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Forms & Applications

The DHS forms and applications listed here are only a portion of those available. Visit your local DHS Office for forms or applications not available through the Internet. The following documents are in PDF format. To view or print PDF files, you will need Adobe Acrobat Reader. If you do not already have Reader installed on your computer, it is available free of charge from Adobe's web site.

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Applications

• Assistance Application (DHS-1171) A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that after you've completed the application, you will need to print it and take it to your local DHS office.

• Solicitud de Asistencia - DHS-1171-SP

• DHS-1171-AR PDF icon

• Central Registry Clearance Request - DHS-1929

• Original License Application Packet Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Energy Supplier Participation Agreement - DHS-355 PDF icon

• Adult Services Application - DHS-390 PDF icon

• Adult Foster Care License Limited Liability Company Governmental Organization and Corporate Application - BCAL-569-C PDF icon

• Adult Foster Care License Individual Application - BCAL-569-I PDF icon

• Application for State Emergency Relief - DHS-1514 PDF icon

• Plan First! Family Planning Program Application - MSA-1582 PDF icon

• Insurance Assistance Program and Insurance Assistance Program-Plus Application - DHS-1661 PDF icon

• Solicitud Para Medicaid Retroactivo - DHS-3243-SP PDF icon

• Retroactive Medicaid Application - DHS-3243 PDF icon

• Asset Declaration Patient and Spouse - DHS-4574-B PDF icon

• Medicaid Application Patient of Nursing Home - DHS-4574 PDF icon

• Declaration De Bienes Paciente Y Esposo/A - DHS-4574-B-SP PDF icon

• Child Development and Care Application - DHS-4583 PDF icon

• Solicitud de Desarrollo y Cuidado de Niños - DHS-4583-SP PDF icon

• Voter Registration Application and Michigan Driver License/Personal Identification Card Address Change Form - NSP-0938-B PDF icon

• Solicitud de Registración del Votante y Licencia de Manejar de Michigan/Instrucciones de la Forma para Cambiar su Dirección en su Tarjeta de Identificación Personal - NSP-0938B-SP PDF icon


Adoption

• Personal Reference Letter - DHS-608 PDF icon

• Notification to Court of Jurisdiction and Child's Lawyer Guardian Ad Litem - DHS-867 PDF icon

• Request for Medical Subsidy for An Adopted Child - DHS-1341-A PDF icon

• Adult Former Sibling Statement to Release Information to Adult Adoptee - DHS-1917 PDF icon

• Release of Information to Adult Adoptee by Brother/Sister as proxy for Deceased Parent - DHS-1918 PDF icon

• Parent's Consent/Denial to Release Information to Adult Adoptee - DHS-1919 PDF icon

• Release of Information Authorization Adult Adoptee - DHS-1920 PDF icon

• Request by Adult Adoptee for Identifying Information - DHS-1925 PDF icon

• Adoption Facilitator Clearing House Record, DHS-4746 Adoption Facilitator Clearing House Record, - DHS-4746


Adult

• Medical Needs - DHS-54-A PDF icon

• Adult Services Application - DHS-390 PDF icon

• Personal Care Services Provider Log - DHS-721 PDF icon

• Insurance Assistance Program and Insurance Assistance Program-Plus Application - DHS-1661 PDF icon


Cash Assistance

• Assistance Application (DHS-1171) A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that after you've completed the application, you will need to print it and take it to your local DHS office.

• Solicitud de Asistencia - DHS-1171-SP

• Solicitud Para Medicaid Retroactivo - DHS-3243-SP PDF icon

• Retroactive Medicaid Application - DHS-3243 PDF icon

• Asset Declaration Patient and Spouse - DHS-4574-B PDF icon

• Medicaid Application Patient of Nursing Home - DHS-4574 PDF icon

• Declaration De Bienes Paciente Y Esposo/A - DHS-4574-B-SP PDF icon


Child Care

• Assistance Application (DHS-1171) A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that after you've completed the application, you will need to print it and take it to your local DHS office.

