Dhs 3688 Verification Form PDF Details

As a Delaware resident, you may be required to complete and submit a DHS 3688 verification form to the Department of Homeland Security. This form is used to verify your identity and citizenship status, and is generally requested when you are applying for a new visa, passport, or other immigration document. Completing the DHS 3688 verification form can be tricky, so here's what you need to know. First, download the form from the DHS website and fill it out completely. Be sure to include your full name, date of birth, place of birth, and citizenship information. Next, gather your identification documents such as your driver's license or passport, then attach copies of these documents to the form. Finally, mail or fax the completed form to the Department

QuestionAnswer
Form NameDhs 3688 Verification Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdhs shelter verification form, shelter verification form dhs michigan, ingham county dhs rent verification form, dhs 3688 pdf

Form Preview Example

Case Name: SUSAN SHARP

Case Number: XXXXXXXXX

Date: MMDDYYYY

DHS Office:

Co: District: Section: Unit: Worker:

Specialist:

Phone:

Fax:

Specialist ID:

Mary Martin

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.

“This institution is an equal opportunity provider.”

AUTHORITY: Federal

7 CFR Food Stamp Act of 1977, Special Security Privacy Act, 454 PA 2004, MCL 445.81 et seq., 1939 PA 280, as amended and MAC 400.7001 – 400.7049

COMPLETION: Required for SER Relocation Services. Optional for other programs.

PENALTY: Decrease or loss of benefits.

SHELTER VERIFICATION

Your shelter obligation must be verified by the verification due date in the box above. You may give this form to your landlord, mortgage company or land contract holder for completion, or you may provide other proofs, such as:

Rental or mortgage contracts, a signed and dated statement from your landlord, mortgage company or land contract holder, that includes the name and address of the client, amount paid and period covered.

Current copies of your property taxes, homeowner’s insurance, assessment, telephone, heat and utility bills.

Contact our office if you have any questions or need additional forms.

To Be Completed by LANDLORD/MORTGAGE CO./LAND CONTRACT HOLDER about Client’s Obligation

Total Monthly Shelter Obligation (Excluding Additional Fees)

 

 

Is the rent reduced because of Section 8 or subsidized housing, etc?

$150

 

 

 

 

 

 

 

 

Yes X No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, how much does the client pay?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of Shelter Unit

 

 

 

 

 

X

Renting

 

If buying, client PAYS (NOT escrowed)

 

901 N. Larch

 

 

 

 

 

 

Buying

 

 

Property Taxes

Homeowners Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Lansing MI 48906

 

 

 

 

 

Date moved in?

 

 

Special Assessments

 

 

 

 

 

 

 

 

 

 

(mm/dd/yy)

 

 

 

Condo Fees $

 

 

per month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10/12/2007

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of Shelter Unit:

 

 

 

 

 

 

 

 

 

 

Is the home free of lead paint or certified

X Apartment

House

 

Condo

Mobile Home

 

Lot Rent

 

lead safe?

 

 

 

 

Room

 

Room and Board (food is provided by the landlord)

 

 

 

 

 

X

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check each of the following that are included in rent:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heat

Electric

X

Water/Sewer X

Cooking Fuel

X

Trash Removal

Telephone

None

Property Owner/Contract Holder/Landlord

 

 

 

Tax ID# of Property Owner

 

 

 

Type of ID (Check one)

Name

Mary Martin

 

 

 

 

 

 

 

 

 

 

 

 

 

MI ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

901 N. Larch

 

 

 

 

 

 

 

 

 

 

 

MI Temporary ID

 

 

 

Lansing MI 48906

 

 

 

 

MDHS Provider ID #, if any

 

 

 

 

Federal ID

 

Mailing Address for Shelter Payment (if different)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Landlord/Mortgagor/Land Contract Holder

 

 

Title

 

 

 

 

 

 

Telephone No.

Date

Mary Martin

 

 

 

 

 

Landlord

 

 

 

 

 

517-241-0719

Today

DHS-3688 (Rev. 10-09) Previous edition obsolete. MS Word

1

Case Name

Case Number

SUSAN SHARP

XXXXXXXXX

To be Completed by AFC/Supported Independent Living Facilities Only:

Specialist

Is your home a DMH/CMH contract home?

 

 

 

 

Yes

No

Facility License Number

Does DMH or CMH pay a subsidy on behalf of the client?

 

 

Yes

No

 

 

 

Client’s monthly shelter responsibility $

 

 

 

 

 

 

 

 

 

 

 

Client is responsible to pay:

Heating

Cooling (including room air conditioner)

 

Electric

Water/Sewer

 

Trash Removal

Telephone

None

 

 

 

 

Client’s monthly uncovered medical expenses:

 

 

$

 

 

per month, or $

 

per day.

Medical services provided for this client:

 

 

 

 

 

 

 

 

 

 

Cooking Fuel

Is your home a non-profit home?

Yes

 

No

Facility License Number

 

 

 

 

 

 

 

AFC Home/Supported Independent Living Facility Name

 

 

 

 

 

Signature of AFC/Supported Independent Living Facility/Representative

 

Title

 

 

Telephone No.

 

 

 

 

 

 

 

 

 

 

 

Date

DHS-3688 (Rev. 10-09) Previous edition obsolete. MS Word

2

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