Medicaid Disability Application

KEEP THIS BOOKLET FOR YOUR RECORDS
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.
Information Booklet
Assistance Application
Steps to Assistance
1 - 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. 2 - 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. 3 - 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. 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 representatives signature (someone filing for you). Before you can be approved for help, you must complete the assistance application.
Department of Human Services (DHS) will not discriminate against any individual or group 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 ningn individuo o grupo a causa de su raza, religin, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, sexo, orientacin sexual, identidad de sexo o expresin, creencias polticas o incapacidad. Si usted necesita ayuda para leer, escribir, or, etc., bajo la Acta de Americanos con Incapacidades, usted est invitado a hacer saber sus necesidades a una oficina de DHS en su rea.
Local office address
DHS specialist name, phone number and email address
DHS-1171 Information Booklet (Rev. 4-09)
Read this information booklet before you sign the assistance application.
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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 10 days 30 days 45 days 45 days 30 days 60 days 10 days Food Assistance Expedited (seven-day processing).................................. Food Assistance Program .............................................. Medical Assistance. .......................................................... With a medical decision on disability. ............................. For pregnant women....................................................... RAPM.............................................................................. Child Development and Care............................................ Cash Assistance Family Independence Program ...................................... Refugee Assistance Program. ........................................ State Disability Assistance.............................................. State Emergency Relief.....................................................
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Your household may qualify for seven-day processing of your food assistance application if:
Expedited Food Assistance Program (Seven-Day Processing)

If your household qualifies for seven-day processing you must:
You have less than $150 in monthly gross Participate in an interview, and income and $100 or less in liquid assets (cash Provide proof of your identity, and on hand, checking or savings accounts, sav Complete the entire application form. ings certificates), or To continue receiving food assistance benefits, Your combined gross income and liquid assets you will be asked to provide proof of other are less than your monthly rent and/or mortinformation (like income, residency, etc.). If you gage 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. A face-to-face interview may be waived and replaced by a telephone interview if your household has a hardship. Hardships include, but are not limited to: Illness. For most programs, DHS will need proof of your households income. If you have proof, send or bring it with your assistance application. Some ways to prove income are: FFCheck stubs Child support receipts FFSocial Security award letter FFSelf-employment records of income and expenses If we need proof, we will send you a list of what we need.
Food Assistance Program (FAP) Interviews
We May Need Proof
Transportation problems. Work hours that prevent participation in an inoffice interview. Tell us if you have a hardship and need a telephone interview. For some programs, we MAY need proof of: FFAge and/or identity Immigration status FFU.S. citizenship Pregnancy FFCurrent medical insurance card FFSchool enrollment, anyone age 16-19 FFIncome that recently started or stopped FFAssets (cash on hand, checking/savings accounts, credit union accounts, etc.) If you need help getting proof, ask your DHS specialist.
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Programs
TABLE OF CONTENTS
Food Assistance Program (FAP). .................................................................................................... 4 Adult Medical Program (AMP)......................................................................................................... 4 - Employer Sponsored Insurance Option.......................................................................... 4 Resident County Hospitalization (RCH)........................................................................................... 4 Medical Assistance (MA). ................................................................................................................ 5 Child Development And Care (CDC)............................................................................................... 6 Family Independence Program (FIP)/Refugee Assistance Program (RAP).................................... 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 Follow Labor Laws If Your Child Care Provider Works In Your Home (CDC)................................ 10 Child Support Actions (Most Programs)......................................................................................... 11 Follow Work Rules and Penalties (FIP or RAP and FAP).............................................................. 11 Work Rule Deferrals and Good Cause (FIP or RAP and FAP)...................................................... 12 Important Things To Know Penalties For Intentional Program Violation Or Fraud (FAP, FIP, SDA)......................................... 13 Hearing Rights............................................................................................................................... 14 If You Think We Discriminate......................................................................................................... 14 Race and Ethnicity......................................................................................................................... 14 Citizens and Non-Citizens. ............................................................................................................ 14 Persons With Disabilities............................................................................................................... 14 Domestic Violence......................................................................................................................... 15 If You Receive Tribal Benefits........................................................................................................ 15 Bridge Card.................................................................................................................................... 15 Repay Agreements Recovery of Medical Costs (MA, AMP).......................................................................................... 15 Lump Sums and Accumulated Benefits (SDA).............................................................................. 15 Information About Your Household That Will Be Shared ......................................................................................... 16 Information DHS Will Get From Others. Information DHS Will Give To Others. ............................................................................................ 16 Coordination of Health Care ......................................................................................................... 16 Web Site References......................................................................................................................... 17 Publications....................................................................................................................................... 18 Filing Form......................................................................................................................................... 19
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Food Assistance Program (FAP)

