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COMBINED MANUAL

ISSUE DATE 10/2019

COMBINED APPLICATION FORM (CAF)

0005.09

MFIP, DWP, SNAP, MSA, GA, GRH: The Combined Application Form (CAF) (DHS-5223) (PDF) allows people to apply for multiple assistance programs on 1 form.

Give the CAF to people who want to apply for any of the following assistance programs:

● Minnesota Family Investment Program (MFIP).

● Refugee Cash Assistance (RCA).

● Diversionary Work Program (DWP).

● General Assistance (GA).

● Minnesota Supplemental Aid (MSA).

● Group Residential Housing (GRH).

● Supplemental Nutrition Assistance Program (SNAP).

● Emergency Assistance.

The CAF includes:

● Instructions on how to complete the form.

● A tear-off page (page number 1) which can be used to set the date of application. See 0005.12.09 (Date of Application), 0004 (Emergencies). This page of the CAF also includes questions to evaluate for emergency need, expedited services, assistance unit composition and size and signature blocks. See 0014 (Assistance Units).

● Several pages with Yes/No questions used to determine eligibility. Use the information provided on these pages to establish eligibility factors including:

- Client information. See 0010 (Verification), 0013 (Basis of Eligibility), 0014 (Assistance Units).

- Basis of eligibility and program coverage. See 0013 (Basis of Eligibility).

- Income, asset, and expense data. See 0015 (Assets), 0017 (Determining Gross Income), 0018 (Determining Net Income).

- Emergency data. See 0004 (Emergencies).

● Several detachable forms, including Client Responsibilities and Rights (DHS-4163) (PDF), Notice of Privacy Practices (DHS- 3979) (PDF), Appeal rights (DHS-3353) (PDF), Notice About Income and Eligibility Verification System and Work Reporting System (DHS-2759) (PDF) and the Civil Rights Notice.

For information on setting the date of application, application interviews and scheduling appointments, see 0005.12.09 (Date of Application), 0005.12.12 (Application Interviews).