paternity was legally parent is who do they established. deceased live with? • Support is court-ordered.  Married Name  Yes  Paternity  Support Relationship  Yes Order # ____________  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes  Yes Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship Name Relationship  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________  Married  Paternity  Support Order # ____________

List person(s) under age 22 in the household

List name of mother/father (ﬁrst, middle, last) Mother Father Mother Father Mother Father Mother Father Mother Father Mother Father Mother Father Mother Father Mother Father Mother Father

DHS-1171 (Rev. 11-12) Previous edition obsolete.

I

E. Child Development and Care (CDC) Information
Do you need more pages? Yes No 1. Do you need help paying for child care?  Yes  No

j

Why do you need help paying for child care? Check all that apply.  Work  High school or GED  Education/training approved by DHS or the work participation program.  Treatment for health or social condition (explain) ______________________________________________ If you check High school or GED or Education/training approved by DHS or the work participation program above, do you need child care for study time?  Yes  No If yes, please indicate the number of hours of child care per week needed for study time _________________ Provider ID number (if known)

Name of child needing care

Provider name

DHS-1171 (Rev. 11-12) Previous edition obsolete.

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F. Medical Information
Do you need more pages? Yes No

S

1. List anyone in your household who is a victim of domestic violence ___________________________  None 2. List any children under six years of age who are not up-to-date on their immunizations (shots) ____________________________________________  None 3. List any children in an Early On® program ______________________________________________  None Name and phone number of Early On coordinator ________________________________________ 4. List any children who receive Children’s Special Health Care Services ________________________  None 5. List anyone who is now or has ever been in a special education class _________________________  None Name and phone number of school ___________________________________________________ 6. List anyone going to an alcohol or drug treatment program _________________________________  None 7. List anyone working with Michigan Rehabilitation Services__________________________________  None Name and phone number of Michigan Rehabilitation counselor ______________________________ 8. List anyone caring for a child, spouse or other person with a disability in the home _______________  None 9. Is the caregiver able and available to work in addition to caring for someone?  Yes  No  None

10. List anyone applying for assistance who is physically or mentally unable to work full time. Person Medical condition

Is this person able to work?  Yes  Yes  Yes  No  No  No

G. Medical Coverage
 Yes

S Q

Does anyone in your household have, or expect to have, medical coverage (other than Medicaid)?

Check which type of coverage and complete the table below.
 Accident (home or car insurance, etc.)  MIChild  Plan/contract (life care contract, etc.) Name and address of insurance company

 No  Workers’ compensation  Health savings account  Other _________________ Claim, contract/group numbers, effective date

 Health/hospital insurance  (employer, parent, etc.)  Medicare Person covered

DHS-1171 (Rev. 11-12) Previous edition obsolete.

K

H. Asset Information
 Yes

Do you need more pages? Yes No 1. Does anyone in your household have any assets? (include assets owned with another person)

S Q
 No

Check all types of assets your household has and complete the table below.

 Checking/Savings accounts  Money market accounts  IRA, KEOGH, 401K or deferred  Certiﬁcates of deposit (CD)  Christmas club accounts compensation account(s)  Cash on hand/in safe deposit box  Savings bonds, stocks or mutual funds  Real estate/property  Trust or annuities  Land contract, mortgage or other  Real estate/property (not  Life estate notes payable to household member including place you live)  Life insurance  Burial plot(s), casket, etc.  Tools/equipment/livestock/crops  Burial trust/funeral contract(s)  Patient trust fund  Lottery/Gambling winnings  Other (tax refunds, mineral rights, any other accounts, funds, resources, in-kind beneﬁts, etc.)  Credit union accounts Balance Name and address Account or policy Owner of asset Type of asset (amount or value) (bank, insurance company, etc.) number, etc.

2. Has anyone in your household: • Sold/given away property, land, stocks, bonds, vehicles, savings, checking or credit union accounts, income, cash, etc., or closed any accounts or removed or added a name to any asset within the last 60 months?  Yes  No If yes,  Who? _______________________________ 

Date
• Filed a lawsuit which may bring money, property, etc.? If yes,  Who? _______________________________ 

What? ___________________________________ How much? $
 Yes  No

Date  If yes,  Who? _______________________________ Date  If yes,  Who? _______________________________ Date I. Vehicle Information
Do you need more pages? Yes No Does anyone in your household have any vehicles?  Yes  Car

What? ___________________________________ How much? $ What? ___________________________________ How much? $ What? ___________________________________ How much? $

• Received a one-time payment (such as workers’ compensation, lottery winnings, insurance settlement lawsuit award, etc.) within the last 60 months (ﬁve years)?  Yes  No

• Acting for another household member put any money, lawsuit settlement, income or assets in a trust, annuity or similar legal device within the last 60 months (ﬁve years)?  Yes  No

 Q
 No  RV Mileage  Other vehicles Amount owed  Motorcycle Make / Model

Check all that apply and complete the table below.
 Truck  Boat  Camper/trailer Year

Owner(s) on vehicle title or registration

DHS-1171 (Rev. 11-12) Previous edition obsolete.

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J. Migrant or Seasonal Farmworker Income
Do you need more pages? Yes No Is anyone in your household a  migrant or  Yes  Complete the table below.  No Has anyone received any income from the same grower within 30 days before the application date? Does anyone expect to receive more income this month? Has anyone received a travel advance? Has anyone recently lost their only source of income?  seasonal farmworker? Date  Yes Name of person(s):  No  Yes Name of person(s):  No  Yes Name of person(s):  No  Yes Name of person(s):  No Last pay date

j Q
Gross pay amount

Gross pay amount

K. Employment Changes

Do you need more pages? Yes No Did anyone in your household have changes in employment in the last 30 days?  Yes Check all that apply and complete the table below.  No Check all that apply  Refused work Reason _____________  Voluntarily reduced hours worked Reason _____________  Quit a job Reason _____________  Was laid off Reason _____________  Was ﬁred Reason _____________  Is participating in a strike Reason _____________ Name of person(s) Name and address of employer

j S Q
Date of change Date and gross amount of ﬁnal pay

L. Self-Employment Income (including odd jobs)

Do you need more pages? Yes No 1. Is anyone in your household self-employed or will anyone be self-employed before the end of the next calendar month?  Yes Complete the table below.  No Self-employed person Type of work or business and date business started Business name and address Gross monthly income Monthly self(amount before any employment expenses) expenses

j S Q

DHS-1171 (Rev. 11-12) Previous edition obsolete.

