Economic supports, cash, food: eDocs, forms and documents

Quick access to frequently needed forms, applications, documents and other publications.

Eligibility determination

Application or redetermination forms
- The Combined Application Form DHS-5223 (PDF) is used to gather information needed to determine eligibility for all Minnesota Department of Human Services cash and food programs.
- The Minnesota Transition Application Form DHS-5223E (PDF) is used to apply for the Minnesota Family Investment Program (MFIP) for clients who currently receive benefits from the Diversionary Work Program (DWP)or have received benefits within the last 30 days.
- The Signed Personal Statement about Assets for Cash Programs DHS-6054 (PDF) can be used by cash program applicants or recipients to attest to the value or availability of certain assets.
- The Verification Request Form A DHS-2919 A (PDF) is sent to clients to request specific verification needed to determine eligibility for human service programs.
- The Verification Request Form B DHS-2919 B (PDF) is sent to clients to request specific verification needed to determine eligibility for human service programs.
Case maintenance forms
- The Combined Application – Addendum DHS-5223C (PDF) is an addendum to the Combined Application Form and is used for adding people to existing cash programs after the application has been processed. It call also be used but not required for collecting information on people added to the Supplemental Nutrition Assistance Program (SNAP) households.
- The Signed Personal Statement about Assets for Cash Programs DHS-6054 (PDF) can be used by cash program applicants or recipients to attest to the value or availability of certain assets.
- The Verification Request Form A DHS-2919 A (PDF) is sent to clients to request specific verification needed to determine eligibility for human service programs.
- The Verification Request Form B DHS-2919 B (PDF) is sent to clients to request specific verification needed to determine eligibility for human service programs.
- The Authorization for Release of Employment Information DHS-2146 (PDF) is a consent form allowing release of employment information required for the determination of eligibility for human service programs.
- The Authorization for Release of Information about State Residence and Shelter Expenses DHS-2952 (PDF) is an authorization form allowing release of residence and shelter expense information required for the determination of eligibility for human service programs.
- The Change Report Form DHS-2402 (PDF) is a reporting form used by clients to report income, asset, and circumstance changes usually on a non-scheduled basis.
- The Household Report Form DHS-2120 (PDF) is a reporting form used by clients to report income, asset, and circumstance changes on a scheduled basis.
Required client notices
- Notice of Privacy Practices DHS-3979 (PDF) - general notice of privacy practices for cash and Supplemental Nutrition Assistance (SNAP) programs advising clients of how their private information may be used, disclosed and how they can receive this information.
- Client Responsibilities and Rights DHS-4163 (PDF) - explains the responsibilities and rights of cash assistance, Supplemental Nutrition Assistance Program (SNAP) and child care assistance applicants and recipients.
- Important Information DHS-3353 (PDF) - explains clients' right to appeal and where to file a discrimination complaint.
- Notice About Income and Eligibility Verification System and Work Reporting System DHS-2759 (PDF) -informs public assistance applicants and recipients of the Income and Eligibility Verification System IEVS and Work Reporting System. This form is distributed with application and recertification packets.

Program brochures

Family cash
- Program information for cash, food, and child care programs DHS-2920 (PDF)- explains the various programs the department manages, who is eligible for those programs and how to apply for them.
- Minnesota Family Investment Program (MFIP) DHS-3179 (PDF) - explains the basic program requirements of the Minnesota Family Investment Program.
- MFIP for Minor Caregivers DHS-3238 (PDF) – explains what constitutes a minor caregiver, requirements for minor caregivers to receive benefits and exceptions to those requirements.
- Minnesota's Diversionary Work Program DHS-4034 (PDF) - explains the basic program requirements of the Diversionary Work Program.
- Domestic Violence Information brochure DHS-3477 (PDF) – explains domestic violence and abuse and how victims can get a waiver from some of the cash and food assistance program rules.
- Do you have a disability? DHS-4133 (PDF) – explains the rights that people with disabilities have and the kind of help that is available to them.
Adult cash
- Program information for cash, food, and child care programs DHS-2920 (PDF)- explains the various programs the department manages, who is eligible for those programs and how to apply for them.
- General Assistance Program brochure DHS-2062 (PDF) – explains the basic program requirements of the General Assistance (GA) program.
- Minnesota Supplemental Aid brochure DHS-1888 (PDF) – explains the basic program requirements of the Minnesota Supplemental Aid program.
- Do you have a disability? DHS-4133 (PDF) – explains the rights that people with disabilities have and the kind of help that is available to them.
Supplemental Nutrition Assistance Program (SNAP)
- Program information for cash, food, and child care programs DHS-2920 (PDF)- explains the various programs the department manages, who is eligible for those programs and how to apply for them.
- Supplemental Nutrition Assistance Program brochure DHS-2814 (PDF) – explains the basic program requirements of the Supplemental Nutrition Assistance Program (SNAP).
- Supplemental Nutrition Assistance Program Reporting Responsibilities DHS-2625 (PDF) - explains the reporting responsibilities for the Supplemental Nutrition Assistance Program (SNAP).
Required general program information
- Program information for cash, food, and child care programs DHS-2920 (PDF)- explains the various programs the department manages, who is eligible for those programs and how to apply for them.
- Reporting Responsibilities for Public Assistance Recipients DHS-3155 (PDF)- explains the importance for clients to report the facts of their situation to avoid fraud charges.
- Domestic Violence Information brochure DHS-3477 (PDF) – explains domestic violence and abuse and how victims can get a waiver from some of the cash and food assistance program rules.
- Do you have a disability? DHS-4133 (PDF) – explains the rights that people with disabilities have and the kind of help that is available to them.
- How to Use Your Minnesota EBT Card DHS-3315A (PDF) - explains how to use the Minnesota Electronic Benefits Transfer (EBT) card.

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Manuals

Cash program
- The Combined Manual (CM) gives financial workers a complete, authoritative and concise set of provisions to determine eligibility for cash and food programs and to issue client benefits on MAXIS.
- The Employment Services Manual contains the policies and procedures of the Employment Services (ES) component of the Minnesota Family Invest Program (MFIP) and Diversionary Work Program (DWP). The primary users of the manual are the Employment Services Providers, who are contracted to help participants become employed and self-sufficient.

Food program
- The Combined Manual (CM) gives eligibility workers a complete, authoritative and concise set of provisions to determine eligibility for the cash and food programs and to issue client benefits on MAXIS.
- The Supplemental Nutrition Assistance Program (SNAP) Employment and Training (SNAP E&T) Manual provides policies and procedures for Employment and Training providers and eligibility workers to help food program participants transition from public assistance to self-sufficiency.

Bulletins

DHS bulletins are official communication to inform county and tribal staff, as well as other business partners, about program changes and required actions by workers and partner agencies.