H - Participants of Refugee Cash Assistance (RCA) when they are working with a Refugee Employment Services Provider. DHS 3543 Request for Payment of Long-Term Care ServicesThis form is completed by enrollees who are requesting payment of long-term care services. 0000025773 00000 n For people in the Safe At Home Program, see 0029.29 (Safe At Home Program). for additional MFIP provisions relating to citizenship and immigration status. See 0010.18.02 (Mandatory Verifications SNAP), 0010.18.02.03 (Non-Mandatory Verifications SNAP). 2023 Minnesota Department of Human Services, 0010.18.03 (Verifying Social Security Numbers), 0010.18.11.03 (Systematic Alien Verification (SAVE)), 0010.18.11 (Verifying Citizenship and Immigration Status), 0011.03.27 (Undocumented and Non-Immigrant People). /ZaDb 5.1626 Tf 4.8399 TL Identity of the applicant and the authorized representative if the authorized representative is applying for the applicant. EMC Verify the exemptions listed below at application time and/or when a change occurs. Residency in Minnesota, unless verification cannot be obtained because the people are homeless, migrant farmworkers, or newly arrived in Minnesota. <1b285431b6d97f0b3d25c629171a4448>] No policy was changed. /MarkInfo << Employment Verification Form 1/ . If the building official finds any work regulated by the code being performed in a manner contrary to the provisions of the code or in a dangerous or unsafe manner, the building official is authorized to issue a stop work order or a notice or order pursuant to part 1300.0110, subpart 4.. q For all applicants give and verbally review during the interview: Give the forms below to all applicants. 0026.12.12 - WHEN NOT TO GIVE ADDITIONAL NOTICE, 0026.12.15 - WHEN TO GIVE RETROACTIVE OR NO NOTICE, 0026.12.21 - VOLUNTARY REQUEST FOR CLOSURE NOTICE, 0026.15 - NOTICE OF DENIAL, TERMINATION, OR SUSPENSION, 0026.21 - NOTICE OF CHANGE IN ISSUANCE METHOD, 0026.24 - NOTICE OF RELATIVE CONTRIBUTION. . /StructTreeRoot 32 0 R << 0002.05 - GLOSSARY: ASSISTANCE STANDARD 0002.17 - GLOSSARY: DISPLACED HOMEMAKER 0002.41 - GLOSSARY: MEDICALLY NECESSARY 0003 - CLIENT RESPONSIBILITIES AND RIGHTS, 0003.03 - CLIENT RESPONSIBILITIES - GENERAL, 0003.06 - CLIENT RESPONSIBILITIES - QUALITY CONTROL, 0003.09.03 - CLIENT RIGHTS - CIVIL RIGHTS, 0003.09.06 - CLIENT RIGHTS - DATA PRIVACY PRACTICES, 0003.09.09 - CLIENT RIGHTS, PRIVATE AND CONFIDENTIAL DATA, 0003.09.12 - CLIENT RIGHTS - LIMITED ENGLISH PROFICIENCY, 0004.01 - EMERGENCIES - PROGRAM PROVISIONS, 0004.03 - EMERGENCY AID ELIGIBILITY - CASH ASSISTANCE, 0004.04 - EMERGENCY AID ELIGIBILITY--SNAP/EXPEDITED FOOD, 0004.06 - EMERGENCIES - 1ST MONTH PROCESSING, 0004.09 - EMERGENCIES - 2ND AND 3RD MONTH PROCESSING, 0004.12 - VERIFICATION REQUIREMENTS FOR EMERGENCY AID, 0004.15 - EMERGENCIES - POSTPONED VERIFICATION NOTICE, 0004.18 - DETERMINING THE AMOUNT OF EMERGENCY AID, 0004.48 - DESTITUTE UNITS--MIGRANT/SEASONAL FARMWORKER, 0004.51 - DESTITUTE UNITS, ELIGIBILITY AND BENEFITS, 0005.06.03 - WHO CAN/CANNOT BE AUTHORIZED REPRESENTATIVES, 0005.06.06 - DISQUALIFYING AUTHORIZED REPRESENTATIVES, 0005.09 - COMBINED APPLICATION FORM (CAF), 0005.09.03 - WHEN PEOPLE MUST