Did you know that the Dhs 20 form is used to apply for a social security card? This form can be downloaded from the Social Security Administration website, and it must be filled out completely in order to process your application. In this blog post, we'll provide an overview of the Dhs 20 form and explain what information is required in order to receive a social security card. We'll also provide some tips on how to fill out the form correctly. So if you're interested in learning more about the Dhs 20 form, keep reading!
| Question | Answer |
|---|---|
| Form Name | Dhs 20 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | mdhhs michigan dhs 20 verification of assets, dhs 3569 form, dhs 20 verifiction of assasts, dhs 20 |
Training Office
7109 West Saginaw Hwy
Lansing, MI 48917
Fifth Third
(EASTERN MICHIGAN)
P.O. BOX 630900 CINCINNATI OH
Case Name: Susan Sharp
Case Number: see your Case Data Sheet
Date: Last Month
DHS Office:
Specialist: A. Specialist
Phone:
Fax:
Specialist ID:
Department of Human Services (DHS) 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 a DHS office in your area.
AUTHORITY: P.A., 280 of 1939
COMPLETION: Required
PENALTY: Inability to determine eligibility for public assistance
VERIFICATION OF ASSETS
AUTHORIZATION: You are hereby authorized to release the information requested below to the Department of Human Services.
AUTORIZACION: Usted está autorizado a dar la información pedida más abajo a Department of Human Services.
Signature of Client or Client’s Representative |
Date |
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Susan Sharp |
Last Month |
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To determine eligibility for assistance it is necessary to verify assets owned by the person named below, either alone or jointly with other persons. If the account is joint, please list the names of the account members.
Please provide current information on the person indicated below. Also, please report on accounts closed within the past 36 months. A stamped, addressed envelope is enclosed for return of the completed form. Thank you.
THIS SECTION IS TO BE COMPLETED BY THE SPECIALIST
Name (Type or Print) |
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Social Security Number |
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Susan Sharp |
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THIS SECTION IS TO BE COMPLETED BY FINANCIAL INSTITUTION |
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NOTE: Please Report on Closed |
Savings/Share Certificate of |
Checking/Draft |
Prepaid |
Other |
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Accounts if Closed Within Past |
Patient Trust |
Burial |
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Account |
Deposit |
Account |
(Explain) |
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36 Months |
Fund |
Account |
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1.Account Number(s): 7007942
2. |
Date Last Withdrawal |
MM/DD/YY |
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3. |
Amount Last Withdrawal |
$910.00 |
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4. |
Current Balance |
$50.00 |
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5. |
Highest Balance |
$960.00 |
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For Month of ______________ |
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6. |
Lowest Balance |
$50.00 |
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For Month of |
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7. Is There a Safety Deposit Box?
Yes |
No |
8. Is There a Trust Fund? |
Yes |
No If Yes, Attach a Copy of the Trust. |
9.For Each Joint Account List Account Number:
Account Members:
10.For Each Joint Account List Account Number:
Account Members:
11. For Each Loan Application Within Past 36 Months List:
Account Number ___________/______________
Type (e.g., Auto, Home) ___________/ ____________
Current Balance ____________/_ ____________
If collateral was used attach a copy of the loan application
12. Remarks:
13. Signature
Teller
14. Title
Teller, Fifth Third
15. Telephone No.
()
16.Date
LAST MONTH