M

Do you need more pages?

Yes

No

M. Employment Income
 Yes

Do you need more pages? Yes No Is anyone in your household working for wages or salary or will anyone begin working before the end of the next calendar month?

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 Complete the information below for each working person.

 No

Name of working person _________________________________________ Start date Employer name/address/phone number __________________________________________________________ Type of work ____________________________________ Job title ____________________________________ If new job, ﬁrst paycheck date Will employment continue?  Yes  No

Day of week pay is received __________________ Most recent or last paycheck date Average # of hours expected to work _____ per  Week  Pay period How often paid:  Weekly  Every two weeks Rate of pay $ __________  Monthly  No  Hourly  Salary  Other ____________  Other _________

 Twice a month  Yes

Do you receive a  Bonus  Commission or  Overtime?

 yes, amount $ _____________ If

How often? _______________________  No per  Week  Pay period  Other _________

Do you receive tips not included in your check?  Yes

 yes, average tips not included $ _______________ If

Name of working person _________________________________________ Start date Employer name/address/phone number __________________________________________________________ Type of work ____________________________________ Job title ____________________________________ If new job, ﬁrst paycheck date Will employment continue?  Yes  No

Day of week pay is received __________________ Most recent or last paycheck date Average # of hours expected to work _____ per  Week  Pay period How often paid:  Weekly  Every two weeks Rate of pay $ __________  Monthly  No  Hourly  Salary  Other ____________  Other _________

 Twice a month  Yes

Do you receive a  Bonus  Commission or  Overtime?

 yes, amount $ _____________ If

How often? _______________________  No per  Week  Pay period  Other _________

Do you receive tips not included in your check?  Yes

 yes, average tips not included $ _______________ If

DHS-1171 (Rev. 11-12) Previous edition obsolete.

N

N. Other Income
Do you need more pages?  Yes Yes No

j S Q
 No  Disability beneﬁts  Unemployment beneﬁts  Rental income  Room and/or board income

1. Does anyone in your household receive, or expect to receive (has applied for), any income other than earnings?

Check all boxes that apply and complete the table below.
 Supplemental Security Income (SSI)  Resettlement Income (FAP only)  Workers’ compensation  Money from friends or relatives, etc.  Interest/dividend income

 Social Security beneﬁts (RSDI)  Pension/retirement beneﬁts  Railroad retirement beneﬁts  Veterans beneﬁts  Military allotments

 Land contract, mortgage or other notes payable to a household member  Income/payments from a tribe (tribal general assistance, land claims, casino proﬁt sharing, per capita, etc.)  Other (tax refund, mineral rights, in-kind monies/beneﬁts, etc.)  Child support/court order docket # ___________________ Person receiving/ expecting money Income source/type How often received Amount received Expected to continue?  Yes  Yes  Yes  No  No  No Date expecting if not yet received

2. If anyone in your household receives Social Security (RSDI) or Railroad Retirement beneﬁts, list the claim number(s) ________________________________________________________________________ 3. Has anyone in your household served in the military or the armed services? If yes,  Does anyone who served in the military or armed services have a disability? Who? ________________________________________________________  anyone a widow(er) or child of a deceased person who served in the military or armed services? Is Who? ________________________________________________________  Is anyone a spouse or child with a disability of a person with a disability who served in the military or armed services? Who? ________________________________________________________  None of these. Has anyone in your household applied for VA health care beneﬁts?  Yes  No Who? _________________ Is anyone in your household receiving VA health care beneﬁts?  Yes  No Who? _______________ YesNo

DHS-1171 (Rev. 11-12) Previous edition obsolete.

O

O. Disability Beneﬁts disability beneﬁts?  Yes Person

Do you need more pages? Yes No 1. Has anyone in your household, who is not receiving disability beneﬁts, applied for or been denied

S
 No

 Check all disability beneﬁts that apply and complete the table below.
Type of beneﬁt Beneﬁt status  Applied for beneﬁts.  Denied beneﬁts.*  Appealed the denial.  Requested a hearing.  Applied for beneﬁts.  Denied beneﬁts.*  Appealed the denial.  Requested a hearing.  Applied for beneﬁts.  Denied beneﬁts.*  Appealed the denial.  Requested a hearing.  Yes  No

Date of action (if known)

 Social Security Claim # _____________________  Self  Spouse  Parent  Supplemental Security Income (SSI)  Other_______________________  Social Security Claim # _____________________  Self  Spouse  Parent  Supplemental Security Income (SSI)  Other_______________________  Social Security Claim # _____________________  Self  Spouse  Parent  Supplemental Security Income (SSI)  Other_______________________

* Social Security Administration has decided they are not disabled.
2. If beneﬁts were denied, have the person’s health problem(s) changed? If yes, List who ________________________________ Date of change ________________________  Health problem is worse  New health problem  Has more than one health problem

P. Dependent Care Expenses and Court-Ordered Support

Do you need more pages? Yes No 1. Does anyone in work, school, or training pay for the care of a  child,  family member with disabilities?  Yes

 S Q

Complete the table below (DO NOT include amounts paid by DHS or anyone else).
Amount paid

 No

Person paying

How often Name of person(s) receiving care  Weekly  Every two weeks $ __________  Twice a month  Monthly  Other $ __________  Weekly  Twice a month $ __________  Weekly  Twice a month  Every two weeks  Monthly  Other  Every two weeks  Monthly  Other  No For whom

2. Does anyone in your household pay court-ordered  child support  spousal support/alimony?  Yes

If either of the boxes are checked above, complete the table below.
Court-order/docket number and county of order Order amount Amount paid per
 Week  Month  Other  Week  Month  Other  Week  Month  Other

Person paying

$_______ $ _______ $_______ $ _______ $_______ $ _______

DHS-1171 (Rev. 11-12) Previous edition obsolete.

