Dhs 1514 Form – Fill Out and Use This PDF

I hereby make application for the State Emergency Relief (SER) Program. I understand that the following information will be used in the determination of my eligibility for SER. I also understand that there may be a delay in processing if there is missing information. If this application is for burial services, I understand that it must be received by the MDHHS office in my area no later than 10 business days after the burial, cremation or donation takes place. For energy related emergencies, the SER crisis season runs from November 1 through

May 31. Requests for those services will be denied June 1 through October 31.

HOUSEHOLD INFORMATION – Attach extra pages if you need to include additional members

List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home. Be sure to include the date of birth and citizenship status for each member. If you are applying for burial assistance only, list the deceased first.

MAILING ADDRESS, if different than above

CONTACT INFORMATION

Has your electricity been turned off?		No	Yes, date service was turned off:
Have you received a past due or shut off notice for your electricity?
No	Yes, when is electric service scheduled to be turned off:

Has your heat been turned off or have you run out of your only heating fuel source?

No	Yes, date heat was turned off or when fuel ran out:

Have you received a past due or shut off notice for your heat or are you at risk of running out of your household heating fuel?

No Yes, number of days until fuel runs out or date service is scheduled to be shut off:
HOME HEATING CREDIT - Did you receive the Home Heating Credit in the last 6 months?				No Yes, month received
HAVE YOU OR DO YOU CURRENTLY RECEIVE OTHER BENEFITS FROM MDHHS?
		Yes		No
HAVE YOU RECEIVED ENERGY ASSISTANCE (Example: MEAP) FROM ANOTHER AGENCY OR THROUGH A PROVIDER-
SPONSORED PROGRAM SINCE OCTOBER 1st?	Yes No

If yes, from which agencies/provider(s)?

EMERGENCY NEED - Check the service(s) you are requesting and the amount needed to resolve the emergency - ATTACH PROOF

*Payment for deliverable fuel will not be made if, at the time of delivery, it is confirmed you have more than 25 percent of fuel remaining in your tank.

DHS-1514 (Rev. 11-15) Previous edition obsolete.

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HOUSEHOLD VEHICLE(S) - Does your household have any vehicles?							No	Yes → ATTACH PROOF OF CURRENT VALUE
Car	Truck	Boat	Camper/trailer		Motorcycle			RV	Other vehicle
Name(s) on Title or Registration				Make and Model			Year		Fair Market Value	Amount Owed

HOUSEHOLD ASSETS - Does your household have any assets or joint accounts? No Yes → ATTACH PROOF OF CURRENT VALUE

Cash		Money market accounts		Savings bonds, stocks or mutual funds		Patient trust fund
Checking account		Christmas club accounts		Land contact, mortgage or other note		Burial plot(s), casket, etc.
Savings account		Life Estate		payable to household member		Burial trust/funeral contract(s)
Credit union account		Life insurance		Tools and equipment, livestock or crops
Real estate		Certificate of deposit (CD)		OTHER (list)
IRA, KEOUGH, 401K or Deferred Comp. account(s)				Expect money from a lawsuit in the next 30 days
Owner(s) of asset(s)	Type(s) of asset(s)		Balance amount or value		Name of bank, insurance company, etc.		Account/policy number
			$
			$
			$

*Please tell us if anyone has closed any accounts, sold or given away property, a vehicle, stocks, bonds, etc. How long ago?

*Has anyone filed a lawsuit or expect money in the next 30 days?		No	Yes → If yes, Explain
HOUSEHOLD INCOME - Does your household have any income?			No	Yes → Total monthly household income $
Please check all sources of income that your household expects to receive in the next 30 days. ATTACH PROOF
Social Security benefits	Disability benefits				Employment/earned income
Supplemental Security Income (SSI)	Self-employment income				Worker’s Compensation
Pension/retirement benefits	Unemployment				Money from family/friends
Veteran’s benefits/Military allotments	Child support				Other, please list (ex: lottery winnings)

Tribal payments (Energy Assistance/LIHEAP, tribal GA, casino/gambling profit sharing, land claims, etc.)

Rental income or a land contract, mortgage or other payment payable to a household member

*Please tell us if there have been any changes or if you expect a change in your household income in the next 30 days. When did or will this change occur?

CURRENT HOUSING EXPENSES

Check all expenses	Monthly	Name of your service provider,	Account number	Is this a shared		Is there theft or		Name and address on
you are required to pay	Expense	landlord, mortgage company, etc.		meter?		illegal use?		bill or account
Heat	$			Yes	No	Yes	No
Electricity	$			Yes	No	Yes	No
Water/sewer	$			Yes	No	Yes	No
Cooking fuel	$			Yes	No	Yes	No
Rent	$
Mortgage	$
Property Taxes	$
Home insurance	$

DHS-1514 (Rev. 11-15) Previous edition obsolete.

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HOUSEHOLD INFORMATION FOR THE PAST SIX MONTHS

Complete the chart below to tell us about your expenses, income and how many people live with you for the last six (6) months. If you did not have the expense, write “NONE” in the box.

