CC0100 Plumbing Work Experience Form. q The advanced tools of the editor will guide you through the editable PDF template. For more information, see 0028.30.09 (Refusing or Terminating Employment). /ID [<1b285431b6d97f0b3d25c629171a4448> 0000019279 00000 n Please seek professional legal advice if you are not sure this is the correct form for your situation. EDAK 0058BEmployment Start and Stop Verification Authorization form allowing release of employment information required for the determination of eligibility for assistance.EDAK 3239Taxi/Limo Driver Income and Expense ReportReport used by participants who are self-employed to report income and expenses each month. endstream endobj 442 0 obj <>/Subtype/Form/Type/XObject>>stream /Tx BMC When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. in SNAP adds a cross-reference to 0028.30.09 (Refusing or Terminating Employment). Human services e-forms. See 0017.15.15 (Income of Minor Child/Caregiver Under 20). See 0011.24 (Time-limited SNAP Recipients) for more information on counted months used in another state. ^ey$>PzVjP~64$b*a`?H"4{p1 j X Counties and tribes must use forms developed by DHS for the purposes of informing and advising clients about their rights and responsibilities, the status of an application or recertification, and ongoing eligibility for assistance. DHS 3549 General Consent/Authorization for Release of Information (PDF) - This form allows you to give Economic Assistance the authority to share specific information with another person or agency. West St. Paul, MN 55118-4765. endstream endobj 419 0 obj <>/Subtype/Form/Type/XObject>>stream Verify at the point of employment termination for participants, and for any employment terminated within 60 days of application for applicants. - Participating regularly in a drug addiction or alcohol treatment and rehabilitation program. Social Security numbers of all people applying for assistance. BT 2.7962 2.7525 Td If there is student income, also give the Financial Aid Information Form (DHS-2646) (PDF). 1 1 7.96 7 re 0.749023 g /Length 4196 For people in the Safe At Home Program, see 0029.29 (Safe At Home Program). f in SNAP deletes all policy about non-mandatory verifications and moves it to 0010.18.02.03 (Non-Mandatory Verifications SNAP) and adds a cross-reference to 0010.18.02.03 (Non-Mandatory Verifications SNAP). Verification Forms: DHS-2146 Authorization for Release of Employment Information - This form is completed by an employer to verify employment start, stop, or wage change. 0000007137 00000 n GEN 375 Voicemail Release - This form is used to allow Economic Assistance to leave a detailed message on a voicemail system for a specific phone number. in general provisions in the 2nd paragraph in the 3rd bullet adds and deletes information. endstream endobj 436 0 obj <>/Subtype/Form/Type/XObject>>stream 0000021969 00000 n 2023 Minnesota Department of Human Services, 0007.15 (Unscheduled Reporting of Changes - Cash), Verification Request Form (DHS-2919) (PDF), 0010.15 (Verification - Inconsistent Information), 0010.18.11 (Verifying Citizenship and Immigration Status), 0010.18.11.03 (Systematic Alien Verification (SAVE)), 0011.03.27 (Undocumented and Non-Immigrant People), (Mandatory Verifications - Cash Assistance). Verification is needed when a client is injured/incapacitated and the injury cannot be observed. for additional MFIP provisions relating to citizenship and immigration status. DHS 3543 Request for Payment of Long-Term Care ServicesThis form is completed by enrollees who are requesting payment of long-term care services. Minneapolis, MN 55487-0718. FAX: 612-321-3488. /H [ 0000001041 0000000192] endstream endobj 430 0 obj <>/Subtype/Form/Type/XObject>>stream Residency in Minnesota, unless verification cannot be