COMPLETE AN APPLICATION, 0005.09.06 - WHEN NOT TO REQUIRE COMPLETION OF AN APPLICATION, 0005.09.09 - WHEN TO USE AN ADDENDUM TO AN APPLICATION, 0005.09.15 - EMERGENCY ASSISTANCE AND APPLICATIONS, 0005.10 - MINNESOTA TRANSITION APPLICATION FORM (MTAF), 0005.12 - ACCEPTING AND PROCESSING APPLICATIONS, 0005.12.03 - WHAT IS A COMPLETE APPLICATION, 0005.12.12.01 - FORMS/HANDOUTS FOR APPLICANTS, 0005.12.12.06 - ORIENTATION TO FINANCIAL SERVICES, 0005.12.12.09 - FAMILY VIOLENCE PROVISIONS/REFERRALS, 0005.12.15 - APPLICATION PROCESSING STANDARDS, 0005.12.15.01 - PROCESSING SNAP APPLICATION NON-MANDATORY VERIFICATION, 0005.12.15.03 - DELAYS IN PROCESSING APPLICATIONS, 0005.12.15.06 - DETERMINING WHO CAUSED THE DELAY, 0005.12.15.09 - DELAYS CAUSED BY THE APPLICANT HOUSEHOLD, 0005.12.15.12 - DELAYS CAUSED BY THE AGENCY, 0005.12.15.15 - DELAYS CAUSED BY THE AGENCY AND APPLICANT, 0005.12.21 - REINSTATING A WITHDRAWN APPLICATION, 06 - DETERMINING FINANCIAL RESPONSIBILITY, 0006 - DETERMINING FINANCIAL RESPONSIBILITY, 0006.06 - MOVING BETWEEN COUNTIES - PARTICIPANTS, 0006.09 - MOVING BETWEEN COUNTIES - MINOR CHILDREN, 0006.12 - ASSISTANCE TERMINATED WITHIN LAST 30 DAYS, 0006.15 - MULTIPLE COUNTY FINANCIAL RESPONSIBILITY, 0006.18 - EXCLUDED TIME FACILITIES AND SERVICES, 0006.21 - TRANSFERRING RESPONSIBILITY - OLD COUNTY, 0006.24 - TRANSFERRING RESPONSIBILITY - NEW COUNTY, 0006.27 - COUNTY FINANCIAL RESPONSIBILITY DISPUTES, 0006.30 - STATE FINANCIAL RESPONSIBILITY DISPUTES, 0007.03.01 - MONTHLY REPORTING - UNCLE HARRY FS, 0007.03.04 - SIX-MONTH REPORTING DEADLINES, 0007.03.07 - PROCESSING A LATE COMBINED SIX-MONTH REPORT, 0007.12 - AGENCY RESPONSIBILITIES FOR CLIENT REPORTING, 0007.15 - UNSCHEDULED REPORTING OF CHANGES - CASH, 0007.15.03 - UNSCHEDULED REPORTING OF CHANGES - SNAP, 0008.03 - CHANGES - OBTAINING INFORMATION, 0008.06 - IMPLEMENTING CHANGES - GENERAL PROVISIONS, 0008.06.01 - IMPLEMENTING CHANGES - PROGRAM PROVISIONS, 0008.06.03 - CHANGE IN BASIS OF ELIGIBILITY, 0008.06.06 - ADDING A PERSON TO THE UNIT - CASH, 0008.06.07 - ADDING A PERSON TO THE UNIT - SNAP, 0008.06.09 - REMOVING A PERSON FROM THE UNIT, 0008.06.12.09 - CONVERTING A PREGNANT WOMAN CASE, 0008.06.15 - REMOVING OR RECALCULATING INCOME, 0008.06.21 - CHANGE IN COUNTY OF RESIDENCE, 0008.06.24 - DWP CONVERSION OR REFERRAL TO MFIP, 0009.03 - LENGTH OF RECERTIFICATION PERIODS, 0009.03.03 - WHEN TO ADJUST THE LENGTH OF CERTIFICATION, 0009.06.03 - RECERTIFICATION PROCESSING STANDARDS, 0009.06.03.03 - PROCESSING SNAP RECERTIFICATION NON-MANDATORY VERIFICATION, 0010.03 - VERIFICATION - COOPERATION AND CONSENT, 0010.06 - SOURCES OF VERIFICATION - DOCUMENTS, 0010.09 - SOURCES OF VERIFICATION, COLLATERAL CONTACTS, 0010.12 - SOURCES OF VERIFICATION - HOME VISITS, 0010.15 - VERIFICATION - INCONSISTENT INFORMATION, 0010.18.01 - MANDATORY VERIFICATIONS - CASH ASSISTANCE, 0010.18.02 - MANDATORY VERIFICATIONS - SNAP, 0010.18.02.03 - NON-MANDATORY VERIFICATIONS - SNAP, 0010.18.03 - VERIFYING SOCIAL SECURITY NUMBERS, 0010.18.03.03 - VERIFYING SOCIAL SECURITY NUMBERS - NEWBORNS, 0010.18.05 - VERIFYING DISABILITY/INCAPACITY - CASH, 0010.18.06 - VERIFYING DISABILITY/INCAPACITY - SNAP, 0010.18.08 - VERIFYING