Spoken Language Written Language
Assistance Application
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Case #:
ID #:
Welcome!
Fill out the Assistance Application
Answer questions about you and your household.
Submit your application for one or more programs
You will need to interview with a MDHHS specialist, unless applying for
healthcare coverage only.
Fill out Program Details:
Healthcare Coverage
Food Assistance Program (FAP)
Cash Assistance
Child Development + Care (CDC)
State Emergency Relief (SER)
Receive your results
If you do not speak English, have a hearing impairment, or have a disability, let us know how we can help you (an
interpreter, sign language, TDD/TTY phone number we should call, assistance listening device, etc.) or bring your
own support.
Si no habla inglés, tiene una discapacidad auditiva o tiene una discapacidad, hagános saber cómo podemos ayudarlo (un
intérprete, un lenguaje de señas, un número de teléfono TDD / TTY al que debemos llamar, un dispositivo de asistencia auditiva,
etc) o puede traer su propio apoyo.
What language do you prefer?
)
. (.....
TDD/TTY
Assistance Application
Family Independence Program (FIP)
Refugee Cash Assistance (RCA)
State Disability Assistance (SDA)
Submit this form by mail, fax, or
bring it into a local MDHHS oce.
If determined eligible, FAP benets
will be issued from the date the
application is lled.
Find your nearest location at
www.michigan.gov/ContactMDHHS.
Apply online:
www.michigan.gov/mibridges.
Refer to the Information
Booklet for details on
each program.
1
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Applicant Registration
Legal Name (First, Middle, Last)
Mailing Address — if dierent from above (Street, City, County, State, ZIP Code)
Signature of Applicant Signature of Representative Date
Have you received assistance in Michigan in the past (or currently)?
My monthly income is less than $150 and I have
$100 or less in cash/accounts right now.
I am a migrant or seasonal farmworker whose
income has stopped and I have $100 or less in
cash/accounts right now.
My household’s combined monthly income and
cash/accounts are less than my household’s
combined monthly rent/mortgage and utilities.
Under penalties of perjury, I state that I have reviewed this application, and to the best of my knowledge and belief, the answers I give within this
application are true. If I am declaring an Authorized Representative, by signing below, I allow this person to sign my application and get ocial
information about this application. For Healthcare only, I authorize my Authorized Representative to act for me on all future matters.
Check any that apply: (You may qualify for 7 day processing of your food assistance)
Yes
Healthcare Food Cash Child Care State Emergency Relief
No
Date of Birth
Cell Phone #
Social Security Number
Home Phone #
Email
Household Street Address — the place where you currently live
City County State
Apt/Lot #
ZIP Code
Homeless
/ /
( ) -
Sign Here
( ) -
@
- -
What programs is your household applying for today?
If you are unable to nish the
entire application today, you
may complete this page and
return it to MDHHS to save
your application date. MDHHS
will still need to receive your
completed application before
any benets can be approved.
The date MDHHS receives your
assistance application or ling
form may aect the date your
benets start. If determined
eligible, FAP benets will
be issued from the date the
application is led.
For FAP, you are only required to
ll in your name, address (unless
homeless), and signature.
For all other programs
include date of birth.
We need a Social Security
number (SSN) for people who
are requesting assistance and
have a SSN or can get one.
See Info Booklet (Pg 30) for
more details.
For FAP only.
Michigan Department of Health and Human Services
2
2
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Household Members
List everyone who lives in your home, including yourself and anyone
who is not there all the time. If applying for healthcare coverage, list
everyone who will be included on your federal tax return this year
(note: you do not need to le taxes to receive assistance).
Need more room to write? Go to notes on last page to answer these questions.
