Dhs 4583 Form – Fill Out and Use This PDF

INSTRUCTIONS:  You must live in Michigan.  Your completed and signed application must be received by DHS before eligibility is determined.  Providing your Social Security Number (SSN) is voluntary. If you do provide it, the SSN may be used for establishing identity and for tracking and reporting purposes.

SECTION 1 – APPLICANT INFORMATION

1.

Full name of applicant (First, middle, last)

2. Former/maiden name

3. Marital status

Never Married

Married

Divorced

Separated

Widowed

4.

Authorized representative name (First, middle, last)

5. Authorized representative address

6.

Will the authorized representative be providing care for any of the children on this application?

No

Yes If yes  Name of child(ren):

7.

Check where you live:

House/apartment/mobile home

Homeless

Other

8.

Address where you live, or address of facility (number, street, rural route, apartment/lot number)

City

State

ZIP code

County

9.

Mailing address (if different from above or PO box)

City

State

ZIP code

County

10. Home phone

11. Cell phone

12. Work phone

13. TTY #

14. Phone number where we can leave a message

Whose is it? (name/relationship)

15. Email address

16. Ethnicity (optional)

17. Race (optional)

Hispanic/Latino

American Indian/Alaska Native – Enter tribe name

Native Hawaiian/Other Pacific Islander

Non-Hispanic/Latino

Asian

Black/African American

White

18. I need child care services for (Check all that apply.)

19. I need study time for (Check all that apply.)

Number of weekly hours

Work

High School or GED Completion

High School or GED Completion

Approved Education/Training/

Approved Education/Training/Employment Preparation

Employment Preparation

Treatment for Health or Social Condition (explain):

SECTION 2 – LIST ALL PERSONS LIVING IN YOUR HOME: (Attach additional sheet if needed.)

					Social Security		Receive cash	Receive
Name	Date of birth	U.S.	Sex	Relationship		Does this person attend school?	assistance
(First, middle, last)		citizen?	(M/F)	to you	Number		benefits	SSI
					(voluntary)			benefit?
							from DHS

	No	M		No	Yes	No	No
			SELF	If yes, where and address
	Yes	F				Yes	Yes
	No	M		No	Yes	No	No
				If yes, where and address
	Yes	F				Yes	Yes
	No	M		No	Yes	No	No
				If yes, where and address
	Yes	F				Yes	Yes
	No	M		No	Yes	No	No
				If yes, where and address
	Yes	F				Yes	Yes
	No	M		No	Yes	No	No
				If yes, where and address
	Yes	F				Yes	Yes

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SECTION 3 – LIST CHILDREN IN YOUR HOME WHO NEED CHILD CARE: (Attach additional sheet if needed.)

SECTION 4 – OTHER INFORMATION: Check all that apply.

I am a foster parent requesting child care only for a foster child(ren).

I need child care only to participate in a required activity for my DHS Protective Services case.

SECTION 5 – INFORMATION ABOUT ALL CHILDREN UNDER AGE 18 WHO LIVE IN YOUR HOME Complete table below. (Attach additional sheet if needed.)

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SECTION 6 – SELF-EMPLOYMENT ONLY – List anyone in your home who is self-employed including yourself. Attach current

proof. (Attach additional sheet if needed.)

		Business					Gross monthly	Date of most
Self-employed				Hours of self-			income (amount
	Start date	name/address/	Type of work					recent or last
person				employment			before any
		phone number						pay check
							expenses)
				Mon
				Tue
				Wed			$
				Thur
				Fri
				Sat
		Business					Gross monthly	Date of most
Self-employed				Hours of self-			income (amount
	Start date	name/address/	Type of work					recent or last
person				employment			before any
		phone number						pay check
							expenses)
				Mon
				Tue
				Wed			$
				Thur
				Fri
				Sat

SECTION 7 – EMPLOYMENT INCOME – List anyone in your home with any earnings including yourself. Attach current proof. (Attach additional sheet if needed.)

If new job, first pay check date

Will employment continue?

Yes

No

Day of week pay is received

Most recent or last pay check date

Average number of hours expected to work

Rate of pay

per

Week

Pay period

$

Hourly

Salary

Other

How often are checks received?

Weekly

Every two weeks

Twice a month

Monthly

Other

Do you receive any of the following?

Do you work Overtime?

Bonus

Commission

OR

No

Yes

 If yes, amount

$

How often?

Do you receive tips not included in your check?

Yes

No

 If yes, average tips not included $

Per

Week

Pay period

Other

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Name of working person

Start date

Employer name/address/

Type of work

Job Title

Work schedule

phone number

Hours

Mon

Tue

Wed

Thur

Fri

Sat

Sun

If new job, first pay check date

Will employment continue?

Yes

No

Day of week pay is received

Date of most recent or last pay check date

Average number of hours expected to work

Rate of pay

per

Week

Pay period

$

Hourly

Salary

Other

How often are checks received?

Weekly

Every two weeks

Twice a month

Monthly

Other

Do you receive any of the following?

Do you work Overtime?

Bonus

Commission

OR

No

Yes

 If yes, amount

$

How often?

Do you receive tips not included in your check?

Yes

No

 If yes, average tips not included $

Per

Week

Pay period

Other

SECTION 8 – UNEARNED INCOME – Attach current proof. (Attach additional sheet if needed.)

