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COMBINED MANUAL

ISSUE DATE 01/2020

FORMS/HANDOUTS FOR APPLICANTS

0005.12.12.01

Certain forms must be given to all applicants. Other forms are required based on the program(s) being applied for. If the program(s) being applied for is known, forms for those programs can be given in the application packet or at the interview, if one is required. If the interview is conducted over the phone, send the required forms by mail.

PAPER APPLICATION PACKETS

Counties and tribes must have paper application packets available to give or send to clients.

The following are required to be included in the paper application packet:

● Combined Application Form (CAF) (DHS-5223) (PDF). Attached to the CAF are the following:

- Notice of Privacy Practices (DHS-3979) (PDF).

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

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

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

● A cover letter including the following:

- The county agency address, office hours, and phone number.

- The importance of returning page number 1 of the CAF as soon as possible.

- Information about the interview and returning the remainder of the CAF.

● Program information brochure for cash, food, child care and health care programs (DHS-2920) (PDF).

● Domestic Violence Information (DHS-3477) (PDF). See 0029.36 (Domestic Violence Brochure).

● Do you have a disability? (DHS-4133) (PDF). Also see 0003.09.03 (Clients Rights - Civil Rights).

The following may also be included in the application packet or handed out at the interview as appropriate:

● Household Report Form (DHS-2120) (PDF).

● Combined Six-Month Report (CSR) (DHS-5576) (PDF).

● Change Report Form (DHS-2402) (PDF). See 0007 (Reporting), 0007.12 (Agency Responsibilities for Client Reporting), 0007.15 (Unscheduled Reporting of Changes - Cash), 0007.15.03 (Unscheduled Reporting of Changes - SNAP).

● Authorization for Release of Information About Residence and Shelter Expenses (DHS-2952) (PDF), if appropriate. See 0010.18 (Mandatory Verifications).

● Application for Social Security number (SS-5), if needed. See 0010.18.03 (Verifying Social Security Numbers), 0012.03 (Providing/Applying for an SSN).

ELECTRONIC APPLICATION PACKETS VIA APPLYMN

Regardless of the program(s) being applied for, ApplyMN applicants have access to the following forms within ApplyMN.

● Program information for cash, food, and child care programs (DHS-2920) (PDF).