Relationship
to you
1
2
3
4
5
is requesting: HEALTHCARE FOOD CASH CHILD CARE STATE EMERGENCY RELIEF NONE
is requesting: HEALTHCARE FOOD CASH CHILD CARE STATE EMERGENCY RELIEF NONE
is requesting: HEALTHCARE FOOD CASH CHILD CARE STATE EMERGENCY RELIEF NONE
is requesting: HEALTHCARE FOOD CASH CHILD CARE STATE EMERGENCY RELIEF NONE
is requesting: HEALTHCARE FOOD CASH CHILD CARE STATE EMERGENCY RELIEF NONE
/ /
/ /
/ /
/ /
/ /
- -
- -
- -
- -
- -
Ethnicity (optional):
Ethnicity (optional):
Ethnicity (optional):
Ethnicity (optional):
Ethnicity (optional):
Hispanic/Latino Not Hispanic/Latino
Hispanic/Latino Not Hispanic/Latino
Hispanic/Latino Not Hispanic/Latino
Hispanic/Latino Not Hispanic/Latino
Hispanic/Latino Not Hispanic/Latino
African American/Black American Indian/Alaska Native Asian Native Hawaiian/Other Pacic Islander White
African American/Black American Indian/Alaska Native Asian Native Hawaiian/Other Pacic Islander White
African American/Black American Indian/Alaska Native Asian Native Hawaiian/Other Pacic Islander White
African American/Black American Indian/Alaska Native Asian Native Hawaiian/Other Pacic Islander White
African American/Black American Indian/Alaska Native Asian Native Hawaiian/Other Pacic Islander White
Race (optional):
Race (optional):
Race (optional):
Race (optional):
Race (optional):
Full Legal Name Date of Birth Social Security # Married
US Citizen/
National
In the
Home?Sex
M F
M F
M F
M F
M F
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Yes, I’ve added more notes.
SSN and US Citizen/National
are optional for people who are
not requesting assistance. See Info
Booklet (Pg 30) for more details.
Ethnicity/Race is optional and will not
aect eligibility or benets. See Info
Booklet (Pg 35) for more details.
Name(s)
Green card, etc.
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
3
3
Household Details
Need more room to write? Go to notes on last page. Yes, I’ve added more notes.
Is anyone in your household pregnant now or were
they in the last 3 months?
If yes, who?
If yes, list below.
Who? Document Type Document Number Date of US Entry
If yes, who?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
No
No
No
No
No
No
No
No
# Expected
Foster Child Foster Parent Adopted Child Non-parent Caregiver
End/Due Date
Does anyone in your household have a disability or
a physical/emotional/mental health condition?
Do any children (under age 20) have a parent who
is living outside the home?
Is anyone in your household currently enrolled in
college/vocational school?
Is anyone temporarily absent from the home
(work, military, hospital, etc.)?
Is anyone in your household a Veteran or has
anyone served in the military or armed forces?
Is anyone in your household a foster child, foster
parent, adopted child, or non-parent caregiver?
Is anyone in your household currently a victim of
domestic violence?
If not a US citizen/national, does anyone have qualied immigration status?
/ /
This page is not required for
SER.
See Info
Booklet
(Pg 35) for
examples of
qualied status.
Non-applicants
should skip
this question.
Not required
for FAP.
For
Healthcare,
only required
for applicants.
Not
required for
eligibility.
(Circle all that apply)
#
/ /
/ /#
#
/ /
If yes, who?
No
Do you believe pursuing child support would be
harmful for you or your child (examples include
threats of abuse, history of abuse, incest, rape)?
If yes, who? No
Migrant Farmworker Refugee or Asylee
Are you a migrant farmworker, refugee or asylee?
(Circle all that apply)
Michigan Department of Health and Human Services
4
4
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Assets
Money + Accounts
Vehicles
Property
Sales + Transfers
If yes, list below.
If yes, list below.
If yes, check below.
If yes, list below.
Checking
Car
House(s) Buildings Burial Plot OtherRental Property Land/Lot
Other:
Savings
Truck Motorcycle Boat Other
No
No
No
No
Does anyone in your household have money or accounts?
Does anyone in your household own vehicles?
Does anyone in your household own property?
Has anyone sold, transferred, or given away assets in the last 5 years?
401K Retirement Plans Life Insurance Stocks Mutual Funds IRAs CDs Burial Funds
Lottery/Gambling Winnings Trusts/Annuities Payroll/Benets Card Other
Who?
Who? Year, Make, + Model Estimated Mileage
Type of Account Name of Bank/Institution Amount
$
$
$
Person Sold/Given To Type of Asset AmountDate
This page is not required
for CDC.
Healthcare-only applicants
should skip this page
(unless
disabled or in need of
longterm care services).