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Q. Medical Expenses

Do you need more pages? Yes No 1. List anyone who has paid or unpaid medical expenses for services provided in the last three months:

S Q

Who? ___________________________________ What months? _________________________________ List anyone who has paid medical premiums in the last three months: Who? ___________________________________
 Yes What months? _________________________________  No 2. Does anyone in your household have any ongoing medical expenses?



Check all expenses that apply and complete the table below.

 Medical care  Dental care  Hospitalization  Transportation for medical care (for pregnancy or ongoing care)  Emergency room  Nursing facility Person with expense

 Prescribed over-the-counter drugs  Service animal  Prescription drugs  Guardian/conservator fees  Prescription drug card  Health insurance premium  Dentures  Medicare premium  Eyeglasses  Medical equipment/supplies  Hearing aids  Personal care/chore services  Prosthetics  Other Medical expense Amount How often (monthly, (checked above) person pays yearly, etc.)

R. Shelter Expenses

Q

Check the boxes that apply and ﬁll in the amount.* 1.  Rent $ ________ (enter ONLY the amount you pay, NOT the amount paid by HUD, Section 8, MSHDA, etc.)  Monthly  Other  Weekly  Renter’s insurance $ __________ per year (answer ONLY if applying for MA for a nursing facility) 2. Does anyone pay for: Rent that includes meals (room/board)  Yes$ ___________  Weekly  Monthly  Other  No Meals only (board)  Yes $ ___________  Weekly  Monthly  Other  No 3.  Mobile home lot rent? $ ___________________________  Weekly  Monthly  Other 4.  Mortgage/mobile home/land contract $ _____________  Weekly  Monthly  Other 5.  Second mortgage or home equity loan $ _____________  Weekly  Monthly  Other 6. Shelter expenses billed separately from rent or mortgage:  Fuel Type (Ex. wood, gas, propane)  Heat (gas, electric, propane, wood, etc.)  Homeowner’s insurance $ ________________ per year  Cooling (including room air conditioner)  Property taxes $ ________________________ per year  Electricity (non-heat)  Special assessments $____________per____________  Water/sewer  Mortgage guarantee insurance $ _________ per ______  Cooking fuel  Cooperative/condominium/association fee $___________  Garbage/trash pick-up  Other _________________________________ $ _____  Telephone 7. Michigan Department of Treasury Home Heating Credit (HHC) - For the current ﬁscal year: a. Has anyone in your household who is applying for FAP received the HHC for the current address?  Yes  No b. Will anyone in your household who is applying for FAP, apply or expect to apply for, the HHC for the current address?  Yes  No

* If you are applying for medical assistance ONLY and you are in a nursing facility and have a spouse or dependent living at home, complete Section R. If you are applying for OTHER medical assistance ONLY, you may skip Section R.
DHS-1171 (Rev. 11-12) Previous edition obsolete. Q

S. Receipt of Beneﬁts

jS Q
 Yes  No
(maiden name, alias, former spouse, etc.)

1. Did anyone in your household ever apply for or receive beneﬁts from Michigan in the past?

If yes, under what name(s)? _______________________________________________________________ If yes, list Social Security number beneﬁts received under. _______________________________________ If yes, have you ever received a Bridge card?  Yes ___  No  If yes, who? ____________________________________________________________________________ If yes, does anyone have a mihealth card?
 Yes  No
For more information about these cards, see the Information Booklet.

Who does not have a mihealth card? ________________________________________________________ 2. Does anyone in your household receive Women, Infants, Children (WIC) beneﬁts?  Yes  No

If yes, who? ____________________________________________________________________________
3. Does anyone in your household receive tribal TANF (cash) beneﬁts?  Yes  No

If yes, who? ____________________________________________________________________________
4. Does anyone in your household receive Adoption subsidy/Guardianship Assistance Payments?  Yes  No

If yes, who? ____________________________________________________________________________
5. If attending college, university, etc., are you enrolled in/paying for a meal plan?  Yes  No

If yes, how many meals per week are included in the plan? _______________________________________ T. Information DHS Needs to Know
Answer for everyone in your household. • Has anyone ever been disqualiﬁed or had their beneﬁts reduced or stopped because they did not follow program rules in any State, including Michigan?  Yes  No

S Q

If yes, who? ____________________________________________________________________________ If yes, what State? ______________________________________________________________________
• Has anyone ever been convicted of fraud or signed a recoupment agreement and/or disqualiﬁcation paperwork for receiving cash or food assistance from two or more states for the same time period?  Yes  No

If yes, who? _____________________________
•

What program(s)? ______________________________ What state(s)? __________________________________________________________________________  No  No  No

Is anyone ﬂeeing from felony prosecution, ﬂeeing an outstanding felony warrant for their arrest, or jail?  Yes Has anyone ever been convicted of a drug-related felony occurring after August 22, 1996?  Yes

If yes, who? ____________________________________________________________________________
• •

If yes, who? __________________________________
Is anyone in violation of probation or parole?

Convicted more than once?  Yes  No  Yes

If yes, who? ____________________________________________________________________________
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U. Offer of State of Michigan Voter Registration Application

jS Q
 Yes  No

If you are not already registered to vote at your current address, would you like to register to vote?

