**Keep in mind that you do not need to mail this print-out to your local agency.**

Transcription

1 **Keep in mind that you do not need to mail this print-out to your local agency.** Thank you for using MI Bridges to apply for benefits! Jackson, your application was sent to the following address on May 1, 2012 at 10:41 A.M. Mailing Address Ingham County DHS PO BOX LANSING MI Phone Number: (517) Your application tracking number is Txxxxxxxx. You will need this number if you want information about the status of your application. In your application, you have asked for these benefits: Child Development and Care Benefits. You may also need to give your worker proof of some of the things you told us in your application. The list below will help you gather these items. Then, you can fax, or mail them to the DHS office listed above. If you cannot find something, your worker may be able to help you get the proof you need. Types of Proof Proof of Identity For the person who is applying for assistance, you will need to give your worker a copy of one of the following: driver's license, state ID, voter registration card, wage stub, identification for health benefits, or birth certificate/record, etc. Proof of Immigration Here are some examples of what you can give your worker to prove your Immigration: Permanent Resident Alien Declaration, Immigration document (Government issued). Proof of Job Income Here are some examples of what you can give your worker to prove your Job Income: Check stubs or earning statements, Employer statement, Verification of Employment, Agricultural Income Verification. Proof of Other Income Here are some examples of what you can give your worker to prove your Other Income: Intent to Contribute Income, Benefit award letter, Other Income Verification. MIBridges Apply For Benefits Page 1

2 Proof of Child Day Care Needs Here are some examples of what you can give your worker to prove your Child Day Care Needs: Work Schedule showing number of hours worked, Pay stubs showing number of hours worked, Employment Verification, Agricultural Worker Income Verification, Employer Statement. Application Summary Here is a summary of what you told us, as well as important information about your rights and responsibilities. Basic Information Your Name Date of Birth Gender Language County Jackson 03/15/1974 Male English Ingham Where You Live Mailing Address 1891 S. Cedar ST Holt, MI, Contact Information Home Phone (517) Work Phone Cell Phone Message Phone Address Best way to get in touch with you Home Phone Phone Type (if Deaf or Hard of Hearing) Best time to get in touch with you Late Afternoon Do you have a Bridge Card? Do you have a mihealth Card? People In Your Home MIBridges Apply For Benefits Page 2

3 Jackson Date of Birth Gender Marital Status Language 03/15/1974 Male Separated English Programs Requested SSN SSN Application Date US Citizen? Sponsor for an immigrant? Yes Resident of MI? Intends to reside in MI? Job commitment or Looking for work? Migrant or Seasonal Farm Worker? Yes Where does he/she Date of or expected Race Ethnicity live? date of leaving facility In this Home Black / African n-hispanic/latino American Veteran On active duty? Spouse of a deceased Veteran? Child of a deceased Veteran? 100% disabled veteran Date of Entry into US Tribal Name Applied for VA health care benefits? Receiving VA health care benefits? Moved or received assistance from another state? Date moved to Michigan Applied for benefits Name under which or received benefits applied or received from Michigan in benefits the past? County Your Case Worker Other State Phone Number MIBridges Apply For Benefits Page 3

4 Denise Jackson Date of Birth Gender Marital Status Language 01/24/2004 Female Never Married English Programs Requested Child Development and Care SSN SSN Application Date US Citizen? Sponsor for an immigrant? Yes Resident of MI? Intends to reside in MI? Job commitment or Looking for work? Migrant or Seasonal Farm Worker? Yes Where does he/she Date of or expected Race Ethnicity live? date of leaving facility In this Home Black / African n-hispanic/latino American Veteran On active duty? Spouse of a deceased Veteran? Child of a deceased Veteran? 100% disabled veteran Date of Entry into US Tribal Name Applied for VA health care benefits? Receiving VA health care benefits? Moved or received assistance from another state? Date moved to Michigan Applied for benefits Name under which or received benefits applied or received from Michigan in benefits the past? County Your Case Worker Other State Phone Number MIBridges Apply For Benefits Page 4

