Michigan Verification Student Form PDF Details

In a world where the provision of public assistance is closely linked to educational attendance and progression, the Michigan Verification Student form emerges as a vital document for families seeking support. It offers an essential communication channel between educational institutions and the Department of Human Services (DHS), aiming to ensure that students benefiting from or applying for public assistance meet their educational requirements. This form is steeped in the principles of non-discrimination, openly inviting individuals of varying races, religions, national origins, and more, reassuring them of fair treatment. Not only does it serve as a confirmation of a student's enrollment, attendance, and academic progress, but it also aligns with federal acts and social security provisions, highlighting its legal grounding. School administrations are called upon to voluntarily provide this crucial information, although they face no penalties for non-compliance, excluding potential impacts on the students' assistance. The given details include everything from basic student information to specifics about their academic status, such as the type of program attended and degree pursued, underlining the form's comprehensive nature. Through gathering this data, the Michigan Verification Student form plays a pivotal role in facilitating the continuation or initiation of public assistance to those in school, eloquently bridging the worlds of education and social welfare.

QuestionAnswer
Form NameMichigan Verification Student Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesverification student information get, michigan verification form online, dhs 3380 verification, michigan student form

Form Preview Example

ENTER ADDRESSEE NAME ENTER ADDRESSEE CARE OF

ENTER ADDRESSEE PO BOX OR STREET ENTER ADDRESSEE CITY/STATE/ZIP

Case Name:

 

Case Number:

 

Date:

 

DHS Office:

 

Specialist / ID:

/

Phone:

 

Fax:

 

Individual ID:

 

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. AUTHORITY: Act 280 of 1939, as amended, and Title IV and XIX of the Social Security Act.

COMPLETION: The school administration's voluntary cooperation is requested.

PENALTY: None for the school administration’s refusal to fill out form. However, failure of school to provide information may result in denial, reduction, or loss of assistance for client.

VERIFICATION OF STUDENT INFORMATION

Student Name

Student’s Birthdate

Date Completed

CLIENT INSTRUCTIONS & RELEASE OF INFORMATION:

•It is necessary to verify school enrollment, attendance and progress for students who are receiving or applying for public assistance. For the Family Independence Program, all children between the ages of 6-18 are expected to be attending school full-time or benefits may be denied, reduced, or terminated.

•This form must be completed by the school. Sign below, then take or mail the form and the return envelope to the school.

• It is your responsibility to have the form completed and returned to your worker by

or your

benefits may be denied, reduced, or terminated.

 

To school official: You are authorized to release the information requested below to the Department of Human Services.

Client Signature

Date

INSTRUCTIONS FOR SCHOOL OFFICIAL:

We are requesting your help in verifying enrollment, attendance and progress of the above-referenced student. Please complete the information on the back of this form and return it to our office. A stamped self-addressed envelope has been enclosed for that purpose.

TO BE COMPLETED BY SCHOOL OFFICIAL:

 

1.

Name of School

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address of School

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

2.

Name of Responsible Person With Whom the Student is Residing

 

 

3. Relationship to Student

 

 

 

 

 

 

 

 

 

 

4.

Address of Student's Home

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

5.

Enrollment Status:

 

 

 

 

 

 

 

 

FULL TIME STUDENT

 

HALF TIME STUDENT

LESS THAN HALF TIME

NOT CURRENTLY ENROLLED

 

6.

Attendance:

 

 

 

 

 

Since (Give Date)

 

 

REGULARLY ATTENDING

 

ATTENDING SOMETIMES

NOT ATTENDING

 

 

 

If not regularly attending, is absence due to disability or periods of extended illness?

Yes

No

 

DHS-3380 (Rev. 10-12) Previous edition obsolete. MS Word

1

 

 

 

Case Name

Case Number

Specialist

7.

Type of Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

VOCATIONAL TRADE OR TECHNICAL TRAINING

 

K-12

 

COLLEGE OR UNIVERSITY

 

YES

NO

Is a High School diploma/GED Required for this program

8.

Curriculum or Major

Participating in Work Study

 

School Year/Term/Semester Begin Date

End Date

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Degree Being Pursued:

 

ASSOCIATE OF ARTS DEGREE

NOT APPLICABLE

 

Expected Date of Completion/Graduation

 

HIGH SCHOOL DIPLOMA

 

B.A./B.S

 

OTHER (Specify)

 

 

21 Day Compliance Test

Complete if box is checked

10. Has the child regularly attended all school days for the past 21 calendar days?

Yes

No

11. Comments

12. Signature of School Official

Title

Phone Number

Date

DHS-3380 (Rev. 10-12) Previous edition obsolete. MS Word

2

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