NOTE: If you do not check either box, DHS will assume you have decided not to register to vote at this time. Checking ‘yes’ does not register you to vote. If you check ‘yes’ or do not respond, a voter registration application will be forwarded to you. Applying or declining to register to vote will not affect the amount of help that you will be provided by this department. If you would like help ﬁlling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may ﬁll out the voter registration application form in private. If you believe that someone has interfered with your right to: • • • • Register to vote. Decline to register to vote. Privacy in deciding whether to register or in applying to register to vote. Choose your own political party or other political preference. Secretary of State PO Box 20126 Lansing, MI 48901-0726

You may ﬁle a complaint with:

V. Representative, Guardian, Conservator or Person Helping with Application

jS Q
 Yes  No

1. If you are eligible for food assistance, do you want someone else to have a Bridge card and access to your food beneﬁts to shop for you?

If yes, enter his/her full name _______________________________________________________________
(This person will be your authorized representative.)

2. Are you ﬁlling this application out for someone else? Are you representing the person applying?

 Yes  No  Yes  No

Check one or both.

 If Yes is checked for one or both questions above, complete the following information:
Name Street address (number, street, rural route, apartment/lot number, PO box) City State Zip code Phone number

Representative’s relationship to applicant (check all that apply) If you are under age 18, are you married?  Guardian  Relative (specify) _______________________  Yes  No  Conservator  Other (specify) _________________________

DHS-1171 (Rev. 11-12) Previous edition obsolete.

S

W. Afﬁdavit
IMPORTANT: Before you sign this application, READ the afﬁdavit.

jS Q

Under penalties of perjury, I swear or afﬁrm that this application has been examined by or read to me, and, to the best of my knowledge, the facts are true and complete. If I am a third party applying on behalf of another person, I swear that this application has been examined by or read to the applicant, and, to the best of my knowledge, the facts are true and complete. I certify that I have received a copy, reviewed and agree with the sections in the assistance application Information Booklet explaining how to apply for and receive help: Programs, Things You Must Do, Important Things to Know, Repay Agreements, and Information About Your Household That Will Be Shared. I certify, under penalty of perjury, that all the information I have written on this form or told my DHS specialist or my representative is true. I understand I can be prosecuted for perjury if I have intentionally given false or misleading information, misrepresented, hidden or withheld facts that may cause me to receive assistance I should not receive or more assistance than I should receive. I can be prosecuted for fraud and/or be required to repay the amount wrongfully received. I understand I may be asked to show proof of any information I have given. When in-person interview completed: Date Signature of department witness/migrant recruiter

Signature of client or representative

Date

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T

Notes

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U

Notes

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V

Notes

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W

Notes

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X

Things You Must Do (continued)
Child Support Actions (Most Programs) (continued)
When you get a FIP grant, you give (assign) to DHS any current support for you (spousal support) or minor children in your home (child support). This means when you get FIP, some of the spousal or child support you get from someone else may go to DHS to pay back some of the FIP grant. You may get a child support payment that is owed to you while on FIP. If you do get a child support payment, call your local DHS ofﬁce to ﬁnd out if you can keep it. If your DHS worker tells you the payment was sent to you in error, you must return the money. If you do not return the money, you may lose your FIP grant or your grant may be reduced. If the amount of support DHS collects is more than your FIP grant for at least two months, DHS may close your FIP case so you can receive support payments directly. If you get MA for your children, you give (assign) your rights to current and past medical support to the Michigan Department of Community Health (MDCH). This means when you get MA, medical support payments you get from someone else will go to MDCH.

Follow Work Rules and Penalties (FIP or RCA and FAP)
Your work rules will depend on whether you receive FIP or RCA cash assistance, FAP beneﬁts with no cash assistance, or time-limited FAP beneﬁts.
FIP or RCA cash assistance work rules. Your family must complete a Family Automated Screening Tool (FAST) and develop a Family Self-Sufﬁciency Plan (FSSP). The FAST and FSSP requirements are for FIP only. The FSSP will list the work activities that you must do up to 40 hours per week to receive FIP. You design this plan with your DHS specialist and the work participation program. • Complete the FAST (FIP only). • Help make and comply with a FSSP (FIP only). • Not quit, refuse work or reduce work hours. • Not get ﬁred from a job due to misconduct or missing work. • Comply with assigned employment and/or selfsufﬁciency activities. Penalties for breaking FIP or RCA work rules. If you break the FIP or RCA work rules without good cause (see “Good Cause” on page 12), DHS will: • Deny your application (you may reapply). • Stop FIP for your whole family for three months for the ﬁrst time, six months for the second time and permanently for the third time. • Count all penalty months toward your 48-month lifetime limit. • Stop RCA for you for at least three months (but the rest of your household might be eligible). • If you receive both FIP and FAP, we may: – Stop or reduce your FAP beneﬁts for at least one month if you are not excused from FAP work rules. – Count your FIP grant amount as income. FAP work rules. (NOTE: If you receive both cash and food beneﬁts, you must follow FIP work rules.) • If you are working, you may not: – Quit a job of 30 hours or more per week. – Voluntarily reduce work hours below 30 hours per week without good cause. • If you are not working, or you work less than 30 hours per week, you may not: – Refuse a job offer. – Refuse to participate in required employment-related activities that must be done to receive FAP. Penalties for breaking FAP work rules. If you receive FAP and you break the work rules without good cause, your beneﬁts will stop or be reduced for: • At least one month for the ﬁrst time, and • Six months for any other time after the ﬁrst time. Time-limited food assistance rules. (NOTE: Time limits are not always in effect, so check with your DHS specialist.) Special time limits and work requirements might apply to you if you are: • A person without a disability. • At least 18 years old but under the age of 50, and • Living in a household with no children under age 18 (related or unrelated).

