Dhs 1514 Form PDF Details

In the landscape of social assistance programs within Michigan, the DHS-1514 form stands as a pivotal document for individuals and families facing immediate financial emergencies. Administered by the Michigan Department of Health and Human Services (MDHHS), this form serves as an application for the State Emergency Relief (SER) program, designed to provide timely aid for various crises such as utility shutoffs, home repairs, burial services, and more. The application process necessitates a thorough declaration of household information, including each member's citizenship status, income, assets, and a detailed exposition of the emergency at hand. Moreover, the timeline for submission is critical, especially in cases of burial services, which require submission within a strict timeframe following the event. Seasonal restrictions apply to certain requests; for instance, energy assistance applications are confined to a specific period of the year. Additionally, the document probes into the applicant's history regarding drug-related felonies, probation or parole violations, and past receipt of any form of energy assistance, thereby underscoring the comprehensive eligibility evaluation undertaken by MDHHS. This form not only encapsulates the applicant's immediate financial distress but also integrates broader socio-economic variables, underpinning the state's effort to tailor emergency relief to the nuanced needs of its residents.

QuestionAnswer
Form NameDhs 1514 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesser form michigan, dhs ser, michigan dhs forms, dhs state michigan online

Form Preview Example

APPLICATION FOR STATE

EMERGENCY RELIEF

Michigan Department of Health and Human Services

Case Name:

 

Case Number:

 

Date:

 

MDHHS Office:

 

Specialist / ID:

/

Phone:

 

Fax:

 

Individual ID:

 

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.

Name

HOUSEHOLD ADDRESS

Relationship to you

Social Security number

Date of birth

Citizen?

 

SELF

 

 

Yes

No

 

 

 

Yes

No

 

 

 

Yes

No

 

 

 

Yes

No

 

 

 

 

 

Address (Number and street name, Apt., etc.)

City

State

Zip code

MAILING ADDRESS, if different than above

Address (Number and Street Name, Apt., etc.)

City

State

Zip code

CONTACT INFORMATION

Phone number to reach you

Contact name and number to leave messages Email address

Has anyone ever been convicted of a drug-related felony that occurred after August 22, 1996? Yes No

If yes, who?

 

 

 

Convicted more than once?

Is anyone in violation of probation or on parole?

Yes No

 

 

If yes, who?

 

 

 

 

HOW DO YOU HEAT YOUR HOME? Natural Gas

Propane

Wood

No heat obligation

 

Fuel oil

Electricity

Coal

Unknown

Yes

No

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.

Eviction/relocation

$

 

 

 

Security Deposit

$

 

 

 

Moving Expenses

$

 

 

 

Mortgage

$

 

 

 

Homeowner’s Insurance $

 

Property Taxes

$

 

 

 

Furnace Repair

$

 

 

 

Home Repairs

$

 

 

 

Type of repair needed?

Heat $

*If deliverable fuel, % remaining in tank

If this is a prepaid account, amount in account $

Electricity $

If this is a prepaid account, amount in account $

Water/Sewer $

Cooking Gas $

Burial/cremation services $

Migrant hospitalization

$

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

1

Case Name

Case Number

Specialist

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

Person With Income

Type of Income

(if employed, name of employer)

Gross Monthly Income

(amount before any expenses or taxes)

How often received?

*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.

2

Case Name

Case Number

Specialist

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.

3

Case Name

Case Number

Specialist

Notes:

If you are not already registered to vote at your current address, would you like to register to vote?

Yes

No

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.

4

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Filling out segment 1 in dhs ser form online application

2. Once your current task is complete, take the next step – fill out all of these fields - CONTACT INFORMATION, Phone number to reach you, Contact name and number to leave, Email address, Has anyone ever been convicted of, Natural Gas Fuel oil No, Yes date service was turned off, Propane Electricity, Wood Coal, Yes, Has your heat been turned off or, Yes when is electric service, No Convicted more than once, Yes, and Yes with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

dhs ser form online application conclusion process shown (stage 2)

3. Your next part is usually straightforward - fill out all of the empty fields in Evictionrelocation Security, If deliverable fuel remaining in, Electricity, If this is a prepaid account, WaterSewer Cooking Gas, and DHS Rev Previous edition obsolete to complete this part.

dhs ser form online application writing process explained (part 3)

4. To go onward, your next form section will require filling out several blanks. Included in these are Case Name, Case Number, Specialist, HOUSEHOLD VEHICLES Does your, Campertrailer, Truck, Boat, Car, Names on Title or Registration, Make and Model, Year, Yes ATTACH PROOF OF CURRENT VALUE, Other vehicle Fair Market Value, Amount Owed, and HOUSEHOLD ASSETS Does your, which you'll find crucial to continuing with this particular PDF.

Step # 4 in filling out dhs ser form online application

5. The very last point to finalize this PDF form is crucial. Make sure to fill out the required fields, for instance HOUSEHOLD INCOME Does your, Yes Total monthly household, Social Security benefits, Disability benefits Selfemployment, Employmentearned income Workers, Person With Income, Type of Income, Gross Monthly Income, if employed name of employer, amount before any expenses or taxes, How often received, Please tell us if there have been, Is this a shared, Is there theft or, and Name and address on, before using the pdf. Failing to do so might generate an unfinished and probably unacceptable paper!

Stage number 5 of completing dhs ser form online application

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