obtained because the people are homeless, migrant farmworkers, or newly arrived in Minnesota. f 4.9716 TL EMC This form reports the verified hours and is adapted for use by unlicensed individuals registered to perform electrical work. in SNAP in the 2nd paragraph in the 1st bullet adds and deletes information about allowing housing costs as a deduction for applications and recertifications. endstream endobj 413 0 obj <>/Subtype/Form/Type/XObject>>stream @4z$]aAhBK503Ix7$&xv;le|Jn+TjeP-4TS Z If there is not enough room on the form to answer a question, attach your own pages. DHS 2114 Request for Medical OpinionMedical consent form allowing release of medical information required for the determination of eligibility for human services programs. Do not verify earned income of a child under age 6. EMC 5 0 obj Please enable scripts and reload this page. endstream endobj 429 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream /MarkInfo << Employment start date: . DHS 2952 Authorization for Release of Information About Residence and Shelter Expenses - This form is used to allow a landlord or homeowner information about your shelter expense. Minnesota Employment Verification Form Use a minnesota employment verification template to make your document workflow more streamlined. See 0010.18.06 (Verifying Disability/Incapacity SNAP). /Contents 6 0 R {e.2J0+z0.lG%12 endstream endobj 417 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream 0000019554 00000 n It also adds a new last paragraph with verification requirements. 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. in SNAP under sub-heading ABAWDs in the 3rd bullet adds and deletes language and cross-references for clarity. 0026.30 - NOTICE, DISQUALIFICATION OF AUTHORIZED REP. 0026.33 - NOTICE, DENYING GOOD CAUSE FOR IV-D NON-COOP, 0026.39 - NOTICE OF OVERPAYMENT AND RECOUPMENT, 0026.42 - NOTICE OF INCOMPLETE OR MISSING REPORT FORM, 0026.51 - NOTICES - CHEMICAL USE ASSESSMENT, 0027.12.03 - APPEAL HEARING EXPENSE REIMBURSEMENT, 0028.03 - COUNTY AGENCY EMPL. (4) Tj GEN 262 Special Diets - This form is used to provide information regarding diets prescribed by a doctor. /Tx BMC q Also see 0010.18.01 (Mandatory Verifications - Cash Assistance) for additional MFIP provisions relating to citizenship and immigration status. 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. /Tx BMC 0000007200 00000 n You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank. 0000024995 00000 n See 0010.18 (Mandatory Verifications) for mandatory verifications that apply to all programs. See 0011.24 (Time-limited SNAP Recipients). PARENT/GUARD. endstream endobj 437 0 obj <>/Subtype/Form/Type/XObject>>stream If the exemptions are not listed below, they do not need to be verified unless questionable. _ ! 0 03. This can be verified with the income verifications that are provided by the client. The process is simple and automated, and most employees are verified within 24 hours. endstream endobj 428 0 obj <>/Subtype/Form/Type/XObject>>stream 3) Workforce and Utilization Analysis. 0 0 9.96 9 re If the injury/disability is expected to last indefinitely, verification is only needed once. endstream endobj 416 0 obj <>/Subtype/Form/Type/XObject>>stream This information can be obtained from the client's Employment Services Provider. EMC >> 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. This can be obtained by contacting the client's Employment Services Provider. A verbal client statement indicating residency in Minnesota meets the verification requirement. Employment & Economic Assistance651-554-5611. Authorization for release of information about residence and shelter expenses, DHS 2952. eDocs; Change report form, DHS 4794. eDocs . 