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Public Assistance

Forms

The following list includes the most commonly requested forms.  If the form you need is not on this list, you can visit the Minnesota Department of Human Services website where you can search eDocs to find the form you need. Some Spanish forms are also available.

Program Renewal Forms and Reporting Forms
DHS 5223C-ENG Combined Application – Addendum (Supplemental Nutrition Assistance Program, Cash Assistance, and Health Care Programs)
This is an addendum to the Combined Application Form and is used for adding people to existing MFIP and GA assistance units after the initial application has been processed. It can also be used but is not required for collecting information on people added to the Supplemental Nutrition Assistance Program (SNAP) or a Minnesota health care program.

DHS 5776-ENG Combined Six-Month Report Form – for Medical Assistance and SNAP
This form is for clients who have a six-month renewal for health care eligibility or a six-month report for the Supplemental Nutrition Assistance Program (SNAP) due. When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs.

DHS 3418-ENG Minnesota Health Care Programs Renewal Form
This is the annual renewal form for all of the Minnesota Health Care Programs except Minnesota Family Planning and Breast and Cervical Cancer.

DHS 2120-ENG Household Report Form – for MFIP/DWP
Reporting form used by clients to report income, asset and circumstance changes usually on a scheduled basis.

DHS 2402-ENG Change Report Form
Reporting form used by clients to report income, asset, and circumstance changes usually on a non-scheduled basis.

DHS 3417D Supplemental Nutrition Assistance Program Addendum to the Minnesota Health Care Programs Application
This form is used to apply for the Supplemental Nutrition Assistance Program (SNAP) if you have completed a Minnesota Health Care Programs Application (DHS-3417).

DHS 3543 Request for Payment of Long-Term Care Services
This form is completed by enrollees who are requesting payment of long-term care services.

Release Forms
DHS 2952-ENG Authorization for Release of Information about Residence and Shelter Expense
Authorization form allowing release of residence and shelter expense information required for the determination of eligibility for human service programs.

EDAK 3670 Consent for Release Regarding Utility Shutoffs And/Or Eviction
Authorization form allowing Dakota County Employment & Economic Assistance permission to contact utility companies and/or landlord for information required for determination of eligibility for assistance.

EDAK 3147 Financial Summary Statement
Report for used by participants to report income and expenses required for the determination of Diversionary Work Program and/or Emergency Assistance eligibility. 

EDAK 0220 Authorization Performance Agreement (AREP Form)
Authorization form giving permission for someone to act on behalf of the client.

EDAK 0031A Informed Consent
Authorization form allowing release of information required for the determination of eligibility for assistance.

Income Forms
EDAK 0058 Employment Verification
Authorization form allowing release of employment information required for the determination of eligibility for assistance.

EDAK 0058A Employment Termination-Leave Verification
Authorization form allowing release of employment information required for the determination of eligibility for assistance.

EDAK 0058B Employment Start and Stop Verification
Authorization form allowing release of employment information required for the determination of eligibility for assistance.

EDAK 3239 Taxi/Limo Driver Income and Expense Report
Report for used by participants who are self-employed to report income and expenses each month. 

DHS 3336-ENG Self-Employment Report Form
Report for used by participants who are self-employed to report income and expenses each month. 

Child Support Forms
DHS 3163B Referral to Support and Collections
This form is used by MinnesotaCare, Medical Assistance and Child Care Assistance recipients for referral to the local child support agency for the purpose of establishing paternity or child support enforcement services. 

DHS 2338 Cooperation with Child Support Enforcement
Form that client completes about cooperating with child support to receive public assistance.

Medical Forms
DHS 2114 Request for Medical Opinion
Medical consent form allowing release of medical information required for the determination of eligibility for human services programs.

DHS 3236 Proof of Pregnancy
Letter to Minnesota Health Care Program enrollees to verify a reported pregnancy.

Other
DHS 0033 Appeal to State Agency
Application form used to initiate or start a human services appeal of a county or state action.

EDAK 3641 DIAL Brochure
Brochure explaining how use the Dakota Information Access Line (DIAL) system.

Last updated: 4/4/2013 6:11 AM