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 11

Things You Must Do (continued)
Work Rule Deferrals and Good Cause (FIP or RCA and FAP)
Work rule deferrals (excused). Some people who receive cash or food assistance may be excused from work rules. If you receive FIP and are excused from the work rules, you may have to do other activities. If you think you should be excused from work rules, talk to your DHS specialist. NOTE: Reasons for being excused may change. You may be excused from FIP or RCA work rules if you are: • Under the age of 16. • Age 65 or older. • A parent of a baby less than two months old. You may be assigned to family strengthening activities once the baby is six weeks old. • Working 40 hours per week. • Caring for a child or spouse with a disability (depending on the person’s needs and the child’s school attendance). • A person with a disability or medical limitations. • Experiencing a domestic violence situation (determined by DHS). You may be excused from FAP work rules if you are: • Age 60 or older. • Personally caring for a child under the age of six who is receiving FAP on your case. • Working 30 hours per week or earning at least minimum wage times 30 hours per week. • Attending high school, adult education, or a GED program at least half-time. • Injured, ill or personally caring for a household member with a disability. • Seven to nine months pregnant. • Pregnant with medical complications. • Applying for FAP at a Social Security ofﬁce. • In substance abuse treatment or rehabilitation. • Applying for or receiving unemployment beneﬁts. • Appealing the denial of unemployment beneﬁts. Good cause. You have the right to claim good cause if you believe you should be excused from the FIP, RCA and/or FAP work rules. If you think you have a good cause reason, contact your DHS specialist right away. NOTE: Reasons for good cause may change. FIP or RCA or FAP - Reasons for good cause: • An unplanned event or factor that does not allow you to meet the work rules (for example, domestic violence, religion, health or safety risk or homelessness). • Illness or injury. • You requested child care that was not provided. • You requested transportation services that were not provided. • Long commute (more than two hours per day or more than three hours per day with child care). • You quit a job to take a comparable job. • Your job required you to commit illegal activities. • You are physically or mentally unable to do the job. • Your employer discriminated against you based on age, race, color, sex, national origin, disability, religion, etc. • You are working 40 hours per week for at least the state minimum wage. • Reasonable accommodation was not provided. FAP only - You may have a good cause reason if you/your: • Are deferred. • Moved due to another household member’s job or education/training. • Have a job that requires you to retire or to join, resign from, or refrain from joining a labor union or organization. • Have a job that is on strike or at a lockout site. • Have unreasonable work conditions. • Have been offered a job that is outside of your work experience during the ﬁrst 30 days as a mandatory FAP work participant. • Employer is not able to keep the promise of work.

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 12

Important Things To Know
Penalties, Intentional Program Violation Or Fraud (FAP, FIP, SDA, CDC)
Intentional Program Violation (IPV) is when you make a false or misleading statement, hide, misrepresent or withhold facts on purpose to receive or continue to receive extra beneﬁts. Fraud/IPV - If we think you committed fraud/IPV, we may hold an administrative hearing, bring criminal charges or ask you to voluntarily sign a disqualiﬁcation agreement. FAP Trafﬁcking - You may also be guilty of fraud/IPV if you trade or sell your FAP beneﬁts or Bridge card. You may not use FAP beneﬁts or Bridge cards that belong to another household for your household. You may not use FAP beneﬁts or Bridge cards to purchase anything other than food or seeds and plants to grow your own food for your household. If it is proven in court that you are guilty of fraud: • You are subject to criminal penalties (for example, ﬁnes up to $250,000, jail/prison time up to 20 years, or both). You may be charged under other federal laws and a court may prevent you from receiving beneﬁts for an additional 18 months; and • You must repay any extra beneﬁts you received because of the fraud/IPV; and • You will be disqualiﬁed from receiving FIP/SDA and/or FAP beneﬁts - see the table below. If it is proven you are guilty of IPV in an administrative hearing, or you voluntarily sign a disqualiﬁcation: • You will be disqualiﬁed from receiving FIP/SDA and/or FAP beneﬁts - see the table below, and • You will have to repay the extra beneﬁts you received because of the fraud or IPV. CDC Penalties - Violation of program rules may result in a disqualiﬁcation of 6 months, 12 months or a lifetime. If you do any of the following: You will lose FIP/SDA and/or FAP beneﬁts for: • Make a false or misleading statement. • Hide, misrepresent or withhold facts to receive or continue to receive • One year for the ﬁrst violation. beneﬁts. • Two years for the second • Trade or sell less than $500 in FAP beneﬁts or Bridge cards. violation. • Use FAP beneﬁts to buy ineligible items such as alcoholic drinks or • Life for the third violation. tobacco. • Use FAP beneﬁts or Bridge cards that belong to someone else for your household. If you are: You will lose FAP beneﬁts for: • Convicted by a court or found guilty by administrative hearing of lying • 10 years. about your identity or where you live to receive beneﬁts on two or more cases at the same time. If you are: You will lose FIP beneﬁts for: • 10 years. • Convicted in court of lying about your identity or where you live to receive beneﬁts* in two or more cases at the same time. *Beneﬁts include programs funded under Title IV-A of the Social Security Act, Medicaid and Supplemental Security Income. This penalty will not stop you from receiving MA. If any member of the household is found guilty in court of: You will lose FAP beneﬁts for: • Trading FAP beneﬁts for drugs. • Two years for the ﬁrst offense. • Life for the second offense. You will lose FAP beneﬁts for: If any member of the household is found guilty in court of: • Trading FAP beneﬁts for ﬁrearms, ammunition or explosives. • Life. • Trading, buying or selling FAP beneﬁts of $500 or more for anything other than food.
Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 13

Important Things To Know (continued)
General Complaints
Clients have the right to make general complaints about matters other than the right to apply, non-discrimination or hearing issues. Written complaints can be sent to:
Michigan Department of Human Services Specialization Action Center 235 S. Grand Avenue PO Box 30037 Lansing, MI 48909 or they may call 1-855-275-6424 or 1-855-ASK-MICH • For FAP only, you can request a hearing verbally, in person or by telephone. • The hearing request must be signed by you or by your parent, spouse, attorney, court-appointed guardian or conservator, or by someone else you name in a signed statement. Michigan Administrative Hearings Service (MAHS) will deny your hearing request if: • We receive your request more than 90 days after we mailed the notice to deny, terminate, or reduce your beneﬁts. • The person who signed the hearing request cannot show a court order or signed statement from you and is not your lawyer, spouse or parent.