Include jointly owned accounts
and/or assets.
Only list vehicles that
are registered in a
household member’s
name.
In the last 90
days for FAP
and SER.
$
$
/ /
/ /
Explain
Monthly Monthly
Michigan Department of Health and Human Services
5
5
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Income
Change in Income
Self-Employment (Includes Odd Jobs)
Additional
If yes, explain.
If yes, list below.
If yes, list below.
No
No
No
Has anyone in your household had a change in employment in the last 30 days?
Is anyone in your household self-employed?
Does anyone in your household have additional income?
Laid o
Unemployment Disability (SSI)
Alimony/Spousal Support
Workers’ Compensation
Social Security (RSDI) Pension/RetirementChild Support
Other:
Quit Fired On strike OtherVoluntarily reduced hours Refused work
Who?
Who?
Type of Income
Type of Work
Amount Received
Income (Before Expenses) Expenses
$
$
$ $
$ $
per Wk 2Wks 2x/Mo Mo Yr
per Wk 2Wks 2x/Mo Mo Yr
Rental Income Foster care Adoption Subsidy Loans/Gifts Interest/Dividends Tribal Income/Benets Net Farming/Fishing
Veterans Benets/Military Allotments Refugee Resettlement Refugee Match Grant Short Term/Long Term Disability
Employment (Includes Temporary/Contract Jobs)
If yes, list below. No
Is anyone in your household employed?
Who? Employer Name Avg Hrs/Wk Wages/Tips (Before Tax)
$
$
per Hr Wk 2Wks 2x/Mo Mo Yr
per Hr Wk 2Wks 2x/Mo Mo Yr
Include anyone who worked in the last 30
days or expects to work next month.
How often
paid?
For Healthcare, only include taxable
income (unemployment, pensions,
social security, alimony, etc.).
Michigan Department of Health and Human Services
6
6
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Expenses
Dependent Care
Court Ordered
Student Loan Interest + Deductions
Medical
If yes, list below.
If yes, list below.
If yes, list below.
If yes, list below.
Childcare (day care, after school programs, etc.)
Child Support
Care for a child or family member with a disability
Alimony/Spousal Support Paid Out
No
No
No
No
Does anyone in your household pay for dependent care expenses?
Does anyone in your household pay for court ordered expenses?
Does anyone pay for student loan interest or other tax deductible expenses?
Does anyone in your household pay for medical expenses?
Who pays?
Who pays?
Who pays?
Who pays?
Who is it for?
Who is it for?
Type of Expense
Type of Expense
Amount
Amount
Amount
Amount
How Often Paid
How Often Paid
How Often Paid
How Often Paid
$
$
$
$
$
$
$
Health Insurance Prescriptions
Guardian/Conservator Expenses
In-Home Care
Co-Pays
Dental
Other
Transportation for Care
Hospital Bills
Not required for
Healthcare.
Including arrearages.
Not required
for Healthcare.
For Healthcare only.
This page is not required for
CDC.
For all expenses, only
include the amount you
are responsible to pay.
Name(s)
Full Name
@
Michigan Department of Health and Human Services
7
7
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Final Details
Fact Check
Has anyone ever been disqualied from public assistance
due to welfare fraud or an intentional program violation in
any state, including Michigan?
Has anyone ever been convicted for receiving cash or food
assistance from two or more states for the same period?
If yes, who?
If yes, who?
If yes, who?
No
No
No
Authorized Representative
If yes, list below. No
Do you want someone else to act for or represent you in this case?
If applying for food assistance, do you want
someone else to have a Bridge card and access
your benets to shop for you?
Name of your Authorized Representative (First, Middle, Last)
Phone # of Representative Email of Representative
Address of Representative (Street, City, State, ZIP Code)
( ) -
If you do not check any box you will be considered to have decided to not register to vote at this time, but a paper voter registration
application form will be mailed to you should you decide to register or update your registration.
Applying to register or declining to register to vote will not aect the amount of assistance that you will be provided, or your eligibility. Your decision
to register to vote or not will be kept condential. If you would like help lling out the voter registration application, we will help you or you can call the
Secretary of State toll-free at 888-SOS-MICH; 888-767-6424 for assistance. The decision to seek or accept help is yours. You may also ll out the
application in private.
