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Financial Workers' Guide to the Combined Application and Worker by cut16095

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									         A
 Financial Workers’
    Guide to the
Combined Application
and Worker Interview
      Forms
                                         Guide Overview

The purpose of this guide is to familiarize you with the Combined Application and Worker
Interview Forms. The Combined Application Form (CAF) (DHS-5223) is the form on which
people apply for multiple assistance programs including: cash, Food Support, Emergency
Programs, and Health Care. Applicants who want to apply for medical assistance only,
should complete the Minnesota Health Care Programs Application (DHS-3417) Form.

This guide reviews all of the questions and indicates which questions are program specific.
The Worker Interview Form (DHS-5223A) is designed for you to record information
gathered in the application interview. This guide refers to the Combined Application Form
Important Information (DHS-5223B) and other forms that you must give to applicants. In
addition, the guide introduces several addendum forms that are used when adding a
person(s) to an existing case or adding a child care program. The guide:

        • Defines and describes each question on the CAF
        • Informs you how the Worker Interview Form is used hand in hand with the CAF
        • Identifies acronyms commonly used for assistance programs such as DWP,
            MFIP, Food Support, MFAP, GA, MA, GAMC and MSA in glossary
        • Discuses forms, sources of verification and documentation
        • Identifies MAXIS panels pertaining to the questions on the CAF
        • Provides references to the Combined Manual and the Health Care Programs
            Manual

You may need to stop and review specific questions of the CAF and specific types of
documents or forms at certain points throughout this guide. This is designed to help you
better understand the information being discussed.

Throughout this guide you will find checkpoints. Take a moment to answer the checkpoint
questions. These questions provide good sources of review and can be used as a tool to
help you measure your comprehension level.




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Combined Application Form (CAF) Overview

The CAF is 12 pages long. Essential questions regarding emergency information,
authorized representatives, and household composition information are on the first three
pages of the CAF. All remaining pages include required information, warnings and
signature blocks.

The CAF questions are clustered to aid you in determining and recognizing eligibility
factors. For example, questions which are used to determine household composition are
clustered together and questions used to determine income eligibility are clustered
together. The panels listed in MAXIS on STAT/SPAN generally follow this order. Specific
MAXIS panels are listed on each section throughout the Worker Interview Form (see next
page) to help you determine where to enter information from the Worker Interview Form
into MAXIS.

The applicant fills out the information on the CAF and is then interviewed for cash and food
programs. Health Care programs do not require in-person interviews. Information from the
interview must be recorded on the Worker Interview Form in sufficient detail for other
workers and supervisors to follow the application process and the accuracy of your
decisions.

You must review each question on the CAF, even if the applicant has answered no to the
question. This includes asking if everyone living with them is listed on Page 3. Additions or
changes on the CAF must be initialed and dated by the applicant.




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Worker Interview Form (WIF) Overview
The WIF (DHS-5223A) is designed for you to record information given in the application
interview. Information from the interview must be recorded on the WIF in sufficient detail for
other workers and supervisors to follow the adequacy of the certification process and the
accuracy of your decisions. The WIF is a fillable, on-line form that you can save to your
computer/county network. You can maintain the completed WIF electronically and/or as a
printed form in the applicants file as long as the form is available to anyone who needs
access to review the case.

Each numbered question on the CAF has a corresponding question on the WIF with
structured spaces and open writing space to record information. The WIF is not a form for
you to fill out in detail, question by question. The “Y/N” question format on the CAF allows
you to have a conversation with the applicant giving you the opportunity to ask as well as
give any clarifying information. This is your opportunity to use good interviewing skills. If
you need to enhance your interviewing skills, contact your training coordinator for
information on how to request Tim Gard’s video “Interviewing with Style” from DHS.