• Verificacion del Proveedor del Cuidado del Nino - DHS-4025-SP PDF icon

• Child Care Provider Verification - DHS-4025 PDF icon

• DHS-1171-AR PDF icon

• Solicitud de Asistencia - DHS-1171-SP

• CDC Daily Time and Attendance Record PDF icon

• Child Development and Care Application - DHS-4583 PDF icon

• Solicitud de Desarrollo y Cuidado de Niños - DHS-4583-SP PDF icon


Child Care Fund

• In Home Care Certification - DHS-167 PDF icon

• In Home Care Certification - DHS-167 (Word)

• Basic Grant Certification - DHS-168 PDF icon

• Monthly Report on Foster Care Under the Family Division of the Circuit Court - DHS-207 (Word)

• Monthly Report on Foster Care Under the Family Division of the Circuit Court - DHS-207 PDF icon

• County Child Care Budget Summary - DHS-2091 PDF icon

• County Child Care Budget Summary - DHS-2091 (Word)

• In Home Care Summary - DHS-2093 PDF icon

• In Home Care Summary - DHS-2093 (Word)

• In Home Care/Basic Grant Budget Detail Report - DHS-2094 PDF icon

• In Home Care/Basic Grant Budget Detail Report - DHS-2094 (Word)

• Basic Grant Summary - DHS-2095 PDF icon

• Basic Grant Summary - DHS-2095 (Word)

• In Home Care Addendum for DHS-206B - DHS-2396 PDF icon

• In Home Care Addendum for DHS-206B - DHS-2396 (Word)

• In Home Care/Basic Grant Program Component Report/Request - DHS-4471 PDF icon

• In Home Care/Basic Grant Program Component Report/Request - DHS-4471 (Word)

• Child Care Fund Summary Report - DHS-4472 PDF icon

• Child Care Fund Summary Report - DHS-4472 (Word)


Child Support

• Child Support Information - DHS-0842 (Word) When requested, complete this form to provide information to your caseworker.

• IV-D Child Support Services Application/Referral - DHS-1201 PDF icon If you are not on public assistance, complete this form to apply for Child Support services

• DHS Child Support Form and Publication Order Form - DHS-1454 PDF icon

• Solicitud Para Servicios de Sostenimento de Ninos (IV-D)/Recomendacion - DHS-1201-SP PDF icon Si usted no está recibiendo asistencia pública, rellene este formulario para solicitar los servicios de Mantenimiento de Hijos


Children's Protective Services

• Central Registry Clearance Request - DHS-1929

• Relative Search Information - DHS-988 (WORD)

• Relative Search Information(Busqueda de Informacion de Parentesco) - DHS-988-SP

• Relative Response Form - DHS-989 (WORD)

• Relative Notification Form Letter for CPS and Foster Care - DHS-990 (WORD)

• INFORMACIÓN SOBRE ABUSO O DESCUIDO DE NIÑOS REAL O SOSPECHADO - DHS-3200-SP PDF icon

• Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 PDF icon

• Report of Actual or Suspected Child Abuse or Neglect (Arabic Version) - DHS-3200-AR PDF icon

• State of Michigan Sudden & Unexplained Child Death Scene Investigation Form PDF icon


Earned Income Tax Credit (EITC)

• Your EITC refund belongs to you PDF icon

• Earned Income Tax Credit Temporary Assistance for Needy Families (TANF) - DHS-3043 PDF icon

• Asistencia Federal Temporal a Familias Necesitadas (TANF) Determinación de Elegibilidad - DHS-3043-SP PDF icon


Emergency & Energy

• Assistance Application (DHS-1171) A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that after you've completed the application, you will need to print it and take it to your local DHS office.

• Solicitud de Asistencia - DHS-1171-SP

• DHS-1171-AR PDF icon

• Energy Supplier Participation Agreement - DHS-355 PDF icon

• Application for State Emergency Relief - DHS-1514 PDF icon

• Solicitud Para Ayuda de Emergencia del Estado - DHS-1514-SP PDF icon


Food Assistance

• Assistance Application (DHS-1171) A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that after you've completed the application, you will need to print it and take it to your local DHS office.

• Solicitud de Asistencia - DHS-1171-SP

• DHS-1171-AR PDF icon


Foster Care

• Search for a Court Form.