Does anyone in your household receive, or expect to receive, any other income other than earnings?

No

YesCheck all boxes that apply and complete the table.

Person(s) receiving/	Income source/type	How often received		Amount received	Expected to continue			Date expecting if not
expecting money	listed above							yet receiving
			$		No	Yes
			$		No	Yes
			$		No	Yes
SECTION 9 – STATE OF MICHIGAN VOTER REGISTRATION APPLICATION
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, the Department will assume you have decided not to register to vote at this time.

Applying or declining 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 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 20126, Lansing, MI 48901-0726.

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SECTION 10 – RIGHTS AND ACKNOWLEDGMENTS:

1.APPLICATION: I understand that I have the right to file an application today or at any time, including prior to any interview or appointment, and the application must be approved or denied within 45 days from the day it is received by the DHS.

2.NON-DISCRIMINATION: I understand that if I believe I have been discriminated against because of race, sex, religion, age, national origin, color, height, weight, marital status, sexual orientation, gender identity, handicap, or political beliefs, I have the right to file a complaint with the Secretary, Department of Health and Human Services in Washington, D.C.

3.REPORTING REQUIREMENTS:

•I understand that the Department needs to know of any changes in income or circumstances of any person listed on this form.

•I will report to the DHS specialist who handles my Child Development and Care (CDC) case, any changes within ten work days of the change. This includes changes in my employment, school/training, income, child care arrangements (i.e. provider, where care is provided), name, address, phone numbers, household members, marital status, etc., and any other change which may affect my eligibility or the amount of benefits.

•I understand that if I neglect or refuse to report required changes, or make false or misleading statements, I can be prosecuted for

fraud or perjury.

If you have any doubt about whether you should report a change, call your specialist at the local DHS office.

4.PROGRAM PENALTIES: Violation of program rules may result in a disqualification of 6 months, 12 months or a lifetime.

5.REPAYMENT OF BENEFITS: I understand that if benefits are overpaid for any reason, the extra benefits received will have to be repaid. If intentional misrepresentation caused the overpayment, the responsible party, including any adult in the program group or the group's authorized representative or provider of goods or services, may be prosecuted for fraud.

6.HEARINGS: I understand that if I do not agree with any decision made on any matter concerning my case, I have the right to ask for an Administrative Hearing. I understand that I can ask for information about an Administrative Hearing by calling the county DHS office, and that I can request an Administrative Hearing by writing to the local DHS office.

7.AFFIDAVIT: I swear or affirm that all the information I have written on this form or told to a DHS specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. If I have intentionally left out any information or given false information which causes me to receive benefits I am not entitled to, or more benefits than I am entitled to, I understand that I can be prosecuted for fraud.

8.RELEASE OF INFORMATION: I authorize the Department to provide information to my child care provider(s) when CDC services have been authorized or when there are changes in the authorization information previously given to the provider or when my application for CDC is denied or withdrawn or my case is closed. I also authorize the Department or any child care provider that may provide care for my child(ren) to release information necessary to determine my right to benefits under any other local, state or federal program.

I authorize the Social Security Administration to give to the Department all information necessary to determine my eligibility for CDC benefits.

9.COMPUTER CROSS-CHECKING: The Department will check with federal, state and private agencies to make sure the information you provide on this application is correct. The Department may check wages, income, assets, unemployment benefits, income tax refunds, Social Security benefits and numbers, immigration status, etc.

I UNDERSTAND THAT:

•If approved for CDC, I may only use child care services during the times that I, and all other parents/substitute parents in my home, are unavailable due to employment, high school completion classes, approved education and training activities and approved activities for a health or social condition.

•I am responsible for any child care costs not paid by the Department, including benefits which may have been authorized but for which I no longer qualify, based on a change in circumstances.

•I am not eligible for CDC benefits before the need exists or before the DHS local office receives my signed application.

•If a reported change results in a reduction in benefits, the reduction will be made as soon as administratively possible by the Department without advance notice.

•Child care must be provided in Michigan by either a licensed child care center, licensed group child care home, registered family child care home, an enrolled unlicensed provider who provides care in the home where the child lives or who is a grandparent, great-grandparent, aunt/great-aunt, uncle/great-uncle or sibling of the child and who provides the care in his/her home.

•I understand that my provider is considered self-employed and not employed by the Department. My provider receives a payment that is issued on my behalf by the Department.

•My application may be one of those chosen for a complete investigation, and a Department representative might call my home and might contact other people in order to verify my eligibility for assistance.

•If I choose an unlicensed provider, he or she will not be enrolled or will not receive payment if:

••He/she, or any adult reported as living in the provider's home, is on the DHS central registry as a perpetrator on a substantiated Children's Protective Services case or has been charged or convicted of certain disqualifying crimes.

••He/she has not completed the Basic Training requirement. (Great Start to Quality Orientation). No care provided prior to the training date will be paid by the Department.

I HAVE READ AND UNDERSTAND ALL PARTS OF THIS FORM. (If you have any questions, be sure to ask your DHS specialist.)

Department of Human Services (DHS) will not discriminate against any individual or group because of	This form is issued under authority of Public Act
race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender	280 of 1939. Completion of this form is voluntary.
identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc.,	However, if it is not completed, your eligibility
under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office	cannot be determined and you will not receive
in your area.	child care services.

DHS-4583 (Rev. 4-12) Previous edition obsolete. MS Word