Form DHS-3380 at a glance
What it is: Verification of Student Information: It is necessary to verify school enrollment, attendance and progress for students who are receiving or applying for public assistance.
Where and when to file: It is your responsibility to have the form completed and returned to your worker, or your benefits may be denied, reduced, or terminated.
A filled-in Form DHS-3380 example: a client has the school verify a student
How to fill out Form DHS-3380, box by box
Student Name, Student's Birthdate and Date Completed
Enter the Student Name, Student's Birthdate and Date Completed.
Client Signature, Date and the school's return date
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.
To school official: You are authorized to release the information requested on this form to the Michigan Department of Health and Human Services.
Sign at Client Signature, then take or mail the form and the return envelope to the school.
Sign the Client Signature line and enter the Client Signature Date.
1. Name of School, Address of School and City
School official: Please complete the information on the back of this form and return it to the MDHHS Office. A stamped self-addressed envelope has been enclosed for that purpose.
Under 1. Name of School, enter the Name of School, the Address of School and the City.
2. Name of Responsible Person, 3. Relationship to Student and 4. Address of Student's Home
Enter 2. Name of Responsible Person With Whom the Student is Residing, 3. Relationship to Student, and 4. Address of Student's Home with its City.
5. Enrollment Status
5. Enrollment Status: Full time student, Half time student, Less than half time and Not currently enrolled.
6. Attendance
6. Attendance: Regularly attending, Attending sometimes, Not attending and Since (Give Date).
If not regularly attending, is absence due to disability or periods of extended illness? Yes or No.
7. Type of Program
7. Type of Program: K-12, College or university and Vocational trade or technical training.
Is a High School diploma/GED Required for this program: YES or NO.
8. Curriculum or Major
8. Curriculum or Major, Participating in Work Study YES or NO, and School Year/Term/Semester Begin Date and End Date.
9. Degree Being Pursued
9. Degree Being Pursued: Associate of Arts degree, Not applicable, High school diploma, B.A./B.S and Other (Specify), with the Expected Date of Completion/Graduation.
10. Has the child regularly attended all school days for the past 21 calendar days?
For the 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 or No.
11. Comments and 12. Signature of School Official
Enter 11. Comments.
12. Signature of School Official, Title, Phone Number and Date.
More rules for Form DHS-3380
This form must be completed by the school.
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.
Sources
[1] Form DHS-3380 (Rev. 6-16), Verification of Student Information, Michigan Department of Health and Human Services (the Official source link on this page).