For questions where the applicant has entered “No” on the CAF and you are satisfied with
that answer, best practices suggest that you put an “N/A” or non-applicable response in the
corresponding section on the interview form. This way other workers, supervisors and
Quality Control will know that this question was covered. The amount of information that is
entered on the WIF should be dictated by the amount of information needed so your
supervisor or co-worker would be able to look at the case and understand the case
situation. Ask your supervisor about specific instructions for your agency.

For all of the questions on the CAF in which an applicant has provided a document(s) such
as a birth certificate, divorce decree, bank statement, car title, etc., and it clearly verifies the
necessary information, you may simply check the verification attached box on the WIF. It is
not necessary to rewrite this information. The documentation guidelines that are noted
under each question, gives an overview of the level of detail needed. If the applicant does
not provide documentation, request the information listed under the questions on the
interview form and record any pertinent information in the “Comments/verification” section.

On the last page of the WIF is the Program eligibility summary box. This summary box can
be used in a variety of ways. For example you can indicate the program(s) that each
applicant is potentially eligible for or you could indicate who has received an EBT card. This
summary box is an optional tool for you and does not have to be completed.

Specific MAXIS panels are listed on each section throughout the WIF to help you determine
where to enter information from the CAF into MAXIS.

More specific information on the corresponding WIF to CAF questions will be interspersed
throughout this guide.

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Documentation Overview

Documentation is a written statement or record that substantiates or validates an assertion
made by a person or an action taken by a person, agency, or entity.

Documentation is done to:
     • Support eligibility determinations
        • Clarify case facts
        • Record possible changes
        • Provide evidence to use in appeals

The WIF is the document for you to record information pertinent to the case or actions
taken by the county agency. You will document or note on the WIF the type of
verification(s) used to verify the information reported on a specific question. On MAXIS
indicate the type of verification used by selecting the code on the panel that corresponds to
the specific WIF question. You will also record case notes in MAXIS.

As you go through this guide, types of verifications the applicant can provide are noted.

What should be done with the verifications documented on the WIF and in MAXIS?
Photocopy the verifications the applicant has provided and place these copies in the case
file. Return the original verifications to the applicant.




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Verification Overview (CM 0010)
Verification is the process and evidence used to establish accuracy or completeness of
information from an applicant, participant, third party, etc.

Any form of verification is acceptable if it confirms the applicant’s statement. Do not
demand a specific document or form of verification if another is more readily available.

Sources of acceptable verification include:
      • Written records or documents (CM 0010.06) - These include documents from
         public agencies, documents the applicant has, or any written confirmation of an
         applicant's statement(s) from a source outside the unit. If you need a specific
         document and the applicant does not have money to get it, your agency must
         pay for the cost.
      • Written or oral statements from a person outside the assistance unit (CM
         0010.09) - A person outside the assistance unit may provide written or oral proof
         of an applicant's statement(s). You may confirm the information with the
         collateral contact. Get written permission from the applicant before contacting
         the collateral source. CAUTION: Keep Data Privacy laws in mind and do not
         use a collateral contact without the written permission of the applicant. When
         collateral contacts are used, be sure to document the contact carefully in case
         notes.
      • Direct observation from home visits (CM 0010.12) – You can verify some
         information, such as residence, by direct observation in an applicant's home.
         Use home visits to verify statements only if documents and collateral contacts
         are not available or are inadequate.

As a last resort when no other form of verification is available, an applicant’s signed
statement/affidavit is acceptable (CM 0010.03).

Whenever you request verifications, give the Verification Request Form (DHS-2919A&B) to
the applicant. When completing the Verification Request Form, do not require one specific
type of document when others are available. The types of verifications listed on the form
are meant to give examples of the different kinds of acceptable verification.


CAUTION: Do not request negative verification from an applicant. For example, do not
request your applicant to provide verification from the Social Security Administration
verifying that they do not receive Social Security benefits if there is no indication that the
applicant is a recipient. Do not request verification if it is not required for program eligibility.