FAP provides benefits that can be used to buy food (or 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 income. No income. 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).
Programs
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. To get a deduction for an allowable expense, you must report and provide proof of the expense if asked by your DHS specialist. If you do not report or provide proof of the expense, we assume you do not want to receive a deduction for the expense. 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 pages 11, 12. Child Support Services - see page 8. Child Support Actions - see page 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. Limited enrollment. We limit the number of people who can receive AMP in Michigan. When Employer-Sponsored Insurance Option
we reach the limit, we must deny your application, even if you meet the eligibility rules. If your employer offers health insurance, AMP may help pay your insurance premium. Instead of receiving AMP, you could receive a voucher (equal to the cost of AMP) to help pay your cost of your employers health insurance plan.
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
DHS-1171 Information Booklet (Rev. 4-09) 4
Do not have other insurance to pay for inpatient hospital care. Each county sets its own financial eligibility rules. For more information, contact the DHS office in your area.
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): Family Independence Program recipient. 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. NOTE: The child must be under age 18, or a full-time high school student graduating before age 20. 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.
If you are applying for MA, also known as Medicaid, we must give you a Medicaid Healthcare Coverage brochure with more complete information. Contact the DHS office in your area if you do not receive this brochure.
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 (DCH) pays for the services covered by Medicaid. DCH 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 page 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 childrens 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.
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 or preventive services case participating in a treatment plan. A FIP or Supplemental Security Income (SSI) recipient. A FIP applicant doing a required Michigan Works! Agency (MWA) activity. You must have a child care need because of: 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. 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* day care aide providing care in the childs home. DHS enrolled* relative care provider providing care in his/her own home. NOTE: The relative must be a grandparent/ step-grandparent, great-grandparent/stepgreat-grandparent, aunt/step-aunt/great-aunt/ step-great-aunt, uncle/step-uncle/great-uncle/ step-great-uncle, or sibling/step-sibling of the child needing care and must not live in the same home as the child.
and prevention and childrens protective services families 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? DHS child care rates are based on the type of provider you choose, the area where the care is provided and the childs age. Current rates are available from your DHS specialist. If you are eligible because you are a low-income family, we pay 70% to 100% of child care costs up to the DHS maximum rate. The percentage depends on your gross monthly income and eligibility. You are responsible for any child care costs not paid by DHS. Program requirements: Child Support Services - see page 8. Child Support Actions - see page 11. Resources: 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 local Community Coordinated Child Care (4C) Association at: 1-866-4CHILDCARE (1-866-424-4532) or online at: www.mi4C.org Gross Monthly Income $0-1607 $0-1990 $0-2367 $0-2746 $0-3123 $0-3500 $0-3877 $0-4254 $0-4634
* 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. How much money can you make and still be eligible? FIP and SSI recipients, licensed foster parents,
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Family Independence Program (FIP) Refugee Assistance Program (RAP)

The main goal of cash assistance programs is to help families become self-supporting and independent. FIP is temporary cash assistance for lowincome families with minor children. RAP is temporary cash assistance for persons recently admitted into the U.S. as refugees. To qualify for FIP or RAP, you must have: Low income, and Cash assets less than $3,000. 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 18-19). 48-month lifetime limit: You cannot receive FIP for more than 48 months in your lifetime unless you qualify for an extension or an exception. Months before October 2007 do not count. Months do not count if you are: Deferred.* Working and following your Family Self-Sufficiency Plan.*
*See Things You Must Do: Follow Work Rules and Penalties.
Living in a county with a high unemployment rate. You may be eligible for RAP if you are: 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. The FIP or RAP grant amount is based on: Number of people in your household group. Court-ordered child support expenses paid by your household. Total income. Child support payments. If child support payments are collected for children on the FIP grant, we may send you some of the support collected each month. We will keep the rest. If the child support collected is more than your FIP grant for at least two months, we will close your FIP case so you can receive the child support payments directly. Program requirements: Follow Work Rules and Penalties - see pages 11, 12. Child Support Services - see page 8. Child Support Actions - see page 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. A person is considered disabled if (s)he is one of the following: 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. 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: 65 or older. Permanently or temporarily disabled. Taking care of a person with a disability who lives with you. AND you have: Cash assets of $3,000 or less, and Low income (different limits for single and married persons).
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. You do NOT have to receive other help from DHS in order to qualify for SER. 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. An OCS support specialist can help: Locate a childs absent parent(s). Establish a childs legal father by: - Voluntary paternity papers. - Court action for paternity. Establish a child support order. Child support services are available if: A child lives in your home whose parent(s) do(es) not live there. 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.
Covered services include: 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 and type of service requested and other factors.
Child Support Services
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 Central Functions Unit PO Box 30744 Lansing, MI 48909 Return the completed DHS-1201 to the DHS in your area, the local PA or FOC, or the address above.
Early On
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.
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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)
By
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. To find the local weatherization operator in your area, go to: www.michigan.gov/dhs-womap Resources: LIHEAP - call the toll-free DHS Energy Assistance hotline at 1-800-292-5650. HHC or WAP - go to: www.michigan.gov/heatingassistance
signing the assistance application, you agree to do these things. ceiving the first payment reflecting the change). 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 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.
Things You Must Do
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 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. 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 re
*Exception: 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.
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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.) You must apply for other benefits you may qualify for, such as: Unemployment benefits. Social Security and Supplemental Security Income (SSI) benefits. 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. 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.
Provide Social Security Numbers (Most Programs)

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 or 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.)
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)

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 familys religious beliefs. Pay at least minimum wage. Provide a W-2. If you fail to follow federal laws, you may have to pay fines and penalties to the federal government. For more information, contact a tax expert.
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Follow Labor Laws If Your Child Care Provider Works In Your Home (CDC)
If your child care provider is caring for your child(ren) in your home (day care aide), you are the employer and must comply with federal labor laws. Under federal law, you may have to: Pay employer taxes (Social Security, Medicare, unemployment, etc.).
Michigan Department of Human Services (DHS) Instructions

