Dhs 4583 Form PDF Details

The Department of Homeland Security has released a new form, DHS 4583. This form is used to apply for specialty occupation worker visas, also known as H-1B visas. The new form is simpler and easier to use than the previous version. It is also more accurate and includes updated information about the current visa process.Anyone who wishes to apply for an H-1B visa should use this new form. Instructions on how to complete the form are included on the website of the U.S. Citizenship and Immigration Services (USCIS). The Department of Homeland Security has released a new form, DHS 4583, which is used to apply for specialty occupation worker visas, also known as H-1B visas. The new

QuestionAnswer
Form NameDhs 4583 Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesCDC, DHS-4583, Michigan, SSN

Form Preview Example

CHILD DEVELOPMENT AND CARE (CDC) APPLICATION

State of Michigan

Department of Human Services(DHS)

 

FOR DHS USE ONLY

Case Name

 

 

 

 

 

 

 

Case Number

 

DHS Specialist

 

 

 

 

DHS Office

 

 

Date

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

CONTINUE ON PAGE 2

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

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

Name of child needing care

Provider Name

Provider ID Number

(if known)

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.)

List the full name of

all children under the age of 18 who live in your home (First, middle, last)

Child 1

Child 2

Child 3

Child 4

List full name of each

 

If the child does

If parent not in the home,

 

 

 

 

 

 

proper box.

 

 

 

child’s mother and

 

not live with a

 

 

 

 

 

 

Is parent

 

 

 

 

 

militarytheIn

 

 

Does the parent

father. Write

parent, who does

Married

Divorced

Separated

Prison

Dead

forAbsent reasonother

Parent’s mailing address if

“Unknown” if you do

living

the child live with

provide child

 

 

 

 

 

 

 

in the

 

 

 

 

 

 

 

different from the applicant.

not know who the

and the

 

 

 

 

 

 

 

support?

home?

 

 

 

 

 

 

 

 

mother or father is.

relationship to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(First, middle, last)

 

the child?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mother

Name

 

No

Yes

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

 

Father

Name

 

No

Yes

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

Mother

 

 

No

Yes

Name

 

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

Father

Name

 

No

Yes

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

Mother

 

 

No

Yes

Name

 

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

Father

Name

 

No

Yes

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

Mother

 

 

No

Yes

Name

 

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

Father

Name

 

No

Yes

No

 

If yes, provide

Yes

Relationship

support # if known

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUE ON PAGE 3

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

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.)

Name of working person

Start date

Employer name/address/

phone number

Type of work

Job Title

Work schedule

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

 

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUE ON PAGE 4

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

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

 

YesCheck all boxes that apply and complete the table.

 

 

 

 

 

 

 

 

 

 

 

Money from friends or relatives, etc. Social Security benefits Unemployment compensation State Disability Assistance (SDA) Pension/retirement benefits

Worker’s compensation

Child support

Education grants or loans

Gaming distribution (lottery)

Income/payments from a tribe (tribal GA, land claims, casino profit sharing, etc.)

Housing assistance Disability benefits Crops and farm income

Veteran’s benefits Military allotments

Land contract, mortgage or rental income

Name of tenant:

Other

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.

CONTINUE ON PAGE 5

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

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.)

Signature of applicant or representative

Date of signature

Signature of DHS specialist

Date of signature

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