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COMBINED MANUAL
ISSUE DATE 01/2020
FORMS/HANDOUTS FOR APPLICANTS
0005.12.12.01
● Do you have a disability? (DHS-4133) (PDF).
● Notice of Privacy Practices (DHS-3979) (PDF).
● General Assistance (DHS-2062) (PDF).
● Minnesota’s Diversionary Work Program (DHS-4034) (PDF).
● Minnesota Family Investment Program (DHS-3179) (PDF).
● Minnesota Supplemental Aid (DHS-1888) (PDF).
● Supplemental Nutrition Assistance Program (DHS-2814) (PDF).
ApplyMN 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 ApplyMN 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).
● Work Registration Notice (DHS-7635).
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: