Form Dhs 2120 PDF Details

Understanding the nuances of the DHS-2120-ENG form is crucial for households looking to maintain or apply for public assistance benefits efficiently. At first glance, the form may seem daunting - it's a comprehensive document designed to gather a wide range of information about your current living situation, income. assets, and expenses. From reporting changes in household composition like someone moving in or out, to detailing earned and unearned income, all the way to listing assets and childcare or adult care expenses, every section serves a purpose. Not to mention, it includes sections specific to those in different living arrangements or with unique care needs, such as individuals in long-term care facilities. The DHS-2120-ENG form also emphasizes the importance of honest and thorough reporting – a safeguard against delays or potential cessation of benefits. Moreover, it outlines rights and processes for those wishing to file a complaint or request a fair hearing, ensuring users understand their protections under the law. Its comprehensive nature is a testament to its goal: to ensure that public assistance benefits are accurately aligned with each household's needs and circumstances.

QuestionAnswer
Form NameForm Dhs 2120
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesdhs 8107 eng, household report form, household report form ramsey county, minnesota dhs report form

Form Preview Example

DHS-2120-ENG 9-17

Household Report Form

Case number:

How to fill out this form:

1.Your report month is:

2.Fill out and return this form or your benefits may be late or stop.

3.Answer Yes or No to each question.*

4.If there is not enough room on the form to answer a question, attach your own pages.

5.Sign and date the form on or after:

6.Return this form no later than:

7.If you need help with the form, call:

*If you receive Medical Assistance ONLY and live in a long-term care facility (LTCF) or an Intermediate Care Facility for People with Developmental Disabilities (ICF-DD), complete ONLY questions 4 and 5 and send in your health care expenses.

Important - Read this

Your right to file a complaint: If you feel the county or the Minnesota Department of Human Services treated you differently in the handling of your public assistance application or benefits because of race, color, national origin, political beliefs, religion, creed, sex, sexual orientation, public assistance status, age, or disability, including physical access to government buildings, you may file a complaint with the county, state or federal agencies.

How we use this information: Our public assistance staff and other agencies allowed by law use the information on this form. We also use it to refer you to other benefit programs. If you move to another state or county, we will send certain information to them.

Your right to a fair hearing: You have the right to a fair hearing if you do not agree with an action taken by the county agency. Request a fair hearing by calling or writing your county human services agency or the Minnesota Department of Human Services, State Appeals Office, P.O. Box 64941, St. Paul, MN 55164-0941.

Denial and notice actions: We may deny or change your cash or health care and/or food benefits because of information you give on this form. We can make changes without giving you 10 days advance notice. We will send you written notice of any change no later than the date the change takes effect or the date you would receive benefits, whichever is earlier.

False information: If you give false information, we may try you for fraud and you could lose your benefits.

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DHS-2120-ENG

 

 

9-17

Household Report Form

 

 

 

 

 

 

 

 

 

1. Address change

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you move during the report month(s)?

Yes

No

 

 

 

 

 

 

 

 

 

If yes, fill in below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF LAST MOVE

NEW PHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEW ADDRESS WHERE YOU LIVE (if you did not have an address, write "homeless")

APT. NUMBER

CITY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NEW MAILING ADDRESS (if different from where you live)

 

 

 

APT. NUMBER

CITY

 

 

 

STATE

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Living situation: (optional, choose one)

 

 

 

 

 

 

 

 

 

 

 

 

 

Own housing; lease, mortgage or roommate

 

Family/friends due to economic hardship

 

 

 

Service provider - foster care, group home

 

Hospital, treatment facility, detox center or nursing home

Jail, prison or juvenile detention facility

 

 

 

Emergency shelter

 

 

 

 

 

Hotel or motel

 

 

 

 

 

 

Declined

 

 

 

 

 

 

 

Place not meant for housing (anywhere outside, a

Unknown

 

 

 

 

 

 

 

vehicle, an abandoned building, or bus/train/airport)

 

 

 

 

 

 

 

 

 

 

2. Rent subsidy

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you have a new rent subsidy or change in your rent subsidy during the report month(s)?