Hearing Rights
If you do not agree with a decision DHS makes to deny, reduce or terminate beneﬁts, or for failure to act with reasonable promptness you have the right to request a hearing. In most cases, if you receive a notice reducing or canceling your beneﬁts and you request a hearing within 11 days of the date the action will take place, your beneﬁts will continue until the hearing is held. Someone else may represent you at the hearing, such as a friend, relative, or lawyer. To ask for a hearing: • Bring, mail or fax a signed, written hearing request* to your DHS ofﬁce.
* DHS-18 available online at www.michigan.gov/dhs-forms.

If You Think We Discriminate
“In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.” To ﬁle a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Ofﬁce of Adjudication, 1400 Independence Avenue, S.W., Washington D.C. 20250Answering questions about race and ethnicity is voluntary. If you do not answer these questions, your eligibility or beneﬁt levels will not be affected.* The information is collected to ensure that program beneﬁts 9410 or call toll free (866) 632-9992 (Voice). Individuals who are hearing-impaired or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). Write HHS, Director, Ofﬁce for Civil Rights, DHHS, 233 N. Michigan Ave., Suite 240, Chicago, IL 60601 or call (312) 886-2359 (Voice); (312) 353-5693 (TDD); fax (312) 886-1807. “USDA and HHS are equal opportunity providers and employers.” are distributed without regard to race, color or national origin. * If you choose not to answer these questions, your DHS specialist may choose an answer for you.

Race and Ethnicity

**Citizens and Non-Citizens/Social Security Numbers
Social Security numbers and immigration papers Receiving food, medical, or emergency assistance are NOT required for a person who is: will not affect your immigration status. If you are here illegally, it may affect your ability to stay in the U.S. • Not applying for help. For some programs, persons claiming U.S. citizenship • An undocumented non-citizen applying only must provide proof of citizenship and identity. Acceptable for medical assistance for emergency services, proof of citizenship includes, but is not limited to, a U.S. pregnancy or childbirth. passport, a certiﬁcate of naturalization, a U.S. public birth • Only applying for child care. (You must give a Social record showing birth in the U.S. or U.S. territories. Security number for the child and the child must be a U.S. citizen or show immigration papers.) Persons receiving SSI, Social Security, Medicare, or adoption assistance; foster children, and newborn “safe Other eligible members of your household will still be delivery” babies are not required to provide proof of able to receive help. U.S. citizenship for DHS programs. You may have to provide information about income and assets of all persons in your household, even if they are not applying. **See pages C-H of this booklet. Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 14

Important Things To Know (continued)
Welfare Fraud
Call 1-800-222-8558 to report suspected welfare fraud.

Persons With Disabilities
You do not have to tell us about disabilities, but some help is only available to persons with disabilities. If you or someone in your household has a disability, we can make exceptions or give you special help. Tell your DHS specialist if you need help. If you do not tell us about a disability now, you can tell us about it later. We may be able to waive some program requirements (such as working, looking for a job, pursuing child support or going to school) if participating would: • • • Put you or a family member in danger of physical or emotional harm. Subject you to sexual abuse. Otherwise be unfair to you. If you are denied special help or an exception you need because of a disability, and you think the denial was wrong, you may ﬁle a complaint of discrimination with: DHS, Americans with Disabilities Act Coordinator P.O. Box 30037, Suite 715 Lansing, MI 48909 (517) 373-8520 You are authorized to receive domestic violence comprehensive services. Contact the DHS ofﬁce in your area or your DHS specialist for more information or to access these services. Resources: • • Online at: www.michigan.gov/domesticviolence. DHS Publication 859, Is Someone Hurting You or Your Children? (also available in Spanish) online at: www.michigan.gov/dhs-publications.

Domestic Violence

If You Receive Tribal Beneﬁts
You cannot receive food beneﬁts from the tribal food distribution program and the food assistance program at the same time. You cannot receive tribal TANF (cash) from a tribe and FIP cash beneﬁts from DHS at the same time. Tribal organizations may receive LIHEAP funds from the federal government. Payments are limited to the highest amount available from either DHS or the tribal organization. DHS will ask you to prove any tribal LIHEAP payment you receive.

Bridge Card
Cash and/or food beneﬁts are accessed by using a debit card. This debit card is called the Bridge card or Electronic Beneﬁt Transfer (EBT) card. Call EBT Customer Service toll-free at 1-888-678-8914 to: • Report a lost, stolen or damaged card. • • • Request a replacement card (your beneﬁts may be reduced when replacing your Bridge card). Establish/change your personal ID number (PIN). Find out your balance.

Repay Agreements
By signing the assistance application, you agree to do these things:

Recovery of Medical Costs (MA, AMP)
If any program run by the Michigan Department of Community Health (MDCH) pays the cost of hospital, surgical or medical services, you agree that the right to recover payments (from insurance, lawsuits, etc.) is transferred to the MDCH. This includes payments from a third person or public or private contractor. Any recovery payment you receive must be paid to the State of Michigan, MDCH. Exception: Payments are not recovered from Medicare.