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Mandatory Verifications (CM 0010.18)

There are some verification’s that are mandatory and must be verified at initial application,
recertification, monthly, or when a change occurs. Combined Manual sections (CM
0010.18.01 Cash), (CM 0010.18.02 Food Support), and the Health Care Programs Manual
(HCPM 09.05 Mandatory Verifications) contain mandatory verification provisions by
program. Please refer to these sections of the manual for additional information.

The verifications required for all programs are:
      • Income
        • Self-employment expenses used as a deduction
        • Inconsistent information
        • Immigration status, ONLY if the applicant reports non-citizen status

Applicant responsibility: It is the responsibility of the applicant to provide the verifications
that are being requested, and to cooperate in obtaining these verifications. If the applicant
is unable to provide the verification, the applicant must give your agency written consent to
obtain the necessary information. You may use Consent for Release of Information About
Assets (DHS-2243), or the General Consent for Release of Information (DHS-2243A) for
this purpose.

Agency responsibility: It is the responsibility of the agency to assist an applicant who is
having difficulty obtaining verifications when written authorization has been given to the
agency.




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Combined Application Form
Important Information
Give the applicant the Combined Application Form Important Information sheet (DHS-
5223B) as part of the application process. This sheet provides the following information:

        •   Social Security numbers
        •   Family Cap information
        •   Important information for non-citizen applicants
        •   Immigration
        •   Proof of citizenship or national status
        •   Family/domestic violence
        •   Liens and estate claims
        •   Denial or changes
        •   Interim aid programs
        •   Food Support Nutrition Education Program
        •   Minnesota’s WorkForce centers
        •   Tax refund Information




Cover Page of CAF
This page is used to explain to the applicant how to fill out the CAF. Applicants who want to
apply for health care coverage only, should complete the Minnesota Health Care Programs
Application (DHS-3417) Form.

Review the instructions. We request that the applicant use black or dark blue ink when
completing the form. Other colors of ink do not copy and/or scan well if your agency uses
an electronic data management system. General information, instructions and questions
are in yellow.

On the bottom of the page, we instruct the applicant to ask for help, if needed, in filling out
the form.

On the back side of the cover page, we have a statement in 10 languages about interpreter
services.



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CAF Page 1 (Tear off page)
The applicant must complete page 1 giving their name, address and signature to the county
office as the first step in applying for assistance. This sets the date of application for the
cash and Food Support programs. Some health care programs can provide coverage for up
to 3 months prior to the date of application.

Inform the applicant of the necessity of submitting a completed page 1 as soon as possible
since many benefits are prorated from the date of application. Page 1 is a tear-off page in
case the applicant does not have time to fill out the entire application. However, this
application is considerably shorter and easier to fill out, so most applicants can complete it
in a relatively short period of time. You must inform the applicant that they will need to
complete the entire application and have an interview, before we can determine any
eligibility for assistance.

There is a blue box in the top right corner of this page where you can indicate the
applicant’s case number, if known.

The CAF page 1 asks for the following information:

HOW MANY PEOPLE LIVE IN YOUR HOUSEHOLD?
Applicant lists all members of their household. Household is defined as people who live
together.

APPLICANT’S LEGAL NAME (last/first/middle) and
OTHER NAMES YOU USE (maiden name, nickname, etc.)

We ask for the legal name as well as any other names they use or are known by. We
request this information to prevent duplicate assistance by using the Person Search
function in MAXIS.

This allows you to enter any other names the person uses onto the system, such as,
maiden names, nicknames, or aliases. All names entered into MAXIS are compared to
persons already known to the system. This helps to prevent the duplication of benefit
issuance and PMI (Person Master Index) numbers if the person is already known to the
system under another name.

When giving an application to a 2-parent household, explain to the applicant that they are
the person who is responsible for the case, receives all mailings, and the EBT card.

Verification Required: DWP and MFIP requires verifying the identity of all adults. GA
requires verifying the identity of each person requesting assistance. Food Support requires
verifying the identity of the applicant and the authorized representative. Most Health Care
programs require identity verification.
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Common Forms of Verification:           Birth certificate, Religious Record, Driver's
License/State ID, Divorce Decree, or Permanent Resident card.