If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to privacy in deciding whether to
register; you may le a complaint with the:
Michigan Department of State: Richard H. Austin Building
430 W. Allegan, Lansing, MI 48918
toll-free at 888-SOS-MICH; 888-767-6424
Not required for Healthcare.
If you name
an Authorized
Representative, you will
give permission for a
trusted person to sign
your application and get
information from MDHHS.
For Healthcare only, I
authorize my Authorized
Representative to act for
me on all future matters.
This information can also
be collected later in the
process.
(This should be someone you trust)
Yes No
Voter Registration
If you are not registered to vote where you live now, would you like to apply
to register to vote here today?
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
Signature of Applicant
Signature of Applicant
Signature of Department Witness
Signature of Representative
Date
Date
Under penalties of perjury, I state that I have reviewed this application, and to the best of my knowledge and belief, the answers I give within this
application are true, including household, citizenship and non-citizenship information, and I have listed all amounts and sources of income and property
I receive/own. If I am declaring an Authorized Representative, by signing below, I allow this person to sign my application and get ocial information
about this application. For Healthcare only, I authorize my Authorized Representative to act for me on all future matters. If I am signing as an Authorized
Representative for Healthcare, I attest to my agreement to meet condentiality and act in the best interest of the beneciary.
Sign Here
Anything Else?
Your Responsibilities
The Department’s Responsibilities
Is there anything else you’d like for us to know about your situation?
When in-person interview completed:
I have told the truth; I understand that I can be held criminally responsible for lying on this application.
I will have to provide papers that show that what I’ve told the department is true.
I will have to repay any benets I should not have received, even if it is the department’s error.
I will have to tell the department about any changes to the information I provided on my application.
I agree to cooperate with state or federal reviewers for an audit.
I agree to release my information for program needs.
I will use my benets legally and will not sell, trade, or give away my benets online or in person.
I understand that upon my death MDHHS has the legal right to seek recovery from some or all of my estate for
services paid by Medicaid. All services paid by Medicaid are subject to estate recovery.
I have received, reviewed, and agree to the information provided in the Information Booklet.
If you think we, the department, made a mistake, you can ask for a hearing.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or
group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan
considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based
on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.
If yes, write below. No
Your Signature
By signing this application
you are agreeing to these
responsibilities.
Refer to your Information Booklet
for a complete description of your
rights and responsibilities.
Sign the bottom of this page
to complete your application.
Michigan Department of Health and Human Services
MDHHS-1171 (Rev. 10-23) Previous edition obsolete.
+
+
Notes
Use this page to add any
additional information/notes.
Caretaker
Child
Tribe
MO/YR - MO/YR
State
Healthcare Coverage
MDHHS-1171-HC (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Additional Group Details
Flint Water System
American Indian or Alaska Native
Did anyone in your home consume water from the Flint Water System and
live, work, or receive childcare or education at an address that was served
by the Flint Water System from April 2014 through present day?
Are you or is anyone in your family American
Indian or Alaska Native?
Has anyone ever received a service or referral from
the Indian Health Service, a tribal health program,
or urban Indian health program?
If yes, are they a member of a federally
recognized tribe?
If no, is anyone eligible to get these services?
Do you have a physical, mental, or emotional
health condition that causes limitations in activities
(like bathing, dressing, daily chores, etc), live in
a medical facility or nursing home, or are you
medically frail?
Was anyone in foster care in Michigan when they
turned 18?
Is anyone applying for health insurance currently
incarcerated (detained or jailed)?
If yes, who?
If yes
If yes, who?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
No
No
No
No
No
No
No
No
Home
Home
Work
Work
School
School
Childcare Facility
Childcare Facility
Names DatesAddress Served by Flint Water (Street, City, Zip code)
Healthcare Coverage
Is anyone the primary caretaker for a child
(under age of 19) in the home?
Fill out the following details along
with the Assistance Application if
seeking Healthcare Assistance.
Only
required for
applicants.
For individuals
under age 21 or
pregnant women.
By checking “yes”
you are requesting
Healthcare.
AI/AN family members may not have
to pay cost sharing and may get special
monthly enrollment periods.