5 Debra Jackson Age: 4 Date of Birth Gender Marital Status Language 04/05/2008 Female Never Married English Programs Requested Child Development and Care SSN SSN Application Date US Citizen? Sponsor for an immigrant? Yes Resident of MI? Intends to reside in MI? Job commitment or Looking for work? Migrant or Seasonal Farm Worker? Yes Where does he/she Date of or expected Race Ethnicity live? date of leaving facility In this Home Black / African n-hispanic/latino American Veteran On active duty? Spouse of a deceased Veteran? Child of a deceased Veteran? 100% disabled veteran Date of Entry into US Tribal Name Applied for VA health care benefits? Receiving VA health care benefits? Moved or received assistance from another state? Date moved to Michigan Applied for benefits Name under which or received benefits applied or received from Michigan in benefits the past? County Your Case Worker Other State Phone Number Relationship Information Denise Relationships is the Father of Denise and is the Primary Caretaker for Denise is the Father of Debra and is the Primary Caretaker for Debra Do they buy food and Can they buy food or Is this person acting eat meals together? meals separately? as a parent? Yes Yes Yes Yes Yes Yes Relationships Do they buy food and Can they buy food or Is this person acting eat meals together? meals separately? as a parent? is the Sister of Debra Yes Yes MIBridges Apply For Benefits Page 5

6 Absent Parent Information Denise Birth Information Who paid for Birth Expenses? Marital Status of Mother? Parents Married Marriage Date 02/14/1996 City County State Country Lansing Ingham Michigan USA Separation Date 12/25/2010 Absent Mother Details Name Date of Birth Age Carmen Jackson 12/08/1972 Social Security Number Status Absence Reason Claim for Good Cause Separation Yes Height Weight Hair Color Eye Color 5'2" 115 lb Red (Includes Auburn) Green Ethnicity Race Tribe name n-hispanic/latino Black / African American Employer Name Employer Address Job Start Date Best Buy Lansing, MI Is there a support order naming him for this child? Court Order Number County State Country Michigan USA Insurance Carrier Policy Number MIBridges Apply For Benefits Page 6

7 Debra Age: 4 Birth Information Who paid for Birth Expenses? Marital Status of Mother? Parents Married Marriage Date 02/14/1996 City County State Country Lansing Ingham Michigan USA Separation Date 12/25/2010 Absent Mother Details Name Date of Birth Age Carmen Jackson 12/08/1972 Social Security Number Status Absence Reason Claim for Good Cause Separation Yes Height Weight Hair Color Eye Color 5'2" 115 lb Red (Includes Auburn) Green Ethnicity Race Tribe name n-hispanic/latino Black / African American Employer Name Employer Address Job Start Date Best Buy Lansing, MI Is there a support order naming him for this child? Court Order Number County State Country Michigan USA Insurance Carrier Policy Number Questions About the People In Your Home Denise Debra Age: 4 Blind or Disabled? Convicted of a Drug Felony? Getting Other FS Benefits? Getting SSI Benefits? N/A N/A Getting Cash Benefits from DHS? Child Development and Care Information MIBridges Apply For Benefits Page 7

8 Approved Activity Child Who needs Child Care? Child Care for Foster Children? Denise, Debra Why do you need CDC? Work, Approved Education / Training / Employment Preparation Need Child Care to participate in DHS Services? Child Information Denise Has a provider been Provider Name Provider Address selected? Yes Happy Elephant 3325 Aurelus Lansing, Michigan Provider Phone Number Provider ID/License Add another Provider Number (517) Yes Has a provider been Provider Name Provider Address selected? Yes Sarah Decker 2414 Dillingham Lansing, Michigan Provider Phone Number Provider ID/License Add another Provider Number (517) Yes Debra Age: 4 Has a provider been Provider Name Provider Address selected? Yes Happy Elephant 3325 Aurelus Lansing, Michigan Provider Phone Number Provider ID/License Add another Provider Number (517) Yes Has a provider been Provider Name Provider Address selected? Yes Sarah Decker 2414 Dillingham Lansing, Michigan Provider Phone Number Provider ID/License Add another Provider Number (517) Yes MIBridges Apply For Benefits Page 8

9 EI - Employment Information Job Income Information You told us that no one in your home has this kind of income, benefit, or bill. MIBridges Apply For Benefits Page 9

10 SI - Self Employment Income Self Employment Information Self- Employment Yes Type of Self- Employment Carpentry or Construction Start Date Earnings per month Hours per month Business Expenses 06/01/2006 $ $ Yes Expected to continue in next 30 days MIBridges Apply For Benefits Page 10

11 OI - Other Income Other Income Questions Denise Debra Age: 4 Getting income from providing room and/or board? N/A N/A Other Income Information You told us that no one in your home has this kind of income, benefit, or bill. MIBridges Apply For Benefits Page 11

12 SE - Shelter Expense Housing Bills Questions Has anyone in your household, who is applying for Food Assistance, received, applied for or will apply for the Michigan Department of Treasury Home Heating Credit for their current address for the current fiscal year? Housing Bills Information Type of Housing Bill Monthly Amount How Often Paid Rent or Lot Rent $ Monthly MIBridges Apply For Benefits Page 12