STATE RESIDENCE - CASH, 0010.18.09 - VERIFYING SELF-EMPLOYMENT INCOME, 0010.18.11 - VERIFYING CITIZENSHIP AND IMMIGRATION STATUS, 0010.18.11.03 - SYSTEMATIC ALIEN VERIFICATION (SAVE), 0010.18.12 - VERIFYING LAWFUL TEMPORARY RESIDENCE, 0010.18.15 - VERIFYING LAWFUL PERMANENT RESIDENCE, 0010.18.15.03 - LAWFUL PERMANENT RESIDENT: USCIS CLASS CODES, 0010.18.15.06 - VERIFYING SOCIAL SECURITY CREDITS, 0010.18.18 - VERIFYING SPONSOR INFORMATION, 0010.18.21 - IDENTIFY NON-IMMIGRANT OR UNDOCUMENTED PEOPLE, 0010.18.21.03 - NON-IMMIGRANT PEOPLE: USCIS CLASS CODES, 0010.18.30 - VERIFYING STUDENT INCOME AND EXPENSES, 0010.24 - INCOME AND ELIGIBILITY VERIFICATION SYSTEM, 0010.24.03 - IEVS MATCH TYPE AND FREQUENCY, 0010.24.09 - PROCESSING IEVS MATCHES TIMELY, 0010.24.12 - DETERMINING IEVS EFFECT ON ELIGIBILITY, 0010.24.15 - RECORDING IEVS RESOLUTION FINDINGS, 0010.24.18 - CLIENT COOPERATION WITH IEVS, 0010.24.21 - IEVS SAFEGUARDING RESPONSIBILITIES, 0010.24.24 - IEVS NON-DISCLOSURE AND EMPLOYEE AWARENESS, 0011.03 - CITIZENSHIP AND IMMIGRATION STATUS, 0011.03.03 - NON-CITIZENS - MFIP/DWP CASH, 0011.03.06 - NON-CITIZENS - MFIP FOOD PORTION, 0011.03.09 - NON-CITIZENS - SNAP/MSA/GA/GRH, 0011.03.12 - NON-CITIZENS - LAWFUL PERMANENT RESIDENTS, 0011.03.12.03 - NON-CITIZENS - ADJUSTMENT OF STATUS, 0011.03.15 - NON-CITIZENS - LPR WITH SPONSORS, 0011.03.17 - NON-CITIZENS - PUBLIC CHARGE, 0011.03.18 - NON-CITIZENS - PEOPLE FLEEING PERSECUTION, 0011.03.21 - NON-CITIZENS - VICTIMS OF BATTERY/CRUELTY, 0011.03.24 - NON-CITIZENS - LAWFULLY RESIDING PEOPLE, 0011.03.27 - UNDOCUMENTED AND NON-IMMIGRANT PEOPLE, 0011.03.27.01 - NON-CITIZENS - CITIZENS OF PALAU, THE FEDERATED STATES OF MICRONESIA, AND THE REPUBLIC OF THE MARSHALL ISLANDS, 0011.03.27.03 - PROTOCOLS FOR REPORTING UNDOCUMENTED PEOPLE, 0011.03.30 - NON-CITIZENS - TRAFFICKING VICTIMS, 0011.03.33 - NON-CITIZENS - IMMIGRATION COURT ORDERS, 0011.06.03 - STATE RESIDENCE - EXCLUDED TIME, 0011.06.06 - STATE RESIDENCE - INTERSTATE PLACEMENTS, 0011.06.09 - STATE RESIDENCE - 30-DAY REQUIREMENT, 0011.12.01 - DRUG ADDICTION OR ALCOHOL TREATMENT FACILITY, 0011.12.03 - UNDER CONTROL OF THE PENAL SYSTEM, 0011.30.06 - 180 TO 60 DAYS BEFORE MFIP CLOSES, 0011.33.02 - MFIP HARDSHIP EXTENSIONS - REMOVING 1 PARENT, 0011.33.03 - MFIP EMPLOYED EXTENSION CATEGORY, 0011.33.03.03 - LIMITED WORK DUE TO ILLNESS/DISABILITY, 0011.33.06 - MFIP HARD TO EMPLOY EXTENSION CATEGORY, 0011.33.09 - MFIP ILL/INCAPACITATED EXTENSION CATEGORY, 0012.06 - REQUIREMENTS FOR CAREGIVERS UNDER 20, 0012.12.03 - INTERIM ASSISTANCE AGREEMENTS, 0012.12.06 - SPECIAL SERVICES - APPLYING FOR SOCIAL SECURITY, 0012.15 - INCAPACITY AND DISABILITY DETERMINATIONS, 0012.15.03 - MEDICAL IMPROVEMENT NOT EXPECTED (MINE) LIST, 0012.15.06 - STATE MEDICAL REVIEW TEAM (SMRT), 0012.15.06.03 - SMRT - SPECIFIC PROGRAM REQUIREMENTS, 0012.21 - RESPONSIBLE RELATIVES NOT IN THE HOME, 0012.21.03 - SUPPORT FROM NON-CUSTODIAL PARENTS, 0012.21.06 - CHILD SUPPORT GOOD CAUSE EXEMPTIONS, 0013.03.03 - PREGNANT WOMAN BASIS - MFIP/DWP, 0013.03.06 - MFIP BASIS - STATE-FUNDED CASH PORTION, 0013.06 - SNAP CATEGORICAL ELIGIBILITY/INELIGIBILITY, 0013.09.09 - MSA BASIS - DISABLED AGE 18 AND OLDER, 