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. Also see Chapter 8 (Changes in Circumstances) for verifications which may be required when a unit has a change in circumstances. endstream endobj 435 0 obj <>/Subtype/Form/Type/XObject>>stream endstream endobj 432 0 obj <>/Subtype/Form/Type/XObject>>stream >> BT f 2.7962 2.7525 Td You must verify that the client is cooperating with the work requirements of this program. 0 0 Td 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. BENEFIT LEVEL - MFIP/DWP/GA, 0022.12.01 - HOW TO CALCULATE BENEFIT LEVEL - SNAP/MSA/GRH, 0022.12.02 - BEGINNING DATE OF ELIGIBILITY, 0022.15.03 - BUDGETING LUMP SUMS IN A PROSPECTIVE MONTH, 0022.15.06 - BUDGETING LUMP SUMS IN A RETROSPECTIVE MONTH, 0022.18.03 - OVERPAYMENTS RELATING TO SUSPENDED CASES, 0022.21 - INCOME OVERPAYMENT RELATING TO BUDGET CYCLE, 0022.24 - UNCLE HARRY FOOD SUPPORT BENEFITS, 0023.09 - HOUSEHOLD FURNISHINGS AND APPLIANCES, 0024.03 - WHEN BENEFITS ARE PAID - MFIP/DWP, 0024.03.03 - WHEN BENEFITS ARE PAID - SNAP/MSA/GA/GRH, 0024.04.03.03 - BENEFIT DELIVERY METHODS--PROGRAM PROVISIONS, 0024.04.04 - CHANGES IN AUTOMATIC BENEFIT DELIVERY METHOD, 0024.06 - PROVISIONS FOR REPLACING BENEFITS, 0024.06.03 - SITUATIONS REQUIRING SNAP BENEFIT REPLACEMENT, 0024.06.03.03 - REPLACING SNAP STOLEN/LOST BEFORE RECEIPT, 0024.06.03.15 - REPLACING FOOD DESTROYED IN A DISASTER, 0024.06.03.18 - REPLACING DAMAGED SNAP CASH-OUT WARRANTS, 0024.09.01 - PROTECTIVE AND VENDOR PAYMENTS-SNAP/MSA/GA/GRH, 0024.09.09 - DISCONTINUING PROTECTIVE AND VENDOR PAYMENTS, 0024.09.12 - PAYMENTS AFTER CHEMICAL USE ASSESSMENT, 0024.12 - ISSUING AND REPLACING IDENTIFICATION CARDS, 0025.03 - DETERMINING INCORRECT PAYMENT AMOUNTS, 0025.06 - MAINTAINING RECORDS OF INCORRECT PAYMENTS, 0025.09.03 - WHERE TO SEND CORRECTIVE PAYMENTS, 0025.12.03 - OVERPAYMENTS EXEMPT FROM RECOVERY, 0025.12.03.03 - SUSPENDING OR TERMINATING RECOVERY, 0025.12.03.09 - CLAIM COMPROMISE & TERMINATION, 0025.12.06 - REPAYING OVERPAYMENTS - PARTICIPANTS, 0025.12.09 - REPAYING OVERPAYMENTS - NON-PARTICIPANTS, 0025.12.12 - ACTION ON OVERPAYMENTS - TIME LIMITS, 0025.15 - ORDER OF RECOVERY - PARTICIPANTS, 0025.18 - ORDER OF RECOVERY - NON-PARTICIPANTS, 0025.21.03 - OVERPAYMENT REPAYMENT AGREEMENT, 0025.24 - FRAUDULENTLY OBTAINING PUBLIC ASSISTANCE, 0025.24.03 - RECOVERING FRAUDULENTLY OBTAINED ASSISTANCE, 0025.24.06.03 - ADMINISTRATIVE DISQUALIFICATION HEARING, 0025.24.07 - DISQUALIFICATION FOR ILLEGAL USE OF SNAP, 0025.24.08 - SNAP ELECTRONIC DISQUALIFIED RECIPIENT SYSTEM, 0025.30 - FINANCIAL RESPONSIBILITY, PEOPLE NOT IN HOME, 0025.30.03 - CONTRIBUTIONS FROM PARENTS NOT IN HOME. 01. > GEN 260 Sponsor Release of Information - This form is used to allow Economic Assistance to communicate with the client's sponsor. There are three variants; a typed, drawn or uploaded signature. If DHS does not provide a form for a given purpose, the county or tribe may develop their own form; however, the form must meet the requirements in TEMP Manual TE12.02.01 (County Designed Forms). >> 6 0 obj 0000007685 00000 n >> US Legal Forms is definitely the industry leader in affordable access to state-specific form templates. AREP Authorization form for SNAP, CASH, Medical (DOC), DHS 2243 Authorization for Release of Information about Assets, DHS 2952 Authorization for Release of Information About Residence and Shelter Expenses, DHS 3549 General Consent/Authorization for Release of Information (PDF), DHS 7823 Authorization to Obtain Information from AVS, DHS-2146 Authorization for Release of Employment Information, GEN 335 General Assistance Advanced Age Form, DHS 5893 Application for Certificate of Clearance for Medical Assistance Claim - Transfer on Death Deed (PDF), DHS 6165A Application for Certificate of Clearance for Medical Assistance Claims - Decree of Descent (PDF), DHS 3543 Request for Payment of Long Term Care Services, Minnesota Department of Human Services Website, Supplemental Nutrition Assistance Program, Medical Assistance Certificate of Clearance, Medical Assistance Claim/Probate Payments. - This form is used to request a Certificate of Clearnace when the property was transferred by a Decree of Descent. Q /Filter /FlateDecode 4.9716 TL in SNAP deletes to verify disability exemption from work registration. 