Yes

No

 

 

If yes, fill in below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUBSIDY AMOUNT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Send proof.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Household members

 

 

 

 

 

 

 

 

 

 

 

 

 

Did anyone move out of your home in the report month(s)?

Yes

No

 

 

 

 

 

 

Did anyone move in with you in the report month(s) (include newborns)?

Yes

No

 

 

 

 

Have you either moved on to a reservation or left a reservation in the last month?

Yes

No

 

 

 

If yes for any question in #3, complete the section below for each person who moved in or out:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was change for 30

Does person buy or

 

Name

 

Relation to you or your children

 

Date of change

days or less?

fix food with you?

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Unearned income

Did you or anyone living with you receive any unearned income during the report month(s)?

Yes

No

If yes, list who got the money, how much they got each month, and date they got it. Send proof.

 

 

Page 2 of 8

Income type

Answer Yes or No

Amount

Who got it

Date received

School loans, grants, scholarships

Yes

No

 

 

 

 

 

 

 

 

 

RSDI (Social Security)

Yes

No

 

 

 

***The agency will verify this income for you.

 

 

 

 

 

 

 

 

 

 

 

SSI (Supplemental Security Income)

Yes

No

 

 

 

***The agency will verify this income for you.

 

 

 

 

 

 

 

 

 

 

 

VA (Veteran's Benefits)

Yes

No

 

 

 

 

 

 

 

 

 

Unemployment Insurance

Yes

No

 

 

 

 

 

 

 

 

 

Workers' Compensation

Yes

No

 

 

 

 

 

 

 

 

 

Retirement benefits

Yes

No

 

 

 

 

 

 

 

 

 

Child or spousal support

Yes

No

 

 

 

 

 

 

 

 

 

Other types, such as gifts or loans, contract for deed income, rental income, lottery winnings, lawsuit settlements, inheritance, disability payments, etc.

Yes No

Yes No

Yes No

5. Earned income

Did you or anyone living with you get income from a job or self-employment during the report month(s)?

Yes No

Does your household have more than one job to report?

Yes

No

Send Pay Stubs or other proof of gross earnings for each job. Your employer may also use the Employers Statement in Section A.

If self-employed, send proof or use the Self-Employment Report Form DHS-3336. For Supplemental Nutrition Assistance Program (SNAP) only cases, if self-employment income is from farming or rental income, you must document and verify all income and expenses.

6. Assets

Is the total value of your assets (cash, bank accounts, stocks and bonds, vehicles) $9800 or more?

Yes

No

If yes, complete Section B.

7. Child or Adult Care Expenses (SNAP only)

Did you or anyone living with you have costs for care of a child or an ill or disabled adult during the report month(s) because you or they were working, looking for work, going to school or training to prepare for work?

Yes No

If yes, complete the section below for each person getting care. Send proof.

Name of person getting care

Name of person paying care

Amount you paid in

report month(s)

Amount paid by someone

else in report month(s)

Name of person giving care

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DHS-2120-ENG 9-17

AMOUNT PAID

8. Court-ordered expenses

Did anyone living in your household pay court-ordered expenses in the report month(s) (child/spousal support,

medical, child care)?

Yes

No

If yes, send proof.

PAID TO WHOM

TYPE OF EXPENSE (child/spousal support, medical, child care)

9. Other changes

Do you or anyone living with you have any other changes to report?

Yes

No

(Examples of things you may be required to report: Starting a new job, stopping work, starting or stopping school, selling or giving away assets, court ordered community service, marriage, immigration, citizenship, or disability status.)

If yes, fill in below. Send proof.

WHO?

DATE OF CHANGE

EXPLAIN THE CHANGE

10. Future changes

In the next two months, do you or anyone living with you expect any changes in what you reported on this form?

Yes No

If yes, fill in below.

WHO?

DATE OF CHANGE

EXPLAIN THE CHANGE

Health Care Expenses

For SNAP only

To receive a medical expense deduction, send copies of medical bills by anyone in your household who is disabled or 60 years or older that were not paid (Do not provide medical bills that are being paid for by any health care program, insurance or someone not living with you).

For Long-Term Care Facility or Intermediate Care Facility for Persons with Developmental Disabilities only

If you are living in a Long-Term Care Facility or Intermediate Care Facility for Persons with Developmental Disabilities and are receiving Medical Assistance, send copies of medical bills that were not paid by Medical Assistance (MA) or were not paid in full by other insurance, including prescription copays, to your worker. Send proof of your medical bills (Do not send medical bills you already gave to your worker).

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DHS-2120-ENG 9-17

Sign and date this report on or after the last day of the report month(s)

I declare that I have examined this form and, to the best of my knowledge and belief, it is a true and correct statement of every material point.

SIGN YOUR NAME HERE

 

 

DATE

PHONE NUMBER

 

 

 

 

 

PRINT YOUR NAME HERE

 

 

PRINT YOUR CASE NUMBER HERE

 

 

 

 

 

HAVE THE SECOND ADULT SIGN HERE

DATE

PERSON WHO HELPED COMPLETE THE FORM SIGN HERE

DATE

 

 

 

 

 

Section A: Employer's Statement

If you do not have pay stubs or other documentation of earned income, your employer may complete this section.

HOUSEHOLD MEMBER

 

 

OCCUPATION

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER

 

STREET ADDRESS

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

HOW MANY HOURS DID YOU WORK IN THE REPORT MONTH?

HOW OFTEN PAID

 

 

 

 

 

 

 

 

Every week

Every 2 weeks

Once a month

Twice a month

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1st check

 

2nd check

3rd check

4th check

5th check

 

 

 

 

 

 

 

 

 

Date pay received

Gross earnings

Tips/bonuses

EMPLOYER SIGNATURE (NEEDED IF YOU DON’T HAVE PAY STUBS)

DATE

Section B: Assets

Only complete if you answered "Yes" to question 6, and your assets total $9,800 or more.

List all assets (including cash, bank accounts, debit accounts, reliacard accounts, money market accounts, certificates of deposits, stocks, bonds, pensions, retirement accounts, car, truck, van, camper, motorcycle, trailer).

Send proof.

Type of asset

Amount or value

Owner's name

Account information (number, location)

Page 5 of 8

DHS-2120-ENG 9-17

(ADA4 [9-15])

For accessible formats of this publication, ask your county worker. For assistance with additional equal access to human services, contact your county's ADA coordinator.

Page 6 of 8

DHS-2120-ENG 9-17

Civil Rights Notice

Keep this page for your records.

CB6 (Food, Cash, SS, HC) 3-18

Discrimination is against the law. The Minnesota Department of Human Services (DHS) and local human services agencies do not discriminate on the basis of any of the following:

• race

• creed

• public assistance status

• disability

color

religion

marital status

sex (including sex stereotypes and gender identity)

national origin

sexual orientation

age

political beliefs

Auxiliary Aids and Services: Human services agencies provide auxiliary aids and services, like qualified interpreters or information in accessible formats, free of charge and in a timely manner to ensure an equal opportunity to participate in their programs. Contact your worker or agency's ADA Coordinator to get auxiliary aids and services.

Language Assistance Services: Human services agencies provide translated documents and spoken language interpreting, free of charge and in a timely manner, when language assistance services are necessary to ensure limited English speakers have meaningful access to information and services. Contact your worker or agency's LEP Coordinator to get language assistance services.

Civil Rights Complaints

You have the right to file a discrimination complaint if you believe you were treated in a discriminatory way by a human services agency. You may contact any of the following four agencies directly to file a discrimination complaint.

U.S. Department of Health and Human Services' Office for Civil Rights (OCR)

You have the right to file a complaint with the OCR, a federal agency, if you believe you have been discriminated against because of any of the following:

• race

• color

• national origin

• age

• disability

• sex

Contact the OCR directly to file a complaint:

Director, U.S. Department of Health and Human Services' Office for Civil Rights 200 Independence Avenue SW, Room 509F

HHHBuilding Washington, DC 20201 800-368-1019 (voice)

800-537-7697 (TDD)

Complaint Portal: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture

(2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov

Office of the Assistant Secretary for Civil Rights

 

1400 Independence Avenue, SW

 

Washington, DC 20250-9410;

 

This institution is an equal opportunity provider.