0013.15.03 - GA BASIS - PERMANENT ILLNESS, 0013.15.06 - GA BASIS - TEMPORARY ILLNESS, 0013.15.09 - GA BASIS - CARING FOR ANOTHER PERSON, 0013.15.12 - GA BASIS - PLACEMENT IN A FACILITY, 0013.15.27 - GA BASIS, SSD/SSI APPLICATION/APPEAL PENDING, 0013.15.33 - GA BASIS - DISPLACED HOMEMAKERS, 0013.15.39 - GA BASIS - PERFORMING COURT ORDERED SERVICES, 0013.15.42 - GA BASIS - LEARNING DISABLED, 0013.15.48 - GA BASIS - ENGLISH NOT PRIMARY LANGUAGE, 0013.15.51 - GA BASIS - PEOPLE UNDER AGE 18, 0013.15.54 - GA BASIS - DRUG/ALCOHOL ADDICTION, 0013.18.09 - GRH BASIS - DISABLED AGE 18 AND OLDER, 0013.18.12 - GRH BASIS - REQUIRES SERVICE IN RESIDENCE, 0013.18.15 - GRH BASIS - PERMANENT ILLNESS, 0013.18.18 - GRH BASIS - TEMPORARY ILLNESS, 0013.18.27 - GRH BASIS - SSD/SSI APPL/APPEAL PEND, 0013.18.33 - GRH BASIS - LEARNING DISABLED, 0013.18.36 - GRH BASIS - DRUG/ALCOHOL ADDICTION, 0013.18.39 - GRH BASIS - TRANSITION FROM RESIDENTIAL TREATMENT, 0014.03 - DETERMINING THE ASSISTANCE UNIT, 0014.03.03 - DETERMINING THE CASH ASSISTANCE UNIT, 0014.03.03.03 - OPTING OUT OF MFIP CASH PORTION, 0014.06 - WHO MUST BE EXCLUDED FROM ASSISTANCE UNIT, 0014.09 - ASSISTANCE UNITS - TEMPORARY ABSENCE, 0014.12 - UNITS FOR PEOPLE WITH MULTIPLE RESIDENCES, 0015.06.03 - AVAILABILITY OF ASSETS WITH MULTIPLE OWNERS, 0015.30 - ASSETS - PAYMENTS UNDER FEDERAL LAW, 0015.48.03 - WHOSE ASSETS TO CONSIDER - SPONSORS W/I-864, 0015.48.06 - WHOSE ASSETS TO CONSIDER - SPONSORS W/I-134, 0015.63 - EVALUATION OF PENSION AND RETIREMENT PLANS, 0015.69.03 - ASSET TRANSFERS FROM SPOUSE TO SPOUSE, 0015.69.09 - IMPROPER TRANSFER INELIGIBILITY, 0015.69.12 - IMPROPER TRANSFERS - ONSET OF INELIGIBILITY, 0016 - INCOME FROM PEOPLE NOT IN THE UNIT, 0016.03 - INCOME FROM DISQUALIFIED UNIT MEMBERS, 0016.06 - INCOME FROM INELIGIBLE SPOUSE OF UNIT MEMBER, 0016.09 - INCOME FROM INELIGIBLE STEPPARENTS, 0016.12 - INCOME FROM PARENTS OF ADULT GA CHILDREN, 0016.18 - INCOME OF INEL. Some Spanish forms are also available. DHS 3418-ENG Minnesota Health Care Programs Renewal FormThis is the annual renewal form for all of the Minnesota Health Care Programs except Minnesota Family Planning and Breast and Cervical Cancer. in SNAP adds a new last paragraph to not request verification of earned income of an elementary, secondary, or GED student IF the student is in school at least half-time, is under age 18, and is working. 0.749023 g in general provisions in the 2nd bullet deletes reference to self-employment deductions and adds to verify self-employment expenses if applicable. endstream endobj 438 0 obj <>/Subtype/Form/Type/XObject>>stream Financial aid information from students attending post-secondary institutions. BT << .lG%12 DHS 5776-ENG Combined Six-Month Report Form for Medical Assistance and SNAPThis form is for clients who have a six-month renewal for health care eligibility or a six-month report for the Supplemental Nutrition Assistance Program (SNAP) due. 2.7962 2.7525 Td The verification must be in existing files. - This form is used to request a Certificate of Clearnace when the property was transferred by a Decree of Descent. . 