	1 MONTH AGO		2 MONTHS AGO			3 MONTHS AGO		4 MONTHS AGO		5 MONTHS AGO	6 MONTHS AGO
Month
# of people in home
Total monthly income	$		$			$		$		$	$
Rent/Mortgage amount	$		$			$		$		$	$
Heat	$		$			$		$		$	$
Electricity	$		$			$		$		$	$
Water, Sewer &	$		$			$		$		$	$
Cooking Gas
INCOME EXPENSES - Does your household pay any of the following? No							Yes → Check all that apply and ATTACH PROOF.
Health insurance premium $					Paid how often?				Covers what time period (1mo., 3 mos., etc.)

Court ordered child support (amount paid per month) $

Actual child care costs paid by the employed person, not MDHHS

Unusual employment related expenses $

Explain expense

BURIAL - If you are applying for burial services, please complete this section. Be sure to answer income, vehicle and asset questions for the individual, his or her spouse or parent(s) of a minor child. ATTACH PROOF.

Name of deceased

Date of death

Is this a cremation?

Date of burial/cremation

No

Yes

Name of funeral home handling services

Address of funeral home

Phone # of funeral home

Place of burial/name of cemetery or crematory

Is payment to the cemetery or crematory separate from

Is there a memorial service?

the payment to the funeral home?

No

Yes

No

Yes

Did you sign a statement of Goods and Services

What is the total cost of the burial/cremation?

Is the deceased a veteran?

with the funeral home? Yes

No

$

No

Yes

What is your legal relationship with the deceased?

Is there a contribution from family and/or friend?

Did the deceased own his or her home?

No

Yes → Amount $

Address of home:

No

Yes

Indicate any death benefits applied for or expected to be received and the amount.

Accident/automobile insurance $

Pre-paid funeral agreement $

Social Security death benefits

$

Veteran’s death benefit $

If yes, is there a co-owner?

No

Yes

Life Insurance $

A Community assistance fund/fraternal organizations $

Name of co-owner:

Labor union benefits $

Other benefit (specify source) $

SIGNATURE REQUIREMENT

I understand failure to provide the above information may result in denial of my application. I understand I have eight calendar days to provide all verifications requested. I understand giving false information can result in referral to the prosecutor for fraud. I understand that my application may be one of those chosen for a complete investigation. A department representative may call at my home and may contact other people in order to verify my eligibility for assistance.

I authorize the department to release my name and address to the local weatherization operator as part of the Weatherization Referral system. I authorize the department to release case and payment information to the Michigan Department of Health and Human Services, its affiliates and/or contracted agencies, for the purpose of research, study and evaluation of the Low Income Home Energy Assistance Program (LIHEAP).

I authorize my energy company to release by phone, fax, email or their computer web site all available information about my account.

UNDER PENALTIES OF PERJURY, I SWEAR OR AFFIRM THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO ME. IF I AM A THIRD PARTY APPLYING ON BEHALF OF ANOTHER PERSON, I SWEAR THAT THIS APPLICATION HAS BEEN EXAMINED BY OR READ TO THE APPLICANT, UNLESS THE APPLICATION IS FOR A DECEASED PERSON. TO THE BEST OF MY KNOWLEDGE, THE FACTS ARE TRUE AND COMPLETE.

Signature of applicant or authorized representative	Date	Signature of spouse	Date
Current address		Signature of MDHHS specialist	Date
Current phone number		Identification of applicant or authorized representative

DHS-1514 (Rev. 11-15) Previous edition obsolete.

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Notes:

NOTE: If you do not check either box, MDHHS will assume you have decided not to register to vote at this time. Checking “yes” does not register you to vote. If you check “yes” or do not respond, a voter registration application will be forwarded to you.

Applying or deciding to register to vote will not affect the amount of help 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 to vote, decline to register to vote, privacy in deciding whether to register or in applying to register to vote, or choose your own political party or other political preference, you may file a complaint with Michigan Secretary of State, PO Box 20126, Lansing, MI 48901-0726.

HEARINGS:

If you believe any action of the department is incorrect, or if the decision to approve or deny your application is not made within 10 (ten) days of the application date, you have the right to a hearing. A request for a hearing must be in writing, signed by you or your authorized representative, and received by the Michigan Department of Health and Human Services within 90 days following the date of this form. Hearing requests should be sent to your local MDHHS office in your area. You are entitled to representation by an attorney or other person of your choice. However, the department does not pay for any legal expenses.

Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to an MDHHS office in your area.

AUTHORITY: Act 280, P.A. 1939, as amended (sections 400.6, 400.14, 400.24, 400.68 MCL); 45 CFR 283, 120(b); Low Income Home Energy Assistance Act of 1981, as amended; MCL 400.10; Administrative Codes Rules 400.7001-400.7049

COMPLETION: Required

PENALTY: Denial of SER.

DHS-1514 (Rev. 11-15) Previous edition obsolete.

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