Interstate Compact

• Interstate Compact on Juveniles Petition for Requsition to Return a Runaway Juvenile - DHS-1908 PDF icon ICJ Form A

• Detention Order - DHS-1909 PDF icon

• Recommendation and Assurance for Pre-Adoption and Requirement Certification - DHS-3005 PDF icon

• Interstate Compact on Juveniles Out of State Travel Permit and Agreement to Return - DHS-3034 PDF icon ICJ Travel Permit

• Interstate Compact on Juveniles Requisition for Escapee/Absconder/Juvenile Charged Delinquent (Rendition Amendment) - DHS-3036 PDF icon ICJ Juvenile Rights

• Interstate Compact on Juveniles Consent for Voluntary Return by Runaway, Escapee or Absconder - DHS-3037 PDF icon ICJ Form III

• Interstate Compact on Juveniles Parole or Probation Investigation Request - DHS-3038 PDF icon ICJ Form IV

• Interstate Compact on Juveniles Parolee/Probationer Report to Receiving State - DHS-3039 PDF icon ICJ Form V

• Interstate Compact on Juveniles Application for Services and Waiver - DHS-3040 PDF icon ICJ Form 1A-VI

• Sending State Priority Home Study Request - DHS-3750 PDF icon

• Interstate Compact Placement Request - DHS-4332 PDF icon

• Interstate Compact Report on Child's Placement Status - DHS-4333 PDF icon

• ICPC Financial/Medical Plan - DHS-4334 PDF icon

• Interstate Compact Checklist - DHS-4335 PDF icon

• Interstate Compact on the Placement of Children Placement Prescreening - DHS-4336 PDF icon


Licensing - Adult Foster Care & Homes for the Aged

• AFC Forms Request PDF icon

• AFC Sample Starter Packet PDF icon

• Worksheet for Rating Residents PDF icon

• Worksheet for Calculating Evacuation Difficulty Score PDF icon

• Finding the Staff Shift Score PDF icon

• Original License Application Packet Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Resident Register - BCAL-0535 PDF icon

• Adult Foster Care License Limited Liability Company Governmental Organization and Corporate Application - BCAL-569-C PDF icon

• Adult Foster Care License Individual Application - BCAL-569-I PDF icon

• Homes for the Aged Application for Licensure - BCAL-1600 PDF icon

• Homes for the Aged Certificate of Appointment of Authorized Representative - BCAL 1603 PDF icon

• HFA Administrator Appointment - BCAL-1606 PDF icon

• Request for Plan Review - BCAL-1605 PDF icon

• Certification of Specialized Programs Application - BCAL-1609 PDF icon Must currently be licensed to be certified

• Appointment of Home for the Aged Resident Authorized Representative - BCAL-1610 PDF icon

• Resident Funds Record Part 1(*) - BCAL-2318 PDF icon

• Resident Funds Record Part II(*) - BCAL-2319 PDF icon

• Assessment Plan for AFC Residents - BCAL-3265

• Resident Care Agreement(*) - BCAL-3266 PDF icon

• AFC Resident Medication Record - BCAL-3267 PDF icon

• Appointment of Designated Representative - BCAL-3268 PDF icon

• What is a Designated Representative - BCAL-3268-I PDF icon

• Resident Information and Identification Record - BCAL-3483 PDF icon

• Resident Weight Record - BCAL-3485 PDF icon

• Medical Clearance Request - BCAL-3704 PDF icon

• Resident Health Care Appraisal(*) - BCAL-3947 PDF icon

• AFC Incident/Accident Report(*) - BCAL-4607 PDF icon

• Request for Modification of the Terms of the Registration/License - BCAL-5055 PDF icon

• AFC/HFA Sample Corrective Action Plan - BCAL-0414 PDF icon


Licensing - Child Care

• Child Care Forms Request PDF icon

• Application for Child Care Plan Review - BFS-13 (Required for new building/renovations only.) PDF icon

• Annual Compliance Certification for School Age Programs Exempt from Inspections PDF icon

• Central Registry Clearance Request - DHS-1929

• Original License Application Packet Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Employee Notification to Child Care Center of Arraignment - BCAL-1486 PDF icon