Assistance Application
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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.
c c c c c
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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? c Yes c No Child Development and Care (CDC) (help with child care payments). Cash Assistance (FIP - Family Independence Program, RAP - Refugee Assistance Program, 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 online at www.michigan.gov/dhs-forms.
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 (517) 3730707. 1. If you do not speak English or you have a disability, how can we help you? c Interpreter c Sign language c Assisted listening device (ALD) c 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 (517) 373-0707. 1. Si usted no habla ingls o tiene una incapacidad, como podemos ayudarle? c Intrprete c Dactilologa c Dispositivo vivo asistido (ALD) c Otro_________________________ 2. Si usted no habla ingls, qu 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. 4-09) Previous edition obsolete.
A. Address Information
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c Juvenile residential facility c Community justice center c Domestic violence shelter c Halfway house c Assisted living c Date unknown c Does not apply
1. Check where you live: c House/apartment/mobile home c Homeless c Other____________________ If you live in a facility or special living arrangement, or have lived in one in the last three months, check what type below: c Home for the aged c Hospital c Jail/prison c Childrens group home c County infirmary c Emergency c Adult foster care home c Nursing facility housing/shelter c Mental health or c Drug or alcohol c Commercial boarding house psychiatric facility treatment center 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
State Cell phone
Zip code
County Work phone
4. Home phone
Phone number where we can leave a message Telephone Typewriter (TTY) number
Whose number is it? (name/relationship) Email address
5. Have you moved from, or received assistance from, another state any time after August 1996? c Yes c No If yes, what state?______________________________ Date you moved to MI What county?_ _____________________________ Caseworker phone number What was your caseworkers name?
6. Do you and your household intend to remain in Michigan (MI)? c Yes c No 7. Did you or someone in your household come to MI with a job commitment or looking for work? c Yes c No 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) City State Zip code County
B. Food Assistance Information
1. Does everyone in the household buy food and fix or eat meals together? c Yes c 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? c Yes c No If yes, list who_ ____________________________________________________________________________
C. Information About You and Your Household
c j S Q
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. so, include your sponsors information in one of the boxes below.
- The patient first.
If you are an alien with a sponsor who has agreed to financially support you, even if (s)he is not doing If you are filling out the application for a patient in a nursing facility, list:

- The patients spouse.
- Any dependents living at home.
Spaces for five more persons in your household are available on the next three pages.
Do you need more household pages? c Yes c No Answer for person 1. Check all boxes that apply. 1. Name (first, middle initial, last; birth name, if different) 2. Date of birth 3. Relationship to you _ __________________________________________________ _ ___________________ _ _________________ SELF 4. c Male c Female 6. Marital status 5. Social Security number* c Never married c Divorced
* (optional if applying ONLY for child care or emergency medical services)
c Married
c Widowed
c Separated
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: ___________ Mothers Maiden Name _______________________ Place of Birth
(county, city, state)
8. Pregnant now/last three months c Yes c No If yes,4Due date/pregnancy end date Number expected/had c One c Twins c Triplets c Other_________________ c Full-time 10. In school now? c Yes c No If yes,4School name________________________________ c Half-time c K-12 c GED c College c Trade school c University c Vocational c Other ***Is the education plan approved? (Complete DHS-4749) c Yes c No 11. Ethnicity (optional) c Hispanic/Latino c Not Hispanic/Latino 12. Race (optional) c American Indian/Alaska Native Enter tribe name________________________________ c Asian c Black/African American c Native Hawaiian/Other Pacific Islander 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____________ at another address? 15. How many days each month does this person stay at the application address? Other address ___________________________________________________________________________ (number, street, , city, state, ***For 16. What kind of help does this person need? c Medical c Emergency help c Food c Child care c Cash assistance c None (not applying) **Applies to FIP, Medicaid and RAP applicants only
DHS-1171 (Rev. 4-09) Previous edition obsolete. C
9. Highest grade completed in school_____________
c Received GED
Answer for person 2. Check all boxes that apply.

1. Name (first, middle initial, last; birth name, if different) 2. Date of birth 3. Relationship to you _ ______________________________________________________ ______________________ ____________________ 4. c Male c Female 6. Marital status 5. Social Security number* c Never married c Divorced
c Married
c Widowed
c Separated
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: ___________ Mothers 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 9. Highest grade completed in school_ ________________ c Received GED 10. In school now? c Yes c No If yes,4School name_ ____________________________________ c Half-time c K-12 c GED c College c Trade school c University c Vocational c Other ***Is the education plan approved? (Complete DHS-4749) c Yes c No 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_
***For local office use only (number, street, , city, state, zip code)
16. What kind of help does this person need? c Food c Child care
**Applies to FIP, Medicaid and RAP applicants only
c Medical c Cash Assistance
c Emergency help c None (not applying)
c Married
c Widowed
c Separated
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: ___________ Mothers 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 Other___________________ c One
9. Highest grade completed in school_ ________________ c Received GED c Full-time 10. In school now? c Yes c No If yes,4School name_ ____________________________________ c Half-time c K-12 c GED c College c Trade school c University c Vocational c Other ***Is the education plan approved? (Complete DHS-4749) c Yes c No 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_ ____________________________________________________________________________________
**Applies to FIP, Medicaid and RAP applicants only DHS-1171 (Rev. 4-09) Previous edition obsolete.

D

c Married
c Widowed
c Separated
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: ____________ Mothers 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 Other___________________ c One
***For local office use only
(number, street, , city, state, zip code)
16. What kind of help does this person need? c Food c Child care **Applies to FIP, Medicaid and RAP applicants only
1. Name (first, middle initial, last; birth name, if different) 2. Date of birth 3. Relationship to you _ ______________________________________________________ ______________________ ____________________ 4. c Male c Female 6. Marital status 5. Social Security number* c Never married c Divorced c Married c Widowed
c Separated
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: ____________ _ Mothers 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___________________
16. What kind of help does this person need? c Food c Child care to FIP, Medicaid and RAP applicants only **Applies