If yes, list below. No
Was anyone in foster care in another state when
they turned 18 on or after January 1, 2023?
If yes, who?
No
Name of Primary Tax Filer
Name
Name
Name
Name of Spouse
Name of Dependent(s)
Healthcare Coverage
MDHHS-1171-HC (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Tax Filers
Dependents
Yearly Income
Does anyone applying plan to le a federal tax return next year?
Are they ling jointly with a spouse?
Are they ling jointly with a spouse?
Are they claiming dependents?
Are they claiming dependents?
Will anyone applying be claimed as a dependent on someone else’s tax return?
Does anyone’s income change from month to month?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
No
No
No
No
No
Dependent
Who?
Tax Filer
Total Estimated Income This Year
Relationship to Tax Filer
Total Estimated Income Next Year
Fill out the following details along
with the Assistance Application if
seeking Healthcare Assistance.
You do not need to le
a tax return to receive
Healthcare.
If you think
it will be
dierent.
If yes, list below.
If yes, list below.
No
No
Name(s)
Name
Name
MM/YYYY
Healthcare Coverage
MDHHS-1171-HC (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Health Coverage Info
Does anyone need help paying for medical bills
from the past 3 months?
To make it easier to determine your Healthcare
eligibility in future years, do you agree to the use
of IRS data for automatic renewals?
If yes, who?
Which months?
No
Did anyone have insurance through a job and lose it in the last 3 months?
Is anyone currently enrolled in health coverage
(even if not applying)?
If yes, list below.
If yes, list below.
No
No
Yes
If yes, for how many years?
No
Who lost coverage?
Type + Name of Coverage Person Covered Policy #
Reason Insurance EndedEnd Date
If Medicare, do you want help paying Medicare premiums?
If employer insurance: Is this COBRA coverage?
Is this a retiree health plan?
If other, is this a limited benet plan (such as a school accident policy)?
Fill out the following details along
with the Assistance Application if
seeking Healthcare Assistance.
This allows the Marketplace and the
State of Michigan to use income data
(including information from tax returns). See
Info Booklet (Pg 7) for more details.
Including Medicaid, CHIP/MIChild,
Medicare, VA Healthcare Programs,
Peace Corps, Employer Insurance,
TRICARE (unless you have direct care
or Line of Duty), and Other.
Healthcare Coverage
Y N
Y N
Y N
Y N
5 4 3 2 1
JAN FEB MAR APR MAY JUN
JUL AUG SEP OCT NOV DEC
Name(s)
Name
Name
Name
Healthcare CoverageHealthcare Coverage
MDHHS-1171-HC (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Complete this page if someone in the household is eligible for health coverage
from a job. Attach a copy of this page for each job that oers coverage.
Health Coverage From Jobs
Is anyone in the household oered health insurance from a job?
(This includes coverage from someone else’s’ job, such as a parent of a spouse)
(This should be the person or department who manages employee benets)
If yes, list below.
If yes, list below.
If yes, when?
Employer won’t oer health coverage
The premium amount will change for the lowest cost plan that meets the minimum value standard
If no, skip this page.
No
No
Can the employee get coverage now or sometime in the next 3 months?
Will the employer make any changes for the new plan year (if you know)?
Date of change
Date of change Employee would pay this premium
List everyone who is eligible for coverage from this job
If yes, how much would the employee have to pay for the lowest cost plan that meets the minimum value standard?
Does the employer oer a health plan that pays at least 60% of the total costs of
benets (the minimum value standard for health plans)?
Phone # of Employer ContactEmployer Contact
Employer Address of Employer
Employee Employee Social Security #
Employer Identication # (EIN)
Email of Employer Contact
If you need assistance, take a
copy of this page to your employer
and have them help you ll it out.
Information on this page won’t impact
your application. It will be passed on to
the federal government to determine
your eligibility for APTC (Advanced
Premium Tax Credits).
Don’t include family plans. If the employer oers wellness programs,
enter
the premium that the employee would pay if they got the maximum
discount for a tobacco cessation program.