1 1 7.96 7 re Follow the step-by-step instructions below to design your hennepin county household report form: Select the document you want to sign and click Upload. Select the link to download, print or save to your computer. Share your form with others Send it via email, link, or fax. Below is a list of frequently requested Human services forms. The stop work order shall be in writing and issued to the owner of the property . DHS 0033 Appeal to State AgencyApplication form used to initiate or start a human services appeal of a county or state action. The verification requirements are as follows: hb``d``~4YAb,_w400q` 0K* `3.vbwH, ,870c``u@ {@U ,Mf1249 ,0e0Z0Pk 0ahcLwLo0`Nb: m13y e-L}~fd``: >> /Tx BMC 5 0 obj 0000001041 00000 n W SNAP: >> Also see 0010.18.01 (Mandatory Verifications - Cash Assistance) for additional MFIP provisions relating to citizenship and immigration status. Truework allows you to complete employee, employment and income verifications faster. Tips on how to complete the Stop working form online: To get started on the form, use the Fill camp; Sign Online button or tick the preview image of the document. Do not require any other form for this purpose. for additional MFIP provisions relating to citizenship and immigration status. In the first, the county agency received a stop - work verification on 4/13. Verification of participation is required every 12 months or when there is a change in the clients participation, whichever comes first. /Size 38 _ ! Removed WB. Some exemptions from the work rules need to be verified. FAX: 612-321-3488. See 0011.24 (Time-limited SNAP Recipients). - This form is used to request a Certificate of Clearance when the property was transferred using a Transfer on Death Deed. Set yourself up for success and utilize the online library to download samples and turn them into . endobj Employment start date: . n Unless questionable, a verbal statement from the client meets the verification requirement. PLUMBING A verbal client statement indicating residency in Minnesota meets the verification requirement. /Metadata 34 0 R Require the client to complete only those items needed to determine eligibility or benefit for the program(s) the client is requesting or receiving. RESPONSIBILITIES, 0028.03.01 - COUNTY AND TRIBAL NATION SNAP E&T RESPONSIBILITIES, 0028.03.02 - ES PROVIDER RESPONSIBILITIES - SNAP E&T, 0028.03.03 - EMPLOYMENT SERVICES/SNAP E&T REQUIRED COMPONENTS, 0028.03.06 - DETERMINING SNAP PRINCIPAL WAGE EARNER, 0028.03.09 - REPORTING CHANGES TO JOB COUNSELOR, 0028.06.02 - UNIVERSAL PARTICIPATION PROVISIONS, 0028.06.03 - WHO MUST PARTICIPATE IN EMPL. EDAK 0220Giving Permission for Someone to Act on My Behalf (Authorized Representative)Authorization form giving permission for someone to act on behalf of the client.EDAK 0031AInformed ConsentAuthorization form allowing release of information required for the determination of eligibility for assistance. See 0011.24 (Time-limited SNAP Recipients) for more information on counted months used in another state. Find the Stop Work Form Hennepin County you require. ]J}5vZZc}s?W0\(+X Go to the Department of Human Services' (DHS) e-Docs site and search for the form by entering the DHS form number. 