E

c Married
c Widowed
c Separated
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: ___________ Mothers 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___________________
***For (number, street, , city, state,
**Applies to FIP, Medicaid and RAP applicants only
Do you need more pages? Yes No Check box(es) below if: If person under age Parents were ever 22 does not live married to each other. List person(s) List name of Check if with a parent, Paternity was legally under age 22 mother/father parent is who do they established. in the household (first, middle, last) deceased live with? Support is court-ordered. c Married Mother Name c Yes c Paternity c Support Relationship Father c Yes Order #_ ____________ Mother Father Mother Father Mother Father c Yes c Yes c Yes c Yes c Yes c Yes Name Relationship Name Relationship Name Relationship c Married c Paternity c Support Order #_ ____________ c Married c Paternity c Support Order #_ ____________ c Married c Paternity c Support Order #_ ____________
F
D. Household Members Under Age 22
c j S Q
E. Medical Information
Do you need more pages? Yes No
c S
1. List anyone in your household who is a victim of domestic violence____________________________ c None 2. List any children under six years of age who are not up-to-date on their immunizations (shots)_____________________________________________ c None 3. List any children in an Early On program_______________________________________________ c None Name and phone number of Early On coordinator_________________________________________ 4. List any children who receive Childrens Special Health Care Services_________________________ c None 5. List anyone who is now or has ever been in a special education class_ _________________________ c None Name and phone number of school_ ___________________________________________________ 6. List anyone going to an alcohol or drug treatment program_ _________________________________ c None 7. List anyone working with Michigan Rehabilitation Services__________________________________ c 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________________ c None 9. Is the caregiver able and available to work in addition to caring for someone? 10. List any person in your household who is blind or has a disability. Person Medical condition c Yes c No c None Is this person able to work? c Yes c Yes c Yes c No c No c No
F. Medical Coverage
c Yes
c
c No c Accident (home or car insurance, etc.) c MIChild c Plan/contract (life care contract, etc.) Name and address of insurance company
Does anyone in your household have, or expect to have, medical coverage (other than Medicaid)?
4 Check which type of coverage and complete the table below.
c Health/hospital insurance (employer, parent, etc.) c Medicare Person covered
c Workers compensation c Other__________________ Claim, contract/group numbers, effective date
G. Asset Information
Do you need more pages? Yes No 1. Does anyone in your household have any assets? (include assets owned with another person) c Yes 4 Check all types of assets your household has and complete the table below. c No
S Q
c Checking accounts c Money market accounts c Patient trust fund c Certificates of deposit (CD) c Christmas club accounts c IRA, KEOGH, 401K or deferred c Cash on hand/in safe deposit box c Savings bonds, stocks or mutual compensation account(s) c Trust or annuities funds c Real estate (not including place c Life estate c Land contract, mortgage or other you live) c Life insurance notes payable to household member c Tools and equipment, livestock c Burial trust/funeral contract(s) c Burial plot(s), casket, etc. or crops c Savings accounts c Other (mineral/water rights, etc.) c 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? c Yes c No If yes, 4Who?________________________________ 4What?____________________________________
4Date
4How much? $
c Yes c No
Filed a lawsuit which may bring money, property, etc.?
If yes, 4Who?________________________________ 4What?____________________________________
4Date
4How much? $
Received a one-time payment (such as workers compensation, lottery winnings, resettlement income, insurance settlement lawsuit award, etc.) within the last 60 months (five years)? c Yes c No If yes, 4Who?________________________________ 4What?____________________________________
4Date
4How much? $
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)? c Yes c No If yes, 4Who?________________________________ 4What?____________________________________
4Date H. Vehicle Information

c Yes c Car
4How much? $
Do you need more pages? Yes No Does anyone in your household have any vehicles?
cQ
c No c RV c Other vehicles Amount owed Make / Model c Motorcycle
4 Check all that apply and complete the table below.