13 UE - Utility Expense Utility Bills Information Type of Utility Bill Monthly Amount How Often Paid Telephone MIBridges Apply For Benefits Page 13

14 OE - Other Expenses Other Bills Questions Denise Debra Age: 4 Child / Spousal Support Payments Dependent Care Bills Medical Bills Medicare Information Child / Spousal Support Payments Dependent Care Bills Medical Bills Medicare Information Child / Spousal Support Payments Dependent Care Bills Medical Bills Medicare Information N/A N/A N/A N/A Dependent Care Bills You told us that no one in your home has this kind of income, benefit, or bill. Medical Bills You told us that no one in your home has this kind of income, benefit, or bill. Medicare Information You told us that no one in your home has this kind of income, benefit, or bill. Child/Spousal Support Payment Information You have told us that no one we asked about has Child Support/Spousal Support Payment Information. Other Information Questions WIC Benefits Adoption Subsidy/Guardianship Assistance Payments N/A MIBridges Apply For Benefits Page 14

15 Denise Debra Age: 4 School Enrollment Information In School? Highest Grade Completed? Type Of School Half time 12th Grade or GED Community College or Completed Junior College Denise Full time 3rd Grade Elementary College, University or Vocational School Additional Information I am self-employed and taking art classes at LCC two nights per week. I work 40 hours per week and I'm in class 8 hours per week. I started my construction business on June 1, Carmen left the home about a year ago. She will not be returning to my home. I either missed it or the online application didn't ask me about assets. I have National City checking account with about $345 in it. I also have a 2004 Dodge Ram 3500 Quad Cab Laramie 2WD truck. I purchased the truck on May 1, I still owe $2000 on it. My mom was watching the girls but she moved to Florida this past week. I didn't have to pay my mom. I hope you can help pay for the girls to be in day care or I'll have to quit my job and drop out of school. Happy Elephant Day Care will watch the girls while I work and my neighbor Sarah Decker will watch them while I'm in class. I don't need day care for study time. MIBridges Apply For Benefits Page 15

16 State of Michigan Voter Registration Application If you are not registered to vote where you live now, would you like to apply to register to vote here today? Yes, I would like a printable voter registration application form. If you select this option, a printable voter registration application form will be provided at the end of the benefits application process. Yes, I would like a voter registration application form to be mailed to me., I decline a voter registration application form. If you checked "yes",a printable voter registration application form was either provided at the end of the benefits application process or will be mailed to you, depending on which option you selected. If you have any questions or experience any problems with the online application process or voter registration process, please contact the office listed on the first page of the PDF. You may also ask your worker for a voter registration application form at any time. DHS will assist you with completion of the voter registration application form (unless you decline such assistance) and submit your completed voter registration application form to the appropriate elections officials. Applying or declining to register to vote will not affect the amount of assistance that you will be provided by this department. If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter registration application form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with: Secretary of State PO Box Lansing, MI MIBridges Apply For Benefits Page 16

17 Electronic Signature Under penalties of perjury, I swear or affirm that this application has been examined by or read to me, and, to the best of my knowledge, the facts are true and complete. If I am a third party applying on behalf of another person, I swear or affirm that this application has been examined by or read to the applicant, and, to the best of his/her knowledge, the facts are true and complete. I certify that I have received, reviewed and agree with the sections in the assistance application Information Booklet explaining how to apply for and receive help: Things You Must Do, Important Things to Know, Information About Your Household That Will Be Shared. I certify, under penalty of perjury, that all the information I have written on this form or told my DHS specialist or my representative is true. I understand I can be prosecuted for perjury if I have intentionally given false or misleading information, misrepresented, hidden or withheld facts that may cause me to receive assistance I should not receive or more assistance than I should receive. I can be prosecuted for fraud and/or be required to repay the amount wrongfully received. I understand I may be asked to show proof of any information I have given. I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalties of perjury, I swear that my answers are correct and complete to the best of my knowledge, including information provided about the citizenship or alien status for each household member applying for benefits. I also certify that: I understand the questions and statements on this application form. I have read and understand my Rights & Responsibilities in the box above. I understand the penalties for giving false information or breaking the rules. I understand that the agency may contact other persons or organizations to obtain needed proof of my eligibility and level of benefits. I understand that failure to report or verify any listed expenses will be seen as a statement by me that I do not want to receive a deduction for the unreported or unverified expenses.verifications must be received within 10 days. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature. By checking this box and typing my name below, I am electronically signing my application. Jackson May 1, 2012 at 10:41 A.M. Rights and Responsibilities Please read the following information carefully. MIBridges Apply For Benefits Page 17