@
( ) -
Yes No
/ /
/ /
/ /
$
per Wk 2Wks 2x/Mo Mo Qr Yr
$
per Wk 2Wks 2x/Mo Mo Qr Yr
- -
Food Assistance Program (FAP)
MDHHS-1171-FAP (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Household Details
Housing Expenses
Utilities
If yes, who?
If yes, who?
If yes, who?
If yes, who?
If yes, who?
State
No
No
No
No
No
Does anyone buy and make food separately from
the rest of the household?
Does anyone in your household pay for housing expenses?
Does anyone in your household pay for utilities (not included in rent)?
Is anyone living in a facility or special living
arrangement (now or within the past 3 months)?
Is anyone in your household going to an alcohol
or drug treatment program?
Does anyone who you do not share food with pay any portion of housing expenses or utilities?
Does anyone in your household receive tribal
food distribution benets?
If utilities are included in your rent, does anyone in your household pay an extra fee for air conditioning?
Has anyone received Food Assistance from
another state in the last 30 days?
Has anyone applying for FAP received more than $20 in the Home Heating Credit (HHC) in the last
12 months?
Only list the amount you pay,
not Housing Choice Voucher
(Section 8), HUD, MSHDA, etc.
Only list Insurance/Property Tax
if not included in mortgage.
Heat types include gas, electric
heating, propane, wood, etc.
Electricity does not include
heat or air conditioning.
Rent
Heat
Homeowner’s Insurance
Electricity
Land Contract
Trash Pickup
Other
Cooking Fuel
Mortgage
Air Conditioning
Mobile Home Lot Rent
Water/Sewer
Property Tax
Phone
If yes, list below.
If yes, check below.
No
No
Who pays? Type of Expense Amount How Often Paid
$
$
Y N
Y N
Y N
Food Assistance Program (FAP)
Rent with meals (room/board) Meals only (board)
Has anyone applying for FAP received more than $20 in State Emergency Relief (SER) energy payments
or Michigan Energy Assistance Program (MEAP) payments in the last 12 months?
Y N
Fill out the following details
along with the Assistance
Application if seeking Food
Assistance.
If yes, who? No
Is anyone in your household a boarder?
If yes, who? No
Was anyone in foster care in Michigan when
they turned 18?
Name(s)
Name(s)
Cash Assistance
MDHHS-1171-CASH (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name
Individual ID #:
Is anyone in the household...
For children in the household
Received Cash Assistance from another state since
August 1996?
Are there children under 6 years of age who are not
up to date on their immunizations (shots)?
Are any children (ages 6–18) in school now?
If yes, who? No
If yes, who? No
If yes, who? No
If yes, who? No
If yes, who? No
If yes, who? No
If yes, who? No
If yes, who? No
If yes, who? No
If yes, who? No
Living in a facility or special living arrangement now
or within the past 3 months?
Going to an alcohol or drug treatment program?
Attending special education classes?
Receiving Michigan Rehabilitation Services?
Receiving medical assistance based on disability
or blindness?
Currently applying (or planning to apply) for
disability benets with the Social Security
Administration (SSA)?
Have or expect to have medical coverage (including
accident insurance, worker’s compensation, health
savings, health/hospital insurance or other)?
In violation of probation or parole?
State
If yes, list below. No
Fill out the following details along
with the Assistance Application if
seeking Cash Assistance.
#
Parent 2
Parent 1
Child Development + Care (CDC)
MDHHS-1171-CDC (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Do you currently live in temporary or emergency housing?
You need child care so that you can participate in (check all that apply):
If you are in school, do you need study time?
How many hours of child care do you need every two weeks?
Is either parent serving active duty in the
US Military?
Is either parent a member of the National
Guard or Military Reserve Unit?
Does the household have total assets that exceed one million dollars?
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Work
High School or GED Completion/College
Activity required by MDHHS Child Protective Services
Treatment for Health or Social Condition (explain):
Training/Employment Preparation
PATH program or other approved activity
Child Legal Name (First, Middle, Last)
Parent Legal Names (First, Middle, Last)
Living at
Home with
the Child?
Child up to date
on Immunizations
(Shots)?
If yes, who?
If yes,
who?
No
No
Children (Age 18 and Under) in Household
Need more room to write? Go to notes on last page. Yes, I’ve added more notes.