• Infant/Toddler Primary Caregiver Documentation - BCAL-4557 PDF icon

• Center Fire and Tornado Drill Record - BCAL-4593 PDF icon

• Assistant Caregiver Certifications - BCAL-4595 PDF icon

• Incident Report - BCAL-4605 PDF icon

• Staffing Plan: Child Care Centers - BCAL-5001 (Excel) Excel icon

• Driver Verification - BCAL-5039 PDF icon

• Child Care Center Record Requirements - BCAL-5041 PDF icon

• Self-Certification of Transportation Provisions for Centers - BCAL-5044 PDF icon

• Certification for Field Trip Transportation - BCAL-5046 PDF icon

• Playground Inspection Certification Summary - BCAL-5047 PDF icon

• Certification by Third-Party Substitute Contracting Agency - BCAL-5051 PDF icon

• Licensing Notebook Summary Sheet - BCAL-5052 PDF icon

• Parent Notification of the Licensing Notebook - BCAL-5053 PDF icon

• Request for Modification of the Terms of the License/Registration - BCAL-5054 PDF icon

• Sample Attendance Record PDF icon

• Sample Attendance Record DOC icon

• Child Care Center Compliance Record, Part 1. General Provisions - BCAL-1888 PDF icon

• Child Care Center Compliance Record, Part 2. Environmental Health Provisions - BCAL-4668 PDF icon

• Child Care Center Compliance Record, Part 3. Fire Safety Provisions - BCAL-722 PDF icon

• Child Care Center Compliance Record, Part 4. Transportation Provisions - BCAL-1891 PDF icon

• Child Care Center Compliance Record, Part 5. Swimming Provisions - BCAL-1890 PDF icon

• Medication Permission and Instructions for Child Care Homes/Child Care Centers - BCAL-1243 PDF icon

• Permiso e Instrucciones Para la Medicación Para Casas de Cuidado/Guarderias - OCAL-1243-SP PDF icon

• Licensing Record Clearance Request - BCAL-1326-CC PDF icon

• Medical Clearance Request - BCAL-3704-C PDF icon

• Child Information Record - BCAL-3731 PDF icon

• Child Information Record - BCAL-3731-AR (Arabic) PDF icon

• Documento de Información del Niño Estado de Michigan - BCAL-3731-SP PDF icon

• Child in Care Statement/Receipt - BCAL-3900 PDF icon

• Declaración/Recibo de Niños en Cuidado - BCAL-3900-SP PDF icon

• Training Record Family/Group Child Care Homes - BCAL-4590 PDF icon

• Incident, Accident, Illness, Death or Fire Report - BCAL-4603 PDF icon

• Staffing Plan: Child Care Centers - BCAL-5001 PDF icon

• Child Care Licensee Designee - BCAL-5003 PDF icon

• Certification of School Building Fire Safety Provisions - BCAL-5043 PDF icon


Licensing - Child Welfare

• Initial Foster/Adoption Home Evaluation - BCAL-3130 This form MUST be saved to your personal computer in order to do spell check and save inputted text.

• Child Welfare Licensing Form Request PDF icon

• Child Caring Institution Rules Review Worksheets

• North American Indian Tribal Affiliation Verification - BCAL-0120A PDF icon

• Application for Child Care Plan Review - BFS-13 PDF icon

• Court Operated Facility Rules Review Worksheets

• Special Investigation Report - BCAL-259 PDF icon

• Health History Record - OCAL-353 PDF icon

• Original License Application Packet Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Child Caring Institution Application - BCAL-1074 PDF icon

• Licensing Record Clearance Request - BCAL-1326-CC PDF icon

• Children's Foster Home Rules Compliance Record - BCAL-3080 PDF icon

• Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 PDF icon

• Child Information Record - BCAL-3731 PDF icon

• Child Information Record - BCAL-3731-AR (Arabic) PDF icon

• Documento de Información del Niño Estado de Michigan - BCAL-3731-SP PDF icon

• Foster Home Reference Questionnaire - OCAL-3739 PDF icon

• Medical Emergency Care Authorization - OCAL-3978 PDF icon

• Emergency Telephone Numbers - OCAL-4234 PDF icon

• Incident, Accident, Illness, Death or Fire Report - BCAL-4603 PDF icon


Relative Licensing

• DHS-972 Relative Agreement for Placement and Licensure Rev 2/14

• Initial Relative Safety Screen - DHS-588 (Word)