 

Page 7 of 8

DHS-2120-ENG 9-17

Keep this page for your records.

Minnesota Department of Human Rights (MDHR)

In Minnesota, you have the right to file a complaint with the MDHR if you believe you have been discriminated against because of any of the following:

race

national origin

creed

sexual orientation

public assistance status

color

religion

sex

marital status

disability

Contact the MDHR directly to file a complaint:

Minnesota Department of Human Rights Freeman Building, 625 North Robert Street St. Paul, MN 55155

651-539-1100 (voice)

800-657-3704 (toll free)

711 or 800-627-3529 (MN Relay)

651-296-9042 (fax) Info.MDHR@state.mn.us (email)

DHS

You have the right to file a complaint with DHS if you believe you have been discriminated against in our health care programs because of any of the following:

• race

• creed

• public assistance status

• disability

color

religion

marital status

sex (including sex stereotypes and gender identity)

national origin

sexual orientation

age

political beliefs

Complaints must be in writing and filed within 180 days of the date you discovered the alleged discrimination. The complaint must contain your name and address and describe the discrimination you are complaining about. After we get your complaint, we will review it and notify you in writing about whether we have authority to investigate. If we do, we will investigate the complaint.

DHS will notify you in writing of the investigation's outcome. You have the right to appeal the outcome if you disagree with the decision. To appeal, you must send a written request to have DHS review the investigation outcome. Be brief and state why you disagree with the decision. Include additional information you think is important.

If you file a complaint in this way, the people who work for the agency named in the complaint cannot retaliate against you. This means they cannot punish you in any way for filing a complaint. Filing a complaint in this way does not stop you from seeking out other legal or administrative actions.

Contact DHS directly to file a discrimination complaint:

Civil Rights Coordinator

Minnesota Department of Human Services Equal Opportunity and Access Division P.O. Box 64997

St. Paul, MN 55164-0997

651-431-3040 (voice) or use your preferred relay service

Page 8 of 8

DHS-2120-ENG 9-17

How to Edit Form Dhs 2120 Online for Free

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With regards to the blanks of this particular PDF, this is what you want to do:

1. You need to fill out the household report form correctly, therefore pay close attention while working with the segments including these particular blanks:

How you can fill in household report form mn dhs part 1

2. The subsequent step is to fill in the next few blank fields: Sign and date the form on or after, Return this form no later than, If you need help with the form, If you receive Medical Assistance, Important Read this cid Your, you differently in the handling of, cid How we use this information, and cid Your right to a fair hearing.

Filling in part 2 in household report form mn dhs

Those who use this PDF frequently make errors while completing you differently in the handling of in this part. Be sure to read again everything you type in right here.

3. This next step is focused on Household Report Form Address, Yes, If yes fill in below, DATE OF LAST MOVE, NEW PHONE NUMBER, NEW ADDRESS WHERE YOU LIVE if you, STATE, ZIP CODE, NEW MAILING ADDRESS if different, APT NUMBER CITY, STATE, ZIP CODE, Living situation optional choose, Own housing lease mortgage or, and Familyfriends due to economic - type in each of these empty form fields.

household report form mn dhs writing process outlined (portion 3)

4. All set to begin working on the next form section! Here you have all of these Household members Did anyone move, Yes, Did anyone move in with you in the, Yes, Have you either moved on to a, Yes, If yes for any question in, Name, Relation to you or your children, Date of change, days or less, Was change for, Does person buy or fix food with, Yes, and Yes blanks to do.

household report form mn dhs completion process described (part 4)

5. Finally, this final section is what you need to wrap up before using the PDF. The blanks at issue are the following: Income type, Answer Yes or No, Amount, Who got it, Date received, School loans grants scholarships, RSDI Social Security The agency, SSI Supplemental Security Income, VA Veterans Benefits, Unemployment Insurance, Workers Compensation, Retirement benefits, Child or spousal support, Yes, and Yes.

Step number 5 of completing household report form mn dhs

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