c Truck c Boat c Camper/trailer Year
Owner(s) on vehicle title or registration
Do you need more pages? Yes No Is anyone in your household a c migrant or c seasonal farmworker? c Yes 4 Complete the table below. c 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? c Yes 4Name of person(s): c No c Yes 4Name of person(s): c No c Yes 4Name of person(s): c No c Yes 4Name of person(s): c No Last pay date Date
I. Migrant or Seasonal Farmworker Income
Gross pay amount
Gross pay amount
Do you need more pages? Yes No Did anyone in your household have changes in employment in the last 30 days? c Yes 4 Check all that apply and complete the table below. c No Name of Name and address Date of Check all that apply person(s) of employer change c Refused work Reason______________ c Voluntarily reduced hours worked Reason______________ c Quit a job Reason______________ c Was laid off Reason______________ c Was fired Reason______________ c Is participating in a strike Reason______________
J. Employment Changes
c S Q
Date and gross amount of final pay
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? c Yes 4 Complete the table below. c No Type of work or business Self-employed and date business Business person started name and address Gross monthly income Monthly self(amount before any employment expenses) expenses
K. Self-Employment Income (including odd jobs)
c j S Q
L. Employment Income
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? c Yes 4 Complete the information below for each working person. c No
c j S Q
Name of working person__________________________________________ Start date Employer name/address/phone number___________________________________________________________ Type of work_ ____________________________________ Job title_ ____________________________________ If new job, first pay check date Will employment continue? c Yes c No
Day of week pay is received___________________ Most recent or last pay check date Rate of Average # of hours expected to work_ _____ per c Week c Pay period pay $___________ How often paid: c Weekly c Every two weeks c Twice a month c Monthly c Hourly c Salary c Other_____________ c Other__________
Do you receive a c Bonus c Commission or c Overtime?
c Yes c No
4 If yes, amount $______________
How often?________________________
Do you receive tips not included in your check? c Yes c No
4 If yes, average tips not included $________________
per c Week c Pay period c Other__________
Name of working person__________________________________________ Start date Employer name/address/phone number___________________________________________________________ Type of work_ ____________________________________ Job title_ ____________________________________ If new job, first pay check date Will employment continue? c Yes c No
Day of week pay is received___________________ Most recent or last pay check date Rate of Average # of hours expected to work_ _____ per c Week c Pay period pay $___________ How often paid: c Weekly c Every two weeks c Twice a month c Monthly c Hourly c Salary c Other_____________ c Other__________
Do you receive a c Bonus c Commission or c Overtime?
c Yes c No
4 If yes, amount $______________
How often?________________________
Do you receive tips not included in your check? c Yes c No
4 If yes, average tips not included $________________
per c Week c Pay period c Other__________
Do you need more pages? Yes No c Yes
M. Other Income
c j S Q
c No
1. Does anyone in your household receive, or expect to receive (has applied for), any income other than earnings?
4 Check all boxes that apply and complete the table below.
c Social Security benefits (RSDI) c Supplemental Security Income (SSI) c Disability benefits c Pension/retirement benefits c Child support c Unemployment benefits c Veterans benefits c Workers compensation c Rental income c Military allotments c Money from friends or relatives, etc. c Room and/or board income c Land contract, mortgage or other notes payable to a household member c Interest/dividend income c Income/payments from a tribe (tribal general assistance, land claims, casino profit sharing, per capita, etc.) c Other c Resettlement Income (FAP only) Person receiving/ Income How often Amount Expected to Date expecting if expecting money source/type received received continue? not yet received c Yes c No c Yes c No c Yes c No
2. If anyone in your household receives Social Security (RSDI) or Railroad Retirement benefits, list the claim number(s)_ ________________________________________________________________________ 3. Check if anyone in c U.S. veteran with a disability c Widow(er) or child of a deceased U.S. veteran your household is a: c Spouse or child with a disability of a U.S. veteran with a disability c None of these List who_________________________________________________________________________________
N. Disability Benefits
Do you need more pages? Yes No 1. Has anyone in your household, who is not receiving disability benefits, applied for or been denied disability benefits? c Yes
4 Check all disability benefits that apply and complete the table below.
Type of benefit Benefit status c Applied for benefits. c Denied benefits.* c Appealed the denial. c Requested a hearing. c Applied for benefits. c Denied benefits.* c Appealed the denial. c Requested a hearing. c Applied for benefits. c Denied benefits.* c Appealed the denial. c Requested a hearing.
c No
Person
Date of action (if known)
c Social Security Claim #______________________ c Self c Spouse c Parent c Supplemental Security Income (SSI) c Other_ _______________________ c Social Security Claim #______________________ c Self c Spouse c Parent c Supplemental Security Income (SSI) c Other_ _______________________ c Social Security Claim #______________________ c Self c Spouse c Parent c Supplemental Security Income (SSI) c Other_ _______________________
2. If benefits were denied, have the persons health problem(s) changed? c Yes c No If yes, 4 List who_________________________________ Date of change_________________________ c Health problem is worse c New health problem c Has more than one health problem
DHS-1171 (Rev. 4-09) Previous edition obsolete. K
* Social Security Administration has decided (s)he is not disabled.
O. 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 c child, c family member with disabilities? c Yes 4 Complete the table below (DO NOT include amounts paid by DHS or anyone else). c No Person paying How often Name of person(s) receiving care c Weekly c Every two weeks $___________ c Twice a month c Monthly c Other c Every two weeks $___________ c Weekly c Twice a month c Monthly c Other $___________ c Weekly c Every two weeks c Twice a month c Monthly c Other Amount paid
c S Q
2. Does anyone in your household pay court-ordered c child support c spousal support/alimony? c Yes 4 Check one or both above and complete the table below. c No Person paying Court-order/docket number and county of order Order amount Amount paid per $_ _______ $________ $_ _______ $________ $_ _______ $________
c Week c Month c Other c Week c Month c Other c Week c Month c Other
For whom
P. Child Care Expenses
j
Is care provided in childs home? c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No
L
1. Do you need help paying for child care? c Yes 4 Check why and complete the table below. c No c Work c High school or GED c Education/training approved by DHS or Michigan Works! Agency c Emotional/health or social program (explain)___________________________________________________ Provider Is provider Name of child Provider name, address and ID related to child? needing care phone number number How? c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No c Yes c No
Date care began
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: _ _ List anyone who has paid medical premiums in the last three months:
Q. Medical Expenses
c S Q
4Who?____________________________________ What months?__________________________________ 4Who?____________________________________ What months?__________________________________

c Yes
2. Does anyone in your household have any ongoing medical expenses?
4 Check all expenses that apply and complete the table below.
c No
c Medical care c Dental care c Hospitalization c Transportation for medical care (for pregnancy or ongoing care) c Emergency room c Nursing facility Person with expense
c Prescribed over-the-counter drugs c Service animal c Prescription drugs c Guardian/conservator fees c Prescription drug card c Health insurance premium c Dentures c Medicare premium c Eyeglasses c Medical equipment/supplies c Hearing aids c Personal care/chore services c Prosthetics c Other Medical expense Amount How often (monthly, (checked above) person pays yearly, etc.)
3. c Check this box if you would like to discuss the Adult Medical Program (AMP) employer-sponsored insurance option with your specialist. For information about this option see the information booklet.
R. Shelter Expenses
Check the boxes that apply and fill in the amount.* 1. c Rent $ _ ________ (enter ONLY the amount you pay, NOT the amount paid by HUD, Section 8, MSHDA, etc.) c Weekly c Monthly c Other c Renters insurance $___________ per year (answer ONLY if applying for MA for a nursing facility) 2. Does anyone pay for: Rent that includes meals (room/board) c Yes4$_ ___________ c Weekly c Monthly c Other c No Meals only (board) c Yes 4$_ ___________ c Weekly c Monthly c Other c No 3. c Mobile home lot rent? $_ ___________________________ c Weekly c Monthly c Other 4. c Mortgage/mobile home/land contract $_ _____________ c Weekly c Monthly c Other 5. c Second mortgage or home equity loan $_ _____________ c Weekly c Monthly c Other 6. Shelter expenses billed separately from rent or mortgage: c Fuel Type (Eg wood, gas, propane) c Heat (gas, electric, propane, wood, etc.) c Homeowners insurance $_ ________________ per year c Cooling (including room air conditioner) c Property taxes $_________________________ per year c Electricity (non-heat) c Special assessments _____________per____________ c Water/sewer c Mortgage guarantee insurance $ _________ per ______ c Cooking fuel c Cooperative/condominium/association fee $___________ c Garbage/trash pick-up c Other_ _________________________________ $ _____ c 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? c Yes c No b. Will anyone in your household who is applying for FAP apply for, or does anyone expect to apply for, the HHC for the current address? c Yes c No
home, complete Section R. If you are applying for OTHER medical assistance ONLY, you may skip Section R.
c* Q
* If you are applying for medical assistance ONLY and you are in a nursing facility and have a spouse or dependent living at
M
S. Receipt of Benefits
_
c j S Q
(maiden name, alias, former spouse, etc.)
1. Did anyone in your household ever apply for or receive benefits from Michigan in the past? c Yes c No
4If yes, under what name(s)?________________________________________________________________

