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COMBINED MANUAL

ISSUE DATE 02/2022

FORMS/HANDOUTS FOR APPLICANTS

0005.12.12.01

● Minnesota Family Investment Program (DHS-3179) (PDF).

● Minnesota Supplemental Aid (DHS-1888) (PDF).

● Supplemental Nutrition Assistance Program (DHS-2814) (PDF).

MNbenefits applicants have access to required forms for the program(s) for which they applied. Applicants must check the box in front of each form attesting they have reviewed the materials before the MNbenefits application can be submitted: ● Notice of Privacy Practices (DHS-3979) (PDF).

● Client Responsibilities and Rights (DHS-4163) (PDF).

● Authorization for Sharing Information and Assignment of Benefits.

● Notice About Income and Eligibility Verification System and Work Reporting System (DHS-2759) (PDF).

● Important Information (DHS-3353) (PDF).

● Additional Important Information.

● Penalty Warnings.

● Employment Services Registration.

● Domestic Violence Information (DHS-3477) (PDF).

● Do you have a disability? (DHS-4133) (PDF).

● How to Use Your Minnesota EBT Card (DHS-3315A) (PDF).

● Civil Rights Notice.

● Supplemental Nutrition Assistance Program reporting responsibilities (DHS-2625).

● Facts on Voluntarily Quitting Your Job If You Are on the Supplemental Nutrition Assistance Program (SNAP) (DHS-2707).

ADDITIONAL PROGRAM SPECIFIC FORMS

Give the following forms/handouts based on the programs applied for and the circumstances of the case at the interview or send them out if the interview is conducted over the phone. Check the cross-referenced sections for procedures for each form/handout listed.

MFIP: ● Reporting Responsibilities for MFIP Households (DHS-2647) (PDF). See 0007.12 (Agency Responsibilities for Client Reporting).

● In cases where there is at least 1 non-custodial parent: - Understanding Child Support - A Handbook for Parents (DHS-3393) (PDF). - Referral to Support and Collections (DHS-3163B) (PDF). (This is in addition to the Combined Application Form or MNbenefits application, for EACH non-custodial parent). See 0012.21.03 (Support From Non-Custodial Parents). - Cooperation with Child Support Enforcement (DHS-2338) (PDF). See 0012.21.06 (Child Support Good Cause Exemptions).

NOTE: This does not apply to a married parent who is out of the home on military duty when there is no breakdown in the marital relationship.