Documentation on the WIF: Note any verification provided for legal and other names.

MAXIS Panels:            STAT/MEMB, STAT/ALIA

References:              CM 0010.18                Mandatory Verifications
                         CM 0010.18.01             Mandatory Verifications - Cash Assistance
                         CM 0010.18.02             Mandatory Verifications - FS
                         HCPM 09.05                Mandatory Verifications


BIRTH DATE
Applicant indicates their date of birth.

ADDRESS WHERE YOU LIVE
The CAF requires the applicant to list their current address. If the applicant is “homeless,”
they are instructed to write “homeless” in this area.

SOCIAL SECURITY NUMBER
The CAF requires Social Security numbers for all household members applying. In this
area, the applicant must list their social security number.

CITY
The applicant indicates what city they live in.

COUNTY
The applicant indicates what county they live in.

STATE
The applicant indicates what state they live in.

ZIP CODE
The applicant indicates what their zip code is.

DO YOU LIVE ON A RESERVATION?
Applicant needs to answer “yes” or “no” to this question. If the applicant answers “yes,” they
will then need to list which reservation they live on. Reservation is defined as the
geographical area recognized by the federal or a state government as being set aside for
the use of Indians and governed by Indians.

PHONE NUMBER WHERE YOU CAN BE REACHED
Applicant lists phone number(s) of where they can be reached, including the area codes.
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DO YOU NEED AN INTREPRETER?
If the applicant expresses a need for an interpreter, follow your agencies procedures so
this service can be provided. DHS strongly recommends using a professional interpreter
with no personal connection to the participant when they complete the CAF and for the
interview. However, DHS understands that participants have a choice in the matter.
When considering whether to use a family member or friend as an interpreter, it is
important to document that:
           1) An offer of a non-family interpreter has been made;
           2) The participant insists on using a friend or family member as an
               interpreter;
           3) Data privacy and confidentiality will not be violated;
           4) The friend or family member is proficient in both languages;
           5) The friend or family member is familiar with the terms used in the CAF
           6) The friend or family member understands his/her role as an interpreter;
               and
           7) The agency has never initiated, suggested, required, or encouraged that a
               friend or family member serve as interpreter.

In order to improve accuracy in identifying and accommodating LEP applicants, the
“Language” field on STAT/MEMB is divided into two fields to distinguish between the
applicant’s primary spoken language and the applicant’s language preference for written
materials.

WHAT IS YOUR PREFERRED SPOKEN LANGUAGE?
This question provides the preferred spoken language of the applicant. The answer is to be
entered on STAT/MEMB for each household member. Therefore, during the interview you
will need to ask this question about all household members’ preferred spoken language and
enter the information accordingly in MAXIS

The Preferred Spoken Language field is a mandatory worker entry. The primary languages
and their MAXIS language codes are:.

        09 Amharic                                 17 Mandarin
        10 Arabic                                  12 Oromo
        08 ASL                                     06 Russian
        14 Burmese                                 11 Serbo-Croatian
        15 Cantonese                               07 Somalian
        99 English                                 01 Spanish
        16 French                                  18 Swahili
        02 Hmong                                   13 Tigrinya
        04 Khmer                                   03 Vietnamese
        20 Korean                                  19 Yoruba
        21 Karen                                   97 Unknown
        05 Laotian                                 98 Other

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WHAT IS YOUR PREFERRED WRITTEN LANGUAGE?

The Written Language field is used to determine which language version the Household
Report Form (HRF) is mailed out. Also, knowing the preferred written language provides
the information necessary for you to send the appropriate language version of the CAF and
other documents or forms that the Department and agencies support in different languages.

Currently, the HRF is the only document sent out in multiple languages automatically by
MAXIS. It is your responsibility to send out other pertinent translated documents that are
available through e-Docs or your local agency.

You will need to update the information in the "Written Language" field as you become
aware of the applicant's preference or change. You will need to ask the applicant what the
preferred written language is for each household member and record it on the WIF to
accordingly enter the information for each household member on STAT/MEMB.

If no code is entered in the Written Language Field, it will default to the language code
entered in the Spoken Language field. When the applicant prefers written materials in
another language other than the “Preferred Spoken Language,” you must enter that
language in the Written Language field. When the Written Language field is left blank the
following warning message will alert you: "WARNING: WRITTEN LANGUAGE IS MISSING
– WILL DEFAULT TO SPOKEN LANGUAGE".

Since the Department produces reports to Federal Agencies on Title VI and other Civil
Rights items, it is of utmost importance that you ask the applicant about the language
preferences for other household members and record this data on STAT/MEMB for each
member. The Department also uses this information to better understand the language
needs of our diverse population and to plan accordingly for technical assistance.

If an applicant does not specify his or her primary written and spoken language, and you
are unable to determine the applicant’s preferred language, select “Unknown.”


Do you need help right away?

The following nine questions will help you determine if the applicant is eligible for expedited
Food Support and emergency services. Determine an applicant’s need for emergency aid
and expedited Food Support services during the applicant’s initial contact with the county
agency. If an applicant’s need for emergency and expedited services arises after the initial
contact, begin using the emergency processing deadlines from the date of discovery.


Verification requirements in emergency situations may differ from those for normal
application situations. Expedited Food Support makes benefits quickly available to units

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unable to meet their food needs. Expedited services are special procedures and priority
processing of applications to make benefits available to applicants with immediate need.

It is important that all applicants complete these questions and you review them
immediately upon receipt to determine if the applicant is eligible. Offer an interview to all
units who appear eligible for expedited Food Support on the same day they file the
application. If they decline the same day interview, CASE/NOTE their decision and
schedule an interview for the next business day.

There is no limit to the number of times a unit can receive expedited Food Support service.


Questions 1 - 4 are related specifically to expedited food support benefits. If any of the
following criteria are met, offer a same day interview:
       • Less than $150 gross monthly income and $100 or less in liquid assets
       • Combined gross monthly income and liquid assets are less than shelter
           expenses
       • Destitute migrant or seasonal farm workers with $100 or less in liquid assets

Question 1                        How much income (cash or checks) did or will your
                                  household get this month?

If applicant is currently receiving income, they need to list how much here.


Question 2                        How much does your household (including children)
                                  have in cash, checking or savings?

The applicant needs to add up the household’s total amount of liquid assets and enter
the amount here. Liquid assets are defined as: cash or property (such as stocks or
bonds) easily converted to cash. We would also consider the amount of money from
child support payments in a Stored Value Card as liquid assets.


Question 3                        How much does your household pay for:
                                  Rent/mortgage?
                                  Utilities?

The applicant needs to provide their actual, monthly rent or mortgage payment information
and their actual, monthly utility expenses. This information is used to determine if their
shelter expenses are greater than their liquid assets.
Question 4                 Is anyone in your household a migrant or seasonal
                           farm worker?
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The applicant needs to indicate whether or not any one in the household is a migrant or
seasonal farm worker. If the applicant or anyone in the household is a migrant farm
worker, they travel away from home on a regular basis, usually with a group of other
laborers, to seek employment in an agriculturally related activity.

A seasonal farm worker is a person employed in seasonal agricultural work that is not
required to be absent overnight from the permanent residence when:
       • Employed on a farm or ranch performing field work related to planting and
          harvesting; or
       • Employed in a canning or processing plant while being transported to or from the
          place of employment through a day-haul operation. A seasonal farm worker is
          not a migrant worker.


Question 5                        Did anyone in your household quit a job in the last 60
                                  days?

If applicant answers “yes,” they will need to list the employer(s) name and dates of
employment.


Question 6                        Does your family expect a change in income?