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 15

Repay Agreements (continued)
By signing the assistance application, you agree to do these things:

Estate Recovery (MA - Long Term Care (LTC)
I understand that upon my death the Michigan Department of Community Health (MDCH) has the legal right to seek recovery from my estate for services paid by Medicaid. MDCH will not make a claim against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. If you receive SDA, you agree to repay DHS if you receive: Lump sum payments such as an inheritance, insurance settlement, etc., or • Accumulated beneﬁts paid retroactively such as unemployment beneﬁts or workers’ compensation. If you receive SDA or state-funded FIP, you agree to repay DHS if you receive retroactive SSI. • An estate consists of real and personal property. Estate Recovery only applies to certain Medicaid recipients who received Medicaid services after the implementation date of the program. MDCH may agree not to pursue recovery if an undue hardship exists.

Lump Sums and Accumulated Beneﬁts (SDA, State-Funded FIP)
You agree to allow Social Security Administration to pay DHS the amount of statefunded assistance you received while your SSI claim was pending. If the ﬁrst accumulated beneﬁt payment is sent to you, you agree to pay DHS right away for the state-funded assistance you received while the claim was pending. If you disagree with the amount DHS keeps, see “Hearing Rights.”

Information About Your Household That Will Be Shared
By signing the assistance application, you agree that DHS can share information about you and your household with others, and that other agencies or people can give us information about you, as stated below:

Information DHS Will Get From Others
Social Security Administration information (all programs) - You agree that the Social Security Administration may give DHS all information needed to determine your eligibility. Quality Control (QC) and/or Ofﬁce of Inspector General (OIG) Investigations - DHS might choose your case for a quality control review or a complete investigation. If your case is chosen, DHS will contact you, other people, employers and/or agencies for proof of the information provided on your assistance application. Law enforcement check (FAP, FIP, SER) DHS receives information from law enforcement ofﬁcials for the purpose of catching persons ﬂeeing to avoid the law. Child care billing information (CDC) Information submitted by your child care provider will be used in determining payment amounts. Computer cross-checking (all programs) DHS will check with federal, state and private agencies to make sure the information you provide on the assistance application is correct. DHS may check wages, income, assets, unemployment beneﬁts, income tax refunds, Social Security beneﬁts and numbers, child support, immigration status, etc. If you give any information that does not match, DHS will check to ﬁnd out what is correct. You may be asked for permission to contact employers, banks or other people. DHS will check records from other states. You may be denied beneﬁts in Michigan if you or other household members were disqualiﬁed in another state.

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 16

Information About Your Household That Will Be Shared (continued)
By signing the assistance application, you agree that DHS can share information about you and your household with others, and that other agencies or people can give us information about you, as stated below:

Information DHS Will Give To Others
Law enforcement check (FAP, FIP, SER) - DHS may give information to law enforcement ofﬁcials for the purpose of catching persons ﬂeeing to avoid the law. Eligibility information (FAP) - DHS sends food assistance program (FAP) eligibility information to schools. This information allows your child(ren) to receive free or reduced-cost meals. CDC - Notice will be sent to your child care provider when: • Your CDC has been approved and authorized. • Changes occur that impact your CDC eligibility. • Your CDC eligibility has ended. Illegal Aliens - DHS may send information about certain illegal aliens to the Department of Homeland Security. Survey Information - You may be contacted for survey information to help evaluate DHS’ quality of programs and customer service.

Coordination of Health Care
• Coordination of health care programs and providers (MA) - The State’s medical assistance program relies on a large number of managed care health programs, mental health and substance abuse programs, and private providers to deliver quality care to persons like you. To make sure you receive a high level of care and that your beneﬁts are coordinated, providers in the program may share information about your care (or your child or ward) with other providers in the program when such information and consultation is clinically needed. • Information about you, your child or ward (MA) - Necessary information may be shared between Medicaid managed care health plans and programs in which you participate. Health plans, programs and providers that deliver health care to you may share necessary information in order to manage and coordinate health care and beneﬁts. This information may include, when applicable, information relative to HIV, AIDS, AIDS-related complex (ARC) or other communicable diseases, information about behavioral or mental health services, and referral or treatment for alcohol and drug abuse as permitted by 42 CFR Part 2.

Web Site References
• • • • • Career education and workforce programs: www.michigan.gov/mdcd Earned Income Tax Credit: www.michiganeic.org Energy Assistance Programs: www.michigan.gov/heatingassistance Family Automated Screening Tool (FAST): www.michigan.gov/fast Michigan Assistance and Referral Service (MARS) program eligibility pre-screening tool: www.michigan.gov/mars NOTE: To ﬁnd out if you may be eligible for any of our programs, you may visit the MARS Web site. You will be asked for information about your family and household that will help determine if you might qualify. • Michigan Department of Community Health (MDCH): www.michigan.gov/mdch – Healthy lifestyles: www.michiganstepsup.org – Ofﬁce of Services to the Aging: www.michigan.gov/miseniors – Women, Infants and Children (WIC) program: www.michigan.gov/wic
Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 17

Web Site References (continued)
• Michigan Department of Human Services (DHS): www.michigan.gov/dhs – Cash Assistance www.michigan.gov/dhs-cash – Cash Assistance - SSI www.michigan.gov/dhs-ssi – Child Care www.michigan.gov/childcare – Child Support www.michigan.gov/childsupport – Client Application Process www.michigan.gov/dhs-applicationprocess – DHS County Ofﬁces www.michigan.gov/dhs-countyofﬁces – DHS Forms and Applications www.michigan.gov/dhs-forms – DHS Policy and Procedural Manuals www.michigan.gov/dhs-manuals – Emergency Services www.michigan.gov/dhs-ser – Food Assistance www.michigan.gov/foodstamps – Medical Services www.michigan.gov/dhs-medical Michigan Disability Resources: www.michigan.gov/disabilityresources

•

Publications
Ask your DHS specialist if you would like any of these publications. The following publications are available online at: www.michigan.gov/dhs-publications. Some are also available in Spanish (Sp). • Child Support Understanding Child Support: A Handbook for Parents (DHS Publication 748) (Sp). What Every Parent Should Know About Establishing Paternity (DHS Publication 780) (Sp). Fatherhood: Taking Responsibility for Your Child (DHS Publication 806). DNA Paternity Testing: Questions and Answers (DHS Publication 865) (Sp).