Child Development + Care (CDC)
Fill out the following details
along with the Assistance
Application if seeking CDC
Assistance.
This is an actual question;
it is required on a federal level.
If in a two-parent household, do the parents’ schedules overlap?
(For example, one parent works 9am – 5pm and the other works 2pm – 7pm)
Yes, list below. No
Parent Name
Days + Times (with AM/PM)
$$
$$
$
$$
$$
$ $
$
State Emergency Relief (SER)
MDHHS-1171-SER (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Emergency Need
Heat Request Details
Electricity Request Details
What services are you requesting? Check below and list the amount needed to resolve the emergency.
How do you heat your home?
Describe your current situation:
Describe your current situation:
Natural Gas Propane Wood Other:
Electricity
My heat has been turned o/I have run out of my household’s heating fuel source.
My electricity has been turned o
I have received a past due or shut o notice/I am at risk of running out of my household’s heating fuel source.
I have received a past due or shut o notice
Date of shut o
Date of shut o
Current balance
(If prepaid account)
Current balance
(If prepaid account)
% remaining in tank
Coal Fuel Oil
Heat (see details below) Property Taxes Burial/Cremation
Water/Sewer Mortgage Security Deposit
Electricity (see details below) Homeowner’s Insurance Migrant Hospitalization
Cooking Gas Home Repairs Moving Expenses
Eviction/Relocation Furnace Repair
State Emergency Relief (SER)
To qualify, tank
cannot be more than
25% full.
/ /
/ /
$
$
%
State Emergency Relief (SER)State Emergency Relief (SER)
MDHHS-1171-SER (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Current Housing Expenses
Household Information
Do you pay for any housing expenses?
Tell us about your expenses, income, and the people who have lived with you over the past 6 months.
If yes, list below. No
Heat
Month
# of People in Home
Rent/Mortgage
Electricity
Water/Sewer
Property Taxes
Cooking Fuel
Home Insurance
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Y N
Name of Service Provider
1 Month Ago 2 Months Ago 3 Months Ago 4 Months Ago 5 Months Ago 6 Months Ago
Name on Bill/Account Account #
Is This a
Shared
Meter?
Is There Theft
or Illegal Use?
Is anyone in the household in violation of
probation or parole?
If yes, who? No
Is anyone in the household eeing from
felony prosecution, an outstanding felony
warrant or jail?
If yes, who? No
Total Monthly Income
(Before Tax)
$ $$ $$ $
Rent/Mortgage $ $$ $$ $
Heat $ $$ $$ $
Electricity
$ $$ $$ $
Water/Sewer
/Cooking Gas
$ $$ $$ $
State Emergency Relief (SER)State Emergency Relief (SER)
MDHHS-1171-SER (Rev. 10-23) Previous edition obsolete.
Michigan Department of Health and Human Services
Your Name:
Individual ID #:
Burial Service Request
If you are applying for burial services, please complete this page. Be sure to
answer questions on the Assistance Application for the deceased, their spouse,
and their parents (if deceased is a minor child).
Name of Deceased (First, Middle, Last)
Is this a cremation?
Is there a memorial service?
Is the deceased a veteran?
Cost of burial/cremation
Is payment to the cemetery/crematory separate from the payment to the funeral home?
Did you sign a statement of goods and services with the funeral home?
Did the deceased own his or her home?
Is there a co-owner for this home?
Is there a contribution from family/friends?
Are there any death benets that you have applied for or expect to receive?
Name of Funeral Home Address of Funeral Home
Place of Burial/Crematory
Your Legal Relationship with the DeceasedDate of Death
Date of Burial/Cremation
Phone of Funeral Home
Y N
Y N
Y N
Y N
Y N
If yes, address? No
If yes, who?
If yes, how much?
If yes, list below.
No
No
No
Accident/Automobile Insurance Pre-paid Funeral Agreement Social Security Death Benets
Veteran’s Death Benets Labor Union Benets
A Community Assistance Fund/
Fraternal Organizations
Life Insurance Other (list below)
Type of Death Benets
Amount
If this application is for burial
services, it must be received by
MDHHS no later than 10 business
days after the burial, cremation,
or donation takes place.
/ /
/ /
( ) -
$
$
$