If applicant answers “yes,” they will need to provide a date of when they expect their
income will change.


Question 7                        Has anyone in the household ever received cash
                                  assistance, medical assistance, commodities or food
                                  support benefits before?

A unit may receive expedited Food Support service in Minnesota even if they received
Food Support in another state during the month of application. For units who have received
Food Support in another state during the month the application is completed, treat the next
month as the month of application and use that month as the basis for determining
expedited eligibility (including postponed verification requirements). Members of an MFIP
assistance unit residing in a battered women’s shelter may receive Food Support or the
food portion twice in a month if the unit that initially received the Food Support or food
portion included the alleged abuser.

On Indian reservations where both food portion and the Food Distribution Program
(formerly called commodities distribution) are available, units must choose which program
to participate in. Units certified to get commodities on the 1st day of a month may not get

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Food Support in that month. The 1st month they are eligible is the month after the month of
termination from the Food Distribution Program.

If the applicant answers “yes,” they must indicate when, where and what type of public
assistance was received.


Question 8                        Is anyone in your household pregnant?

If answered yes, ask if they are applying for health care coverage. Health care must be
processed within 15 days for pregnant applicants, and an interview is not required. If the
pregnant person requests an interview, it must be given within 5 days and eligibility must be
determined within 10 days of the interview, to meet the 15 day processing requirement.


Question 9                        Do you need help now because of a medical or other
                                  emergency?

If an applicant answers “yes” to either of these questions, further assessment must be done
to evaluate the emergency need for EMSA or EGA. Agencies may have their own
emergency programs so be sure to follow the procedures that are applicable to your
agency.




Signature block:
Before the applicant signs the first page, they are instructed to read their responsibilities
and rights on the back page of the application. They also attest to making true statements
on the application. The agency also signs the first page and dates it (can be agency date
stamped).




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CAF Page 2
Page 2 is used to designate an authorized representative, a legal guardian and a Principle
Wage Earner (PWE). It also is used to determine what other kinds of help an applicant may
need and to refer applicants to county and local community resources.

The top box is where the applicant can designate an Authorized Representative to either:
   • help applicants complete forms or apply on their behalf
   • get notices and complete forms on their behalf
   • get and use the applicant’s Food Support benefits on their behalf




Designating an Authorized Representative

There are two ways to designate an authorized representative. One is by completing the
authorized representative section on page 2 and signing the CAF on page 7. The second is
by providing a separate written and signed statement designating the scope of the
authorized representative's responsibilities. Case note the function(s) that the authorized
representative will serve.



Who can be an Authorized Representative

In general, a Diversionary Work Program (DWP), Minnesota Family Investment Program
(MFIP), General Assistance (GA), or Minnesota Supplemental Aid (MSA) authorized
representative is:
      • any person who has sufficient knowledge of the applicant’s circumstances to
          provide the necessary information, and
      • at least 18 years old, and
      • authorized, in writing, to act on the applicant's behalf.
The Food Support program does allow a minor to be an authorized representative if the
person is a household member. Food Support authorized representatives who are not
household members must be 18 years old or older. The Food Support authorized
representative may be a different person than the authorized representative for agency
contacts.

The county may appoint a person to act as the authorized representative for applicants who
have difficulties due to incapacity or incompetence. County agency employees who
determine eligibility for assistance cannot be authorized representatives.

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MAXIS Panel:             STAT/AREP

References:              CM 0005.06                Authorized Representatives
                         CM 0005.06.03             Who Can/Cannot Be Authorized
                                                   Representatives
                         CM 0005.06.06             Disqualifying Authorized Representatives


Legal Guardian

The next box is where an applicant can report if they have a legal guardian. “Legal
guardian” or “guardian” is a person appointed by a parent's will or by the court to have the
powers and responsibilities of a parent, except that the guardian is not legally obligated to
provide support for the ward out of the guardian's own funds. If the applicant has a legal
guardian, conservator or power of attorney, they will need to provide this information and
attach copies of legal documentation.