more information about these cards, see the 4If yes, does anyone have a Bridge card? c Yes c No For Information Booklet. _ If yes, who?_____________________________________________________________________________
4If yes, does anyone have a mihealth card? c Yes
c No c Yes c No c Yes c No
_ _
Who does not have a mihealth card?_________________________________________________________
2. Does anyone in your household receive Women, Infants, Children (WIC) benefits? 3. Does anyone in your household receive tribal TANF (cash) benefits?
4If yes, who?_____________________________________________________________________________ 4If yes, who?_____________________________________________________________________________
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? Has anyone ever been convicted of fraud for receiving cash or food assistance from two or more states for the same time period? Is anyone fleeing from felony prosecution or jail?
S Q
c Yes c No
4If yes, who?_____________________________________________________________________________

c Yes c No c Yes c No
4If yes, who?_________________________________ What program(s)?_ ____________________________ 4If yes, who?_____________________________________________________________________________

Has anyone ever been convicted of a drug-related felony occurring after August 22, 1996? c Yes c No
4If yes, who?_____________________________________________________________________________

Is anyone in violation of probation or parole? c Yes c No
4If yes, who?_____________________________________________________________________________
U. State of Michigan Voter Registration Application

If you are not already registered to vote at your current address, would you like to register to vote? c Yes c No NOTE: If you do not check either box, DHS will assume you have decided not to register to vote at this time. 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 or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: Secretary of State PO Box 20126 Lansing, MI 48901-0726
DHS-1171 (Rev. 4-09) Previous edition obsolete. N
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? _
V. Representative, Guardian, Conservator or Person Helping with Application
c j S Q
c Yes c No Check one or both.
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? Name
c Yes c No c Yes c No
4 If Yes is checked in one or both questions above, complete the following information:
Phone number
Street address (number, street, rural route, apartment/lot number, PO box) City State Zip code
Representatives relationship to applicant (check all that apply) If you are under age 18, are you married? c Guardian c Relative (specify)________________________ c Yes c No c Conservator c Other (specify)__________________________ IMPORTANT: Before you sign this application, READ the affidavit.
W. Affidavit
c j S Q
Under penalties of perjury, I swear 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, 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. Signature of client or representative When in-person interview completed: Date Signature of department witness/migrant recruiter Date
Notes

If you receive benefits from FIP, FAP, MA or CDC, and
Child Support Actions (Most Programs)

you have a minor child in your home whose parent(s) do(es) not live there, you will receive a letter from a support specialist about the child support program. You must contact the support specialist when you receive the letter. You must work with the Office of Child Support, the Prosecuting Attorney and Friend of the Court. Good cause. DHS will not require you to pursue paternity or support if you have good cause. To claim good cause, tell your DHS specialist and ask for the Claim of Good Cause 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: Remove the food assistance benefits of the person not cooperating for at least one month. Deny or stop your medical benefits for at least one month. We will not deny or stop Medicaid for children or pregnant women. Deny or stop your child care benefits for at least one month. Deny or stop cash assistance for your entire household for at least one month.
Deny SER for failure to comply with a requirement of FIP. For FIP only, support you get from another person for yourself (spousal support) or any minor household member (child support) when you are receiving or applied for cash from DHS will no longer be sent to you but will be given (assigned) to DHS. While you are receiving FIP, all support money will go to pay back DHS. This includes money owed to you from past months. DHS may send some of what is collected back to you each month. If the total support collected is more than your FIP grant for at least two months, DHS may close your FIP case so you can receive the support payments directly. Court-ordered child support payments received after your FIP case is opened must be returned to DHS. Failure to do so may result in the loss or reduction of benefits. If you have questions about whether or not your payment must be returned, contact your DHS specialist. For MA only, medical support payments will be given (assigned) to the Michigan Department of Community Health for children receiving Medicaid.
ily must complete a Family Automated Screening Tool (FAST) and develop a Family Self-Sufficiency Plan (FSSP). This plan will list the work activities that you must do up to 40 hours per week to receive FIP or RAP. You design this plan with your DHS specialist and the Michigan Works! Agency. Adults (and children age 16 and older who are not in school full-time) who receive FIP or RAP must: Complete the screening tool (FAST). Help make and comply with an FSSP. 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 RAP work rules. If you break the FIP or RAP 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 and second time and 12 months for the third and any future times. NOTE: For the first non-compliance without good cause, your benefits might continue if you agree to complete the assignment given to you by your
Your work rules will depend on whether you receive FIP or RAP cash assistance, FAP benefits with no cash assistance, or time-limited FAP benefits. DHS specialist within 10 days. You only get this FIP or RAP cash assistance work rules. Your fam one chance. Count all penalty months toward your 48-month lifetime limit. Stop RAP for you for at least three months (but the rest of your household might be eligible).
Follow Work Rules and Penalties (FIP or RAP and FAP)
one month if you are not excused from FAP work rules. Count your FIP grant amount as income for three or 12 penalty months. FAP work rules. (NOTE: If you receive both cash and food benefits, you must follow FIP work rules.)
If you receive both FIP and FAP, we will: Stop or reduce your FAP benefits for at least
If you are working, you may not: Quit a job of 30 hours or more per week. Voluntarily reduce work hours below 30 hours
work. 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 employmentrelated activities that must be done to receive FAP.
Be fired from a job for misconduct or missing
per week without good cause.
11