•

Home Heating Credit - Notice to Potential Home Heating Credit Recipients (DHS Publication 788) (Sp). The following publications are available online at: www.michigan.gov/mdch. Select MDCH Brochures Available for Download from the Quick Links. • Medicaid Healthy Kids (MDCH Publication 655) - explains medical coverage for pregnant women, babies, and children. Medicaid Fair Hearings: Rights and Responsibilities (MDCH Publication). Your Rights and Responsibilities in a Health Plan (MDCH Publication 201). Medicaid Deductible Information (MDCH Publication 617) - explains how your medical costs can be used to get your income at or below the income limits to be eligible for Medicaid. Nursing Facility Eligibility (MDCH Publication 726) - explains eligibility for persons in or entering a nursing facility. Medicare Savings Program: (MDCH Publication 769) - explains how to get help paying Medicare expenses. Medicaid Fee for Service Handbook (MDCH Publication 669). State Emergency Relief State Emergency Relief Program (DHS Publication 563). You and Your Energy Bills (DHS Publication 631). DHS Can Help With Temporary Assistance (DHS Publication 783).

•

Read this information booklet before you sign the assistance application.
DHS-1171 Information Booklet (Rev. 11-12) Previous edition obsolete. 18

Filing Form
Michigan Department of Human Services (DHS)
You have the right to apply for help today. If you cannot ﬁnish the entire assistance application today, you may complete this ﬁling form and return it to the DHS ofﬁce in your area to protect your application date. If applying for only FAP, you must ﬁll in your name, address (unless homeless) and signature or your representative’s signature.* The date DHS receives your ﬁling form may affect the date your beneﬁts start. DHS will still need to receive your completed assistance application before any beneﬁts can be approved.
*Exception: If you are applying for SSI and FAP beneﬁts before being released from an institution, the ﬁling date for your beneﬁts will be the date you get out of the facility.

If you need help ﬁlling out this application, DHS must help you. If you are refused help, you may call (855) 275-6424. If you do not speak English or you have a disability, how can we help you?  Interpreter  Sign language  Assisted listening device (ALD)  Other _____________ If you do not speak English, what language do you speak? _________________________________ 1. I received help from Michigan in the past.  Yes  No Case/recipient number ___________
(if known)

2. I am applying for:  Food Assistance Program (FAP) (seven-day processing can begin today if you complete the back of this form and your household qualiﬁes).  Medical Assistance (MA) (doctor or hospital bills, prescriptions, Medicare premiums).  Child Development and Care (CDC) (help with child care costs).  Cash Assistance (FIP- Family Independence Program, RCA - Refugee Cash Assistance, SDA - State Disability Assistance) (help with cash for pregnant women, families with children, refugees, adults with disabilities, live-in caretakers of adults with disabilities or residents of special living arrangements). 3. Legal name (ﬁrst, middle, last; birth name, if different) 4.  Male  Female 5. Date of birth** / /
**Not needed for food assistance.

6. Social Security number***
– –

7. Phone number
– –

8. Message number
– –

***Voluntary if applying ONLY for child care or emergency medical.

9. Address where you live (number, street, rural route, apartment/lot number) City County State

 Homeless Zip code

10. Mailing address (if different from above or PO box) City County State Zip code

Signature
Under penalties of perjury, I swear or afﬁrm that this ﬁling form has been examined by or read to me, and, to the best of my knowledge, the facts are true and complete. If I am a third party applying on behalf of another person, I swear that this ﬁling form has been examined by or read to the applicant, and, to the best of my knowledge, the facts are true and complete. Signature of client or representative Date
Read this information booklet before you sign the assistance application.
DHS-1171-F Information Booklet (Rev. 11-12)

Expedited Food Assistance Program Seven-Day Processing



1. Does everyone in the household buy and ﬁx food together?  Yes  No If no, list who does not __________________________________________________________________ 2. How much are the total cash assets belonging to your household? (Include cash, savings, checking, savings bonds, etc.)  $ ____________

 3. How much is the total monthly gross income (before any deductions such as taxes) for your household? (Include earnings, unemployment beneﬁts, child support, Social Security beneﬁts, etc.) $ ____________ 4. Does anyone in your household receive tribal food distribution beneﬁts?  Yes  No If yes, list who ________________________________________________________________________ 5. What is the total amount you pay for your monthly rent and/or mortgage payment, property taxes, homeowners insurance, etc.? $ ____________ 6. Do you pay for heat? 7. Do you pay for cooling (including room air conditioner)?  Yes  Yes  No  No

8. If you do not pay for heating or cooling, check which utilities you pay: Non-heat electric Water/sewer    Telephone  Cooking fuel  Garbage/trash 9. Is anyone in your household a  migrant or  seasonal farmworker?  Yes  Complete the table below.  No Has anyone received any Date income from the same grower within 30 days before  Yes Name of person(s):  No the application date? Does anyone expect to receive  Yes Name of person(s): more income this month?  No Has anyone received a travel advance? Has anyone recently lost their only source of income?  Yes Name of person(s):  No  Yes Name of person(s):  No Birth date Last pay date Gross pay amount Social Security number

Gross pay amount

10. Names of all household members

11. Do you need more pages?  Yes
For ofﬁce use only

 No
Case name Application number Specialist name Specialist phone Specialist email Fax Case number

Date application received in local ofﬁce

Read this information booklet before you sign the assistance application.
DHS-1171-F Information Booklet (Rev. 11-12)

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