• Waiver of Foster Home Licensure-Relative Caregiver - DHS-875 (Word)


Native American Affairs (NAA) & Indian Outreach Services (IOS)

• American Indian/Alaska Native (AI/AN) Child Case Notification DHS-120 DOC icon

• ICWA/MIFPA Multiple Document Mailing Cover Sheet DHS-120-A DOC icon

• Transfer To Tribal Agency/Court DHS-120-B DOC icon

• American Indian/Alaska Native Child Welfare Cultural Plan DHS-120-C DOC icon

• American Indian/Alaska Native Ancestry Review Acknowledgement DHS-120-D DOC icon

• Notice to Canadian Indian Tribe Concerning Court Proceeding DHS-121 DOC icon

• American Indian/Alaska Native Descendant Child Welfare Case Notification DHS-121-A DOC icon

• Indian Child Welfare Act Performance Checklist PDF icon

• Indian Outreach Services Referral IOS 382 DOC icon

• Indian Outreach Services Contract Log IOS 383 DOC icon

• Indian Outreach Services Packet Cover IOS 384 DOC icon

• Indian Outreach Service Report Cover IOS 385 DOC icon


Medical Services

• Assistance Application (DHS-1171) A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that after you've completed the application, you will need to print it and take it to your local DHS office.

• Solicitud de Asistencia - DHS-1171-SP

• Irrevocable Funeral Contract Certification - DHS-8-A PDF icon

• Deductible Report - DHS-114A PDF icon

• Informe de Deducible - DHS-114A-SP PDF icon

• Plan First! Family Planning Program Application - MSA-1582 PDF icon

• Retroactive Medicaid Application - DHS-3243 PDF icon

• Solicitud Para Medicaid Retroactivo - DHS-3243-SP PDF icon

• Asset Declaration Patient and Spouse - DHS-4574-B PDF icon

• Medicaid Application Patient of Nursing Home - DHS-4574 PDF icon

• Declaration De Bienes Paciente Y Esposo/A - DHS-4574-B-SP PDF icon


Other

• Request for Hearing - DHS-18 PDF icon

• Hearing Request Withdrawal - DHS-18-A PDF icon

• Certification of Translation for Non-English Speaking Applicants or Recipients - DHS-848 PDF icon

• Request for Emergency Shelter Temporary Assistance for Needy Families (TANF) - DHS-3041-ES (PDF) - For homeless shelter providers ONLY PDF icon

• Voter Registration Application and Michigan Driver License/Personal Identification Card Address Change Form - NSP-0938-B PDF icon

• Solicitud de Registración del Votante y Licencia de Manejar de Michigan/Instrucciones de la Forma para Cambiar su Dirección en su Tarjeta de Identificación Personal - NSP-0938B-SP PDF icon


Safe Delivery

• Voluntary Medical Background Form - DHS-4819 PDF icon If the surrendering parent wishes to provide information about their medical background, this information would assist with the newborn's care.

• Forma Voluntaria de Antecedentes Medicos para un Recien Nacido Entregado - DHS-4819-SP PDF icon La Forma Voluntaria de Antecedentes Médicos para un Recién Nacido Entregado es llenada por el Proveedor de Servicios de Emergencia.

• Voluntary Release for Adoption - DHS-4820 PDF icon The Voluntary Release for Adoption of a Surrendered Newborn by Parent form is a written affirmation that the surrendering parent voluntary released their parental rights to their newborn child.

• Entega Voluntaria Para Adopcion De Un Recien Nacido Por Parte De Un Padre - DHS-4820-SP PDF icon


Volunteer

• Registration for Ongoing Volunteers - DHS-1182-A PDF icon

• Registration for Short Term Volunteers - DHS-1182-B PDF icon

• Registration for Group Volunteers - DHS-1182-C PDF icon

• Request for Central Registry - DHS-1929 (Word)




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