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.)
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 RAP work rules if you are: Under the age of 16. Age 65 or older. A parent of a baby less than three months old. You may be assigned to family strengthening activities once the baby is six weeks old. A parent of a child who is active with Early On. Working 40 hours per week. Age 16-19, in school full-time, and expected to graduate before age 20. Caring for a child or spouse with a disability (depending on the persons needs and the childs school attendance). A person with a disability or medical limitations. Experiencing a temporary critical event such as domestic violence (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.
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).
Work Rule Deferrals and Good Cause (FIP or RAP and FAP)
Good cause. You have the right to claim good cause if you believe you should be excused from the FIP or RAP 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 RAP or FAP - Reasons for good cause: An unplanned event or factor that does not allow you to meet the work rules (e.g., 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 members 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.
12
Important Things To Know

Penalties For Intentional Program Violation Or Fraud (FAP, FIP, SDA)
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 (e.g., 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.
If you do any of the following: Make a false or misleading statement. Hide, misrepresent or withhold facts to receive or continue to receive benefits. Trade or sell less than $500 in FAP benefits or Bridge cards. Use FAP benefits to buy ineligible items such as alcoholic drinks or tobacco. Use FAP benefits or Bridge cards that belong to someone else for your household. If you are: Convicted by a court or found guilty by administrative hearing of lying about where you live to receive benefits on two or more cases at the same time. If you are: Convicted in court of lying about where you live to receive benefits* on 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.
You will lose FIP/SDA and/or FAP benefits for: One year for the first violation. Two years for the second violation. Life for the third violation.
You will lose FAP benefits for: 10 years. You will lose FIP benefits for: 10 years.
If any member of the household is found guilty in court of: Trading FAP benefits for drugs. If any member of the household is found guilty in court of: Trading FAP benefits for firearms, ammunition or explosives. Trading, buying or selling FAP benefits of $500 or more for anything other than food.
You will lose FAP benefits for: Two years for the first offense. Life for the second offense. You will lose FAP benefits for: Life.
Important Things To Know (continued)

Hearing Rights
If you do not agree with a decision DHS makes to deny, reduce or terminate benets, you have the right to request a hearing. In most cases, if you receive a notice reducing or canceling your benets and you request a hearing within 11 days of the date the action will take place, your benets 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 or mail a signed, written hearing request* to your DHS ofce (no faxes or photocopies).
* DHS-18 available online at www.michigan.gov/dhs-forms.
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. State Ofce of Administrative Hearings and Rules (SOAHR) 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 benets. 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. USDA, Director, Ofce of Civil Rights 1400 Independence Avenue, S. W. Washington, D.C. 20250 (800) 795-3272 (voice) or (202) 260-0087 (TTY) Email: cr@usda.gov HHS, Director, Ofce for Civil Rights U.S. Department of Health and Human Services 200 Independence Avenue, S.W. Washington, D.C. 20201 (877) 696-6775 Email: OCRComplaint@hhs.gov
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. USDA and HHS are equal opportunity providers and employers. You may le a complaint of discrimination with DHS or contact USDA or HHS.
Answering questions about race and ethnicity is voluntary. If you do not answer these questions, your eligibility or benet levels will not be affected.* The information
Race and Ethnicity

is collected to ensure that program benets 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. Receiving food, medical, or emergency assistance will not affect your immigration status and your ability to stay in the U.S. For some programs, persons claiming U.S. citizenship must provide proof of citizenship and identity. Acceptable proof of citizenship includes, but is not limited to, a U.S. passport, a certicate of naturalization, a U.S. public birth record showing birth in the U.S. or U.S. territories. Persons receiving SSI, Social Security, Medicare, or adoption assistance; foster children, and newborn safe delivery babies are not required to provide proof of U.S. citizenship for DHS programs.
Citizens and Non-Citizens

Social Security numbers and immigration papers are NOT required for a person who is: Not applying for help. Only applying for medical assistance for emergency services, pregnancy or childbirth. Only applying for child care. (You must give a Social Security number for the child and the child must be a U.S. citizen or show immigration papers.) Other eligible members of your household will still be able to receive help. You must tell us about income and assets of all persons in your household, even if they are not applying.
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.
Persons With Disabilities

If you are denied special help or an exception you need because of a disability, and you think the denial was wrong, you may le a complaint of discrimination with: DHS, Americans with Disabilities Act Coordinator 235 S. Grand Ave., Suite 1412 Lansing, MI 48909 (517) 373-8520
14
Important Things To Know (continued)

Domestic Violence
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. You qualify for 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.
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.
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 1-888-6788914 to:
Bridge Card

Report a lost, stolen or damaged card. Request a replacement card. Establish/change your personal ID number (PIN). Find out your balance.
By signing the assistance application, you agree to do these things:
Repay Agreements
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 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.
or private contractor. Any recovery payment you receive must be paid to the State of Michigan, MDCH. Exception: Payments are not recovered from Medicare.
Lump Sums and Accumulated Benefits (SDA, State Funded FIP)

You agree DHS will keep enough of the accumulated benefit to pay back any state funded assistance you received while your claim was pending. DHS will send the rest to you right away. 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.
15
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) investigations (all programs) - DHS might choose your case for a quality control review. 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) - DHS receives information from law enforcement officials for the purpose of catching persons fleeing to avoid the law. Child care information (CDC) - DHS will use information from your child care provider to determine CDC eligibility and 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, 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.
Information DHS Will Give To Others

Law enforcement check (FAP, FIP) - 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 - DHS will send information and notices to your child care provider when your CDC: Application is denied or withdrawn. Payments are approved or changed. Case is closed.
Coordination of Health Care