0016 (Income from People Not in the Unit), Combined Six-Month Review (DHS-5576) (PDF), 0022.03.01.03 (Prospective Budgeting - SNAP Provisions), 0017.15.36 (Student Financial Aid Income), 0017.15.15 (Income of Minor Child/Caregiver Unde. Do not verify earned income of a child age 6 or older who has verified they are enrolled in school full-time in elementary, secondary, or GED. This program was suspended 12/1/14. BT Questions about legal documents can be directed to the County Attorneys Office: 763-324-5550. /O 4 0000007200 00000 n 0 0 Td 0000000025 00000 n See 0010.18.06 (Verifying Disability/Incapacity - SNAP). EDAK 3641DIAL BrochureBrochure explaining how use the Dakota Information Access Line (DIAL) system. Verifiers love Truework because it's never been easier and more streamlined to verify an employee, learn more here. Other Items to Consider. MCRE #: Employer: I grant permission to the Employer listed to provide and verify the information requested on this form. /Prev 0000025930 EMC %PDF-1.5 DHS 5223C-ENG Combined Application Addendum (Supplemental Nutrition Assistance Program, Cash Assistance, and Health Care Programs)This is an addendum to the Combined Application Form and is used for adding people to existing MFIP and GA assistance units after the initial application has been processed. Employment and Earnings Statement. For non-mandatory verifications for SNAP, see 0010.18.02.03 (Non-Mandatory Verifications SNAP). 4.9716 TL GEN 335 General Assistance Advanced Age Form - This form is used to verify a person meets the advanced age guidelines for General Assistance. Human services e-forms. 1 1 7.96 7 re 1 1 7.96 6.88 re endstream endobj 418 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream SNAP Application Packet - This packet provides SNAP program information to people applying for SNAP benefits. GEN 205 Emergency Programs Release Form - This form is used to allow Economic Assistance to contact landlords and utility companies in order to complete our Emergency Assistance or Emergency General Assistance application. Q DHS 8107 Household Update Form - This form is for people currently open on Cash or SNAP programs that need to complete a review following the COVID emergency. 0000007708 00000 n Human services 0.749023 g updates cross-references to 0007.03.02 (Six-Month Reporting) only due to section title changes. endstream endobj 434 0 obj <>/Subtype/Form/Type/XObject>>stream q This is valid for 1 year or when I withdraw it in writing. 481 0 obj <>/Filter/FlateDecode/ID[<6D1378B16692F9479C354AD2C049B183>]/Index[409 149]/Info 408 0 R/Length 206/Prev 521012/Root 410 0 R/Size 558/Type/XRef/W[1 3 1]>>stream f'G!&MCa a@e9\$!E!@m`R`IF\n@ 0 If you are not able to find the form you are looking for, search for additional forms below: Searchable document library (eDocs) / Minnesota Department of Human Services (mn.gov) Contact a human services representative Phone: 612-596-1300 M-F, 8 a.m. to 4:30 p.m. OF MINOR CRGVR, 0016.18.01 - 200 PERCENT OF FEDERAL POVERTY GUIDELINES, 0016.21 - INCOME OF SPONSORS OF IMMIGRANTS WITH I-134, 0016.21.03 - INCOME OF SPONSORS OF LPRS WITH I-864, 0016.27 - INCOME FROM SPOUSES WHO CHOOSE NOT TO APPLY, 0016.33 - INCOME OF INELIGIBLE NON-CITIZENS, 0016.39 - INCOME OF TIME-LIMITED RECIPIENTS, 0017.03 - AVAILABLE OR UNAVAILABLE INCOME, 0017.09 - CONVERTING INCOME TO MONTHLY AMOUNTS, 0017.12 - DETERMINING IF INCOME IS EARNED OR UNEARNED, 0017.15.03 - CHILD AND SPOUSAL SUPPORT INCOME, 0017.15.12 - INFREQUENT, IRREGULAR INCOME, 0017.15.15 - INCOME OF MINOR CHILD/CAREGIVER UNDER 20, 0017.15.18 - EMPLOYMENT, TRAINING, AND NATIONAL SERVICE INCOME, 0017.15.33.03 - SELF-EMPLOYMENT, CONVERT INC. TO MONTHLY AMT, 0017.15.33.24 - SELF-EMPLOYMENT INCOME FROM FARMING, 0017.15.33.27 - SELF-EMPLOYMENT INCOME FROM ROOMER/BOARDER, 0017.15.33.30 - SELF-EMPLOYMENT INCOME FROM RENTAL PROPERTY, 0017.15.36 - STUDENT FINANCIAL AID INCOME, 0017.15.36.03 - WHEN TO BUDGET STUDENT FINANCIAL AID, 0017.15.36.06 - IDENTIFYING TITLE IV OR FEDERAL STUDENT AID, 0017.15.36.09 - STUDENT FINANCIAL AID DEDUCTIONS, 0017.15.42 - INTEREST AND DIVIDEND INCOME, 0017.15.45.03 - HOW TO DETERMINE GROSS RSDI, 0017.15.48 - DISPLACED HOMEMAKER PROGRAM INCOME, 0017.15.51 - PAYMENTS RESULTING FROM DISASTER DECLARATION, 0017.15.54 - CAPITAL GAINS AND LOSSES AS INCOME, 0017.15.57 - PAYMENTS TO PERSECUTION VICTIMS, 0017.15.63 - RELATIVE CUSTODY ASSISTANCE GRANTS, 0017.15.78 - NATIONAL AND COMMUNITY SERVICE PROGRAMS, 0017.15.84 - CONTRACTS FOR DEED AS INCOME, 0018.06.06 - PLAN TO ACHIEVE SELF-SUPPORT (PASS), 0018.12.03 - ALLOWABLE SNAP MEDICAL EXPENSES, 0018.15.03 - SHELTER DEDUCTION - HOME TEMPORARILY VACATED, 0018.33 - CHILD AND SPOUSAL SUPPORT DEDUCTIONS, 0018.39 - PRIOR AND OTHER INCOME REDUCTIONS, 0018.42 - INCOME UNAVAILABLE IN FIRST MONTH, 0019.03 - GROSS INCOME TEST - WHAT INCOME TO USE, 0019.09 - GIT FOR SEPARATE ELDERLY DISABLED UNITS, 0020.03 - PEOPLE EXEMPT FROM NET INCOME LIMITS, 0020.06 - CHOOSING THE ASSISTANCE STANDARD TABLE, 0022 - BUDGETING AND BENEFIT DETERMINATION, 0022.03 - HOW AND WHEN TO USE PROSPECTIVE BUDGETING, 0022.03.01 - PROSPECTIVE BUDGETING - PROGRAM PROVISIONS, 0022.03.01.03 - PROSPECTIVE BUDGETING - SNAP PROVISIONS, 0022.03.03 - INELIGIBILITY IN A PROSPECTIVE MONTH - CASH, 0022.03.04 - INELIGIBILITY IN A PROSPECTIVE MONTH - SNAP, 0022.06 - HOW AND WHEN TO USE RETROSPECTIVE BUDGETING, 0022.06.03 - WHEN NOT TO BUDGET INCOME IN RETRO. 0000001409 00000 n endstream endobj 417 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 2.7962 2.7525 Td 0000006270 00000 n Q Use the Verification Request Form (DHS-2919) (PDF) to request needed verification. See 0010.18 (Mandatory Verifications) for mandatory verifications that apply to all programs. endstream endobj 422 0 obj <>/Subtype/Form/Type/XObject>>stream q If the injury/disability is expected to last indefinitely, verification is only needed once. /Outlines 33 0 R 0000001677 00000 n Create your signature and click Ok. Press Done. H W You may be trying to access this site from a secured browser on the server. Edit your form online Type text, add images, blackout confidential details, add comments, highlights and more. You must verify that the client is cooperating with the work requirements of this program. Open it up using the cloud-based editor and begin altering. 0 0 9.96 9 re 0000025069 00000 n endstream endobj 436 0 obj <>/Subtype/Form/Type/XObject>>stream