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BAM 115 3 of 36 APPLICATION PROCESSING BPB 2026-003 2-1-2026

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

Signature Requirement All Programs Before the application or MDHHS-1171, Filing Form, is registered, it must be signed by the client or authorized representative (AR). Note: The signature(s) establishes both of the following: • Client and/or AR understand their rights and responsibilities. • Client and/or AR prepared the application or filing form truthfully under penalty of perjury. Medicaid A MDHHS-1171, Filing Form, is not used to register a request for assistance. CDC Only An applicant who is unable to write may sign with an X, witnessed by one other person such as a relative, friend, department specialist, etc. If the MDHHS-1171 is updated by the client to request CDC, it must be re-signed and dated. FIP, SDA, RCA, and FAP Only If an in-person interview is held, the client and/or AR must sign and date the application in the specialist's presence, even if it was already signed. Sign and date the application as a witness. FAP Only If the FAP group does not have an adult or an AR, a minor group member must sign the application. FIP Only If an in-person interview is held (all adult mandatory group members in the home must sign the application in the presence of the specialist if physically able. If a telephone interview is an option for the group, the specialist must do all of the following:

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Official source

BAM 115 3 of 36 APPLICATION PROCESSING BPB 2026-003 2-1-2026

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

Signature Requirement All Programs Before the application or MDHHS-1171, Filing Form, is registered, it must be signed by the client or authorized representative (AR). Note: The signature(s) establishes both of the following: • Client and/or AR understand their rights and responsibilities. • Client and/or AR prepared the application or filing form truthfully under penalty of perjury. Medicaid A MDHHS-1171, Filing Form, is not used to register a request for assistance. CDC Only An applicant who is unable to write may sign with an X, witnessed by one other person such as a relative, friend, department specialist, etc. If the MDHHS-1171 is updated by the client to request CDC, it must be re-signed and dated. FIP, SDA, RCA, and FAP Only If an in-person interview is held, the client and/or AR must sign and date the application in the specialist's presence, even if it was already signed. Sign and date the application as a witness. FAP Only If the FAP group does not have an adult or an AR, a minor group member must sign the application. FIP Only If an in-person interview is held (all adult mandatory group members in the home must sign the application in the presence of the specialist if physically able. If a telephone interview is an option for the group, the specialist must do all of the following: