Form Dhs 1201 PDF Details

DHS 1201 is a form used to request advance parole for an alien who is in the United States without lawful admission. The form must be completed and submitted by the alien or their representative. There are many reasons why an alien may need advanced parole, such as to travel for medical treatment or to attend an educational institution. Advance parole may also be granted for humanitarian purposes, such as when an alien needs to return to their country of origin due to a family emergency. There are several important things to keep in mind when completing and submitting a DHS 1201 form, so read on for more information.

QuestionAnswer
Form NameForm Dhs 1201
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesdhs 1202 form, OCS, DHS, Birthdate

Form Preview Example

IV-D CHILD SUPPORT SERVICES APPLICATION/REFERRAL

Michigan Department of Human Services (DHS) – Office of Child Support (OCS)

Please check your relationship to the children for whom you are applying for child support services:

 

 

 

FOR OFFICE USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Requested

 

Date Provided

 

Date Filed

 

Program

 

748

 

 

 

 

 

 

 

 

 

 

 

Provided

 

 

 

 

 

 

 

 

 

 

 

 

IV-D Case No.

 

DHS Case No.

 

 

County

District

 

Unit

 

Worker

 

 

 

 

 

 

 

 

 

 

 

 

Custodial Parent

Non-Custodial Parent or Alleged Father

Other Caretaker, Specify

•Custodial Parent - Complete all sections of the form, enter information about you in Section A.

•Non-Custodial Parent or Alleged Father – Complete all sections of the form except Section F, enter information about you in Section B.

•Other Caretaker - Complete all sections of the form, enter information about you in Section A. Complete information about each parent who is not in the home in Section B. (Please complete a separate application for each parent who is not in the home.)

A. INFORMATION ABOUT THE CUSTODIAL PARENT/CARETAKER OF THE CHILD

1. Name (First, Middle, Last, Suffix)

Maiden Name (If applicable)

2. Birthdate

3. Social Security No.

 

 

 

 

 

 

 

 

 

4.

Home Address (P.O. Box No., No. and Street)

City

 

State

Zip Code

County

 

 

 

 

 

 

 

5.

Home Phone No.

6. Work Phone No.

 

7. Cell Phone No.

 

(

)

(

)

 

(

)

 

 

B. INFORMATION ABOUT THE PARENT WHO IS NOT IN THE HOME

8. Parent’s Name (First, Middle, Last, Suffix)

 

 

 

 

Maiden Name (If applicable)

 

 

9. Social Security No.

10. Birthdate

 

 

11. Age

 

12. Sex (M or F)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Home Address (P.O. Box No., No. and Street)

Current

Last Known

City

 

 

 

 

 

State

 

Zip Code

 

14. Home Phone No.

 

15. Cell Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

(

)

16.

Weight

 

 

 

 

 

 

17. Height

 

 

 

 

18. Hair Color

 

 

 

 

 

 

 

19. Eye Color

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

Birthplace (City, State)

 

 

 

 

21. Driver’s License Number

 

22. Car (Make, Model and Year)

 

 

 

 

23. License Plate Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

Race or Ethnic Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. Any Visual Marks or Scars?

 

 

 

Alaskan Native

 

 

Hispanic

 

 

 

 

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian

 

Multiracial – More than one racial-ethnic group

Middle Eastern

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Asian or Pacific Islander

 

Black, not of Hispanic origin

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26.

First Employer Name

Current

Last Known

27. Employer Address (P.O. Box No., No. and Street)

 

City

 

 

 

State

 

Zip Code

 

28. Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

29.

Second Employer Name

Current

Last Known

30. Employer Address (P.O. Box No., No. and Street)

 

City

 

 

 

State

 

Zip Code

 

31. Phone No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

C. MARITAL STATUS INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

32a. Has the mother ever married?

 

 

b. Name of Spouse

 

 

 

 

c. Date Married

 

 

 

d. Place (City, County, State)

 

 

 

 

 

 

 

No

Yes, If Yes>>

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33a. Is the mother

 

 

 

 

b. Date

 

c. Court Order Exist?

 

d. Court Order No.

e. Where (City, County, State)

 

 

 

 

 

 

Separated

Legally Separated >>

 

 

 

 

No

 

Yes, If Yes>>

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34a. Is the mother

 

 

 

 

b. Date

 

c. Court Order Exist?

 

d. Court Order No.

e. Where (City, County, State)

 

 

 

 

 

 

Divorced

 

Divorce filed >>

 

 

 

 

 

No

 

Yes, If Yes>>

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please attach a copy of all court orders pertaining to the family members listed on this application, including Personal Protection Orders and guardianship papers.

DHS-1201 (Rev. 5-06) MS Word

1

D. INFORMATION ABOUT CHILD(REN)

Child One (Please include separate pages if more than three children)

35a. Child’s Full Name (First, Middle, Last, Suffix)

 

 

 

b. Birthdate

c. Social Security Number

d. Sex (M or F)

 

 

 

 

 

 

 

 

e. City, County & State of Birth

 

 

 

f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?

 

 

 

 

 

 

 

g. When and where did the mother become pregnant?

 

 

 

 

 

Date

 

City

 

County

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? If yes, provide the following information about that document:

Yes

No

Date

City

County

State

CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)

36a. Policy Holder’s Name

b. Health Care Company Name (Non-Medicaid)

c. Coverage Type

PPO PPOM

Traditional

d. Policy or Group No.

Child Two

37a. Child’s Full Name (First, Middle, Last, Suffix)

 

 

 

b. Birthdate

c. Social Security Number

d. Sex (M or F)

 

 

 

 

 

 

 

 

e. City, County & State of Birth

 

 

 

f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?

 

 

 

 

 

 

 

g. When and where did the mother become pregnant?

 

 

 

 

 

Date

 

City

 

County

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? If yes, provide the following information about that document:

Yes

No

Date

City

County

State

CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)

38a. Policy Holder’s Name

b. Health Care Company Name (Non-Medicaid)

c. Coverage Type

PPO PPOM

Traditional

d. Policy or Group No.

Child Three

39a. Child’s Full Name (First, Middle, Last, Suffix)

 

 

 

b. Birthdate

c. Social Security Number

d. Sex (M or F)

 

 

 

 

 

 

 

 

e. City, County & State of Birth

 

 

 

f. Who paid for the birth of child (Medicaid, Private Insurance, Mother, Father, Other)?

 

 

 

 

 

 

 

g. When and where did the mother become pregnant?

 

 

 

 

 

Date

 

City

 

County

 

State

 

 

 

 

 

 

 

 

 

 

 

 

 

h. Has the father completed a document admitting he is the father of the child, such as an Affidavit of Parentage or is there a court order establishing paternity? If yes, provide the following information about that document:

Yes

No

Date

City

County

State

CHILD’S HEALTH CARE COVERAGE INFORMATION (attach copy of card(s), front & back)

40a. Policy Holder’s Name

b. Health Care Company Name (Non-Medicaid)

c. Coverage Type

 

d. Policy or Group No.

 

 

PPO

PPOM

Traditional

 

 

 

 

 

 

 

DHS-1201 (Rev. 5-06) MS Word

 

 

 

 

 

2

E. GENERAL INFORMATION

41.

I believe that disclosure of my address or other identifying information may result in physical or emotional harm to me or the child.

Yes

No

 

 

42.

I have received or I am currently receiving benefits from the Family Independence Program (FIP) or I have received past benefits from Aid to Dependent Children (ADC).

 

Yes

No

 

 

 

 

 

 

 

If yes, when?

 

 

 

Where?

 

 

 

 

 

 

 

 

 

 

 

43.

I have received or I am currently receiving Medicaid (MA).

Yes

No

 

 

 

 

 

If yes, when?

 

 

 

Where?

 

 

 

 

 

 

 

 

 

 

 

44.

I am currently receiving: Food Assistance Program (FAP)

Yes

No

Child Development and Care (CDC)

Yes

No

 

 

 

 

 

 

 

 

 

 

F. ACKNOWLEDGEMENT FOR CUSTODIAL PARENTS AND CARETAKERS

The Michigan Office of Child Support (OCS) processes child support payments through the Michigan State Disbursement Unit (MiSDU), which is part of the Department of Human Services (DHS). The MiSDU

receipts and distributes payments by direct deposit to a bank account, to a debit card, or by paper check.