0000006624 00000 n (4) Tj See 0010.18.30 (Verifying Student Income and Expenses). Authorization for Release of Information About Residence and Shelter Expenses (DHS, 0004.12 (Verification Requirements for Emergency A, 0010.18.01 (Mandatory Verifications - Cash Assistance), 0010.18.02 (Mandatory Verifications - SNAP), 0017.15.15 (Income of Minor Child/Caregiver Under 20), 0010.18.02.03 (Non-Mandatory Verifications SNAP). 557 0 obj <>stream /F1 10 0 R Use of the information collected based on this verification form is restricted to the purposes cited above. Q All Section 8 Forms Applicants Participants Property Owners BT GEN 280 Drug Felony Release form - This form is used to allow Economic Assistance to obtain information regarding drug test results. 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. Verify the exemptions listed below at application time and/or when a change occurs. If the injury/disability is expected to last indefinitely, verification is only needed once. H Sign and date the form on or after: 6. 1300.0170 STOP WORK ORDER. 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. Each form includes instructions about where and how to turn it in. After completing all three and making an online payment of $250, send the finished documents as attachments to compliance.mdhr@state.mn.us. Decide on what kind of signature to create. /Tx BMC 2.2948 3.1191 Td %PDF-1.6 % If you are not able to find the form you are looking for, search for additional forms below: Searchable document library (eDocs) / Minnesota Department of Human Services (mn.gov). for additional MFIP provisions relating to citizenship and immigration status. 4 0 obj /ZaDb 5.0258 Tf Show details How it works Open the mn employment verification and follow the instructions Easily sign the minnesota employment verification form with your finger DHS 2402-ENG Change Report FormReporting form used by clients to report income, asset, and circumstance changes usually on a non-scheduled basis. H$ 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. /ZaDb 5.1626 Tf This change was EFFECTIVE 02/01/16. 0000007179 00000 n /Tx BMC 1 1 9.04 9.4 re MFIP, DWP, MSA, GA, GRH: /Font << << To learn more about what might be personally identifiable information . - Unfit for Employment. EMC (4) Tj QD~bJmb}`!lsUJ3>11g.x z;eY#\. W If no other form of verification is available or if the client chooses to use a form to verify residence or shelter expenses, you may use the Authorization for Release of Information About Residence and Shelter Expenses (DHS-2952) (PDF). Document this verbal statement in CASE/NOTEs. Removed WB. Do not require any other form for this purpose. Other Items to Consider. x]K$ 0zb%Ynl!?$(_)UkggTRHTQ?[LIt_=?I}~J@NxO?3O~CJK? 5}X}t^ x{Jk? "H`DH.~ "9H0:@X,r,bb{5 I& |##(9$L @/b > /Tx BMC 7V,%2EPEr_:b9~*x8|s.R&"WN,I# /|!