Coordination of health care programs and providers (MA) - The States 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.
16
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 Michigan Department of Human Services (DHS): www.michigan.gov/dhs Cash Assistance Cash Assistance - SSI Child Care Child Support Client Application Process DHS County Offices DHS Forms and Applications DHS Policy and Procedural Manuals Emergency Services Food Assistance Medical Services www.michigan.gov/dhs-cash www.michigan.gov/dhs-ssi www.michigan.gov/childcare www.michigan.gov/childsupport www.michigan.gov/dhs-applicationprocess www.michigan.gov/dhs-countyoffices www.michigan.gov/dhs-forms www.michigan.gov/dhs-manuals www.michigan.gov/dhs-ser www.michigan.gov/foodstamps www.michigan.gov/dhs-medical
Michigan Disability Resources: www.michigan.gov/disabilityresources
17
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 Care Provider Handbook and Reporting Instructions for Child Care Providers - (DHS Publication 230). (Only available online at: www.michigan.gov/dhs/publications) Accreditation: Added Security When Choosing Child Care (DHS Publication 626) (Sp). 4 Steps to Choosing Quality Child Care - Parents Checklist (DHS Publication 836) (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). Domestic Violence - Is Someone Hurting You or Your Children? (DHS Publication 859) (Sp) explains about domestic violence and program waivers. Food Assistance Program (FAP) - Food Assistance Benefits in Michigan (DHS Publication 16) (Sp) - explains the food assistance program. 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 Responsibilties in a Health Plan (MDCH Publication 201). Medicaid Deductible Information (DCH 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: Get the most out of life by getting the most out of health care (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).
18
Publications
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 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.
Michigan Department of Human Services (DHS)
Filing Form
If you need help filling out this application, DHS must help you. If you are refused help, you may call (517) 373-0707. If you do not speak English or you have a disability, how can we help you? c Interpreter c Sign language c Assisted listening device (ALD) c 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____________ 2. I am applying for: FFFood Assistance Program (seven-day processing can begin today if you complete the back of this form and your household qualifies). FFMedical Assistance (doctor or hospital bills, prescriptions, Medicare premiums). FFChild Development and Care (help with child care payments). FFCash Assistance (FIP- Family Independence Program, RAP - Refugee Assistance Program, 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) 6. Social Security number***

(if known)
4. c Male c Female
5. Date of birth** / /

**Not needed for food assistance.
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 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
19
Expedited Food Assistance Program Seven-Day Processing
1. Does everyone in the household buy food and fix or eat meals 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, saving 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. What is the total amount you pay for your monthly rent and/or mortgage payment? 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 heat, check which utilities you pay: Non-heat electric Water/sewer Telephone Cooking fuel Garbage/trash 8. Is anyone in your household a c migrant or c seasonal farmworker? c Yes 4 Complete the table below. c No Has anyone received any Date income from the same grower within 30 days before c Yes 4Name of person(s): c No the application date? Does anyone expect to receive c Yes 4Name of person(s): more income this month? c No Has anyone received a travel advance? Has anyone recently lost their only source of income? c Yes 4Name of person(s): c No c Yes 4Name of person(s): c No Birth date
Gross pay amount
Last pay date Gross pay amount Social Security number
9. Names of all household members
10. Do you need more pages? c Yes c No

For office use only Date application received in local office Case name Application number Specialist name Specialist phone Specialist email Fax Case number
20

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KEEP THIS BOOKLET FOR YOUR RECORDS

Welcome to the State of Michigan Department of Human Services (DHS)

Local office address

DHS specialist name, phone number and email address

DHS-1171 Information Booklet (Rev. 4-09)

Expedited Food Assistance Program (Seven-Day Processing)

Food Assistance Program (FAP) Interviews

We May Need Proof

DHS-1171 Information Booklet (Rev. 4-09)

Food Assistance Program (FAP)

Adult Medical Program (AMP)

Resident County Hospitalization (RCH)

Medical Assistance (MA)

Child Development And Care (CDC)

* Enrollment is not allowed if the provider, or

Family Independence Program (FIP) Refugee Assistance Program (RAP)

State Disability Assistance (SDA)

State Emergency Relief (SER)

Child Support Services

Low Income Home Energy Assistance Program (LIHEAP)

Things You Must Do

Give Correct Information and Report Changes (All Programs)

DHS-1171 Information Booklet (Rev. 4-09)

Things You Must Do (continued)

Provide Social Security Numbers (Most Programs)

Pursue Other Benefits (Most Programs)

Immunize Children Under Age Six - Get Shots (FIP)

Michigan Department of Human Services (DHS) Instructions

For office use only

Date application received in local office

DHS-1171 (Rev. 4-09) Previous edition obsolete.

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

State Cell phone

County Work phone

Whose number is it? (name/relationship) Email address

DHS-1171 (Rev. 4-09) Previous edition obsolete.

B. Food Assistance Information

C. Information About You and Your Household

- The patients spouse.

- Any dependents living at home.

9. Highest grade completed in school_____________

Answer for person 2. Check all boxes that apply.

c Medical c Cash Assistance

c Emergency help c None (not applying)

Answer for person 3. Check all boxes that apply.

c Medical c Cash Assistance

c Emergency help c None (not applying)

Answer for person 4. Check all boxes that apply.

***For local office use only

c Medical c Cash Assistance

c Emergency help c None (not applying)

Answer for person 5. Check all boxes that apply.

c Medical c Cash Assistance

c Emergency help c None (not applying)

Answer for person 6. Check all boxes that apply.

**Applies to FIP, Medicaid and RAP applicants only

c Medical c Cash Assistance

D. Household Members Under Age 22

c Emergency help c None (not applying)

If yes, 4Who? 4What?____

4Who? What months? 4Who? What months?

4If yes, who?_ 4If yes, who?_

4If yes, who?_________________________________ What program(s)?_ 4If yes, who?_________________________________________________