 

If I am sent money in error or overpaid, the MiSDU will take all the necessary steps to correct errors in the processing of my child support payments. By checking the “yes” box below, I give OCS permission to

withhold an incremental amount specified below from future child support payments owed to me. To revoke my consent, I must notify the Friend of the Court office. Failure to check “yes” has no effect on my

eligibility for IV-D Child Support services through OCS.

 

Yes, (circle one) 10% 25% or 50%

Failure to choose a percentage will result in a default amount of 25%.

 

No, please contact me before you attempt to recover an amount from my support payments.

 

 

 

G. ACKNOWLEDGEMENT FOR ALL APPLICANTS

 

 

 

 

I request child support services available under Title IV-D of the Social Security Act.

Authorities:

 

All Services

 

45 CFR 302.33 Completion: Application is voluntary for non-

Locate Only (for custodial parents and caretakers only)

assistance applicants.

 

Medical Support Only (for Medicaid cases only)

R 400.3009 MAC and R 400.5008 MAC Failure to complete may result in

 

 

I understand that disclosure of my Social Security number is mandated by the Social Security Act, 42 USC 666(a)(13), in order that

loss of benefits from Child Development and Care (CDC) and the Food

Michigan’s child support program may provide services related to the establishment of paternity and the establishment, modification

Assistance Program (FAP). Current FAP and CDC recipients are not

and enforcement of child support obligations. I understand that I must cooperate in taking support action to ensure that my child

required to sign the form.

support case remains open. I declare that the information provided above is true and correct to the best of my knowledge and agree

 

to report changes in my circumstances that may affect support action in my case.

42 USC 654(29) Failure to provide information may result in loss of

I certify that I have received a copy of DHS Publication 748, “Understanding Child Support, A Handbook for Parents.”

Family Independence Program (FIP) benefits for all family members and

loss of Medicaid (MA) for all adult members.

 

 

 

 

 

Applicant’s Signature (Signature is Required)

Date

 

 

 

Return completed application to:

Applicant’s Printed Name

 

 

 

 

Michigan Office of Child Support

 

 

Central Functions Unit

Department of Human Services (DHS) will not discriminate against any individual or group because of race, sex, religion, age,

P.O. Box 30744

national origin, color, height, weight, marital status, political beliefs or disability. If you need help with reading, writing, hearing, etc.,

Lansing, MI 48909

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.

 

 

 

 

 

DHS-1201 (Rev. 5-06) MS Word

 

 

3

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Be mindful when filling in this form. Ensure every single blank is filled out accurately.

1. You need to fill out the MiSDU correctly, hence be careful when filling in the areas that contain all of these blank fields:

Stage no. 1 in completing dhs 1202 form

2. After finishing the previous part, go to the subsequent stage and fill in the essential details in all these blanks - American Indian, Asian or Pacific Islander, Black not of Hispanic origin, Multiracial More than one, Middle Eastern, Other, First Employer Name, Current, Last Known, Employer Address PO Box No No and, City, Second Employer Name, Current, Last Known, and Employer Address PO Box No No and.

Part # 2 for completing dhs 1202 form

Always be extremely mindful while completing Middle Eastern and Current, because this is the part in which many people make mistakes.

3. The following step is about D INFORMATION ABOUT CHILDREN Child, e City County State of Birth, g When and where did the mother, b Birthdate, c Social Security Number, d Sex M or F, f Who paid for the birth of child, Date, City, County, State, h Has the father completed a, Yes, Date, and City - fill in all of these fields.

b Birthdate, Date, and Date in dhs 1202 form

4. The next subsection will require your input in the subsequent parts: h Has the father completed a, Date, City, County, State, CHILDS HEALTH CARE COVERAGE, a Policy Holders Name, b Health Care Company Name, c Coverage Type, d Policy or Group No, Child Three, a Childs Full Name First Middle, e City County State of Birth, g When and where did the mother, and PPO. Be sure to give all of the required info to go onward.

Stage number 4 for filling out dhs 1202 form

5. Last of all, this final part is what you need to wrap up prior to closing the PDF. The fields in this case are the next: E GENERAL INFORMATION, I believe that disclosure of my, Yes, Yes, I have received or I am currently, If yes when, Where, Yes, If yes when, Where, I am currently receiving Food, Yes, Child Development and Care CDC, Yes, and F ACKNOWLEDGEMENT FOR CUSTODIAL.

The best way to complete dhs 1202 form stage 5

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