(C4YhB##v4 4kec$%:E>E7 ,)`) %bi,rKh,a% yi z.3~@m&wWs3)/Rn%p Verify eligibility factors at initial application. /Pages 1 0 R << 0010.18.02.03 (Non-Mandatory Verifications SNAP), 0010.15 (Verification Inconsistent Information), 0010.18.06 (Verifying Disability/Incapacity SNAP), 0010.18.02 - MANDATORY VERIFICATIONS - SNAP. /ZaDb 5.1626 Tf AREP Authorization form for SNAP, CASH, Medical (DOC)Opens a New Window. Unless questionable, a verbal statement from the client meets the verification requirement. Below is a list of frequently requested Human services forms. DHS 2952-ENG Authorization for Release of Information about Residence and Shelter ExpenseAuthorization form allowing release of residence and shelter expense information required for the determination of eligibility for human service programs. For all applicants give and verbally review during the interview: Give the forms below to all applicants. Paperwork can also be submitted by email to EADocs@co.anoka.mn.us. If you are submitting a PDF form that contains personally identifiable information (i.e. SERV. n (4) Tj /Tx BMC See 0017.15.15 (Income of Minor Child/Caregiver Under 20). 0000024780 00000 n SNAP: DHS 2120-ENG Household Report Form for MFIP/DWPReporting form used by clients to report income, asset and circumstance changes usually on a scheduled basis. @ @3Nd&` ` xP Verify additional eligibility factors required by each program as noted in the specific program provisions in 0004.12 (Verification Requirements for Emergency Aid), 0010.18.01 (Mandatory Verifications - Cash Assistance), 0010.18.02 (Mandatory Verifications - SNAP). @4z$]aAhBK503Ix7$&xv;le|Jn+TjeP-4TS Z 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. Registered unlicensed individuals, as part of renewing their registration, must provide verification of their employment by a licensed contractor or registered employer during the registration period. f endstream endobj 414 0 obj <>/Subtype/Form/Type/XObject>>stream Verifiers love Truework because it's never been easier and more streamlined to verify an employee, learn more here. EMC Use the Verification Request Form (DHS-2919) (PDF) to request needed verification. Non-Mandatory Verifications The stop work order shall be in writing and issued to the owner of the property . 0000025750 00000 n 0000022117 00000 n 1 1 7.96 7 re 1. 0 0 9.96 8.88 re See 0010.18.11 (Verifying Citizenship and Immigration Status), 0011.03.27 (Undocumented and Non-Immigrant People). /OutputIntents [31 0 R] endstream endobj 434 0 obj <>/Subtype/Form/Type/XObject>>stream EMC 0000001677 00000 n trailer 0.749023 g .lG%12 % 0000007708 00000 n /T 0000025941 0.749023 g Edit your form online Type text, add images, blackout confidential details, add comments, highlights and more. If no other form of verification is available or if the client chooses to use a form to verify residence or shelter expenses, you may use the Authorization for Release of Information About Residence and . 0000019304 00000 n Applying for MNsure Helpful Information - This document gives you step by step instructions for completing an online MNsure application. Immigration status, ONLY if the applicant reports a non-citizen status, including non-citizens, naturalized and derived citizen status. If the injury/disability is temporary, new verification will be needed if the injury/disability extends past the anticipated end date. Put the particular date and place your e-signature. MCC Recipient Notice - Instructions for getting reimbursed for Medical Transportation, MCC Trip Log 2020-2021 - Record your trips used for Medical Appointments. The number of hours of employment or work program activities. /Marked true Q 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. The participant's last day of employment was 01/13 and received the last check 1/13. %%EOF CASES, 0022.09 - WHEN TO SWITCH BUDGET CYCLES - CASH, 0022.09.03 - WHEN TO SWITCH BUDGET CYCLES - SNAP, 0022.12 - HOW TO CALC. Change the template with exclusive fillable fields. A verbal client statement indicating residency in Minnesota meets the verification requirement. endstream endobj 441 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream @4z$]aAhBK503Ix7$&xv;le|Jn+TjeP-4TS Z 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. /Tx BMC 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.