Principal Wage Earner (PWE)

You must determine the Principal Wage Earner (PWE) at application, recertification, and
when unit composition changes. If there is more than 1 adult, give the adults in the unit the
option to designate which adult is the PWE. For units with no children in the unit who do not
designate which adult is the PWE: the PWE is the unit member with the most earned
income in the 2 months before the date of application, voluntary quit, or work registration
non-compliance. For units that include an adult parent(s) with children in the home OR an
adult unit member(s) with parental control over children in the home who do not designate
which adult is the PWE, the county will designate the PWE.

If you cannot determine who to designate as the PWE based on available information
above, the primary contact person is the PWE.

MAXIS Panel:             STAT/WREG

References:              CM0028.03.06              Determining the Food Support PWE




Check if you need help with or information about the following areas.

This box allows the applicant to check the areas they need help or information. If the
applicant checks any of the boxes, you must make the appropriate referral(s) for the
services requested. This area is optional.

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              CHECKPOINT




1. On what form do you record information from the interview?




2. What do you do with the verifications that the applicant provides?




3. What form do you use to request verifications from the applicant?




4. Why are the CAF questions “clustered”?




5. Who can be the Principal Wage Earner (PWE)?




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CAF Page 3
List all people living in your home even if you are not applying for them and/or the
person is not asking for assistance. Program rules require some people to get benefits
together. You have to give a Social Security number only for people who are applying for
help. If anyone in the household uses another name (maiden name, nickname, etc.) list the
other name(s) in the “OTHER NAMES” boxes below.

List in this order: Yourself, your spouse, other adult(s), children, all other people, anyone
temporarily away from the home. If anyone is pregnant, list fetus as “unborn child” and the
due date. For more than four household members, go to page 8.

The applicant must list all persons living in the household, even if they are not applying for
assistance. If the applicant has not listed people who live in the household, either because
they are not related or are not requesting assistance, have the applicant add them to the
CAF during the interview. If there are more than five household members, the applicant will
need to go to page 8 to list additional household members.

Defining An Assistance Unit
The Combined Manual defines an assistance unit as a person or group of people who live
together; whose needs, assets, and income are considered together; and who receive a
single benefit from a cash assistance program or the Food Support program. Each of
these programs has its own rules to determine who is in a unit and who is excluded from a
unit.

The RACE and ETHNICITY questions are optional and used to assure that race, color
or national origin do not affect eligibility or the level of benefits issued.

Codes are provided for the applicant to use when completing the Martial Status and Race
fields. The codes are:

Marital Status: (choose one):
N = Never married       M = Married living with spouse      D = Divorced
S = Separated (married, living apart)    L = Legally separated       W = Widowed

Race: (choose all that apply)
N = American Indian/Alaska Native                 A = Asian             B = Black or African American
P = Pacific Islander/Native Hawaiian              W = White

Verification Required: DWP and MFIP require you to verify the identity of all adults. GA
requires you to verify the identity of each person requesting assistance. Food Support
requires you to verify the identity of the applicant and the authorized representative. Most
Health Care programs require identity verification.

A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10        19
Common Forms of Verification:           Birth certificate, Religious Record, Driver's
License/State ID, Divorce Decree, or Permanent Resident card.

Documentation on the WIF: Note any verification provided for other names. Ask for and
note any other Social Security numbers associated with the other names.

MAXIS Panels:            STAT/MEMB, STAT/ALIA

References:              CM 0010.18                Mandatory Verifications
                         CM 0010.18.01             Mandatory Verifications - Cash Assistance
                         CM 0010.18.02             Mandatory Verifications - FS
                         HCPM 09.05                Mandatory Verifications


PERSON 1 YOUR LEGAL NAME (last/first/middle)

The applicant needs to complete this section regarding themselves. Some of the requested
information is a repeat from question 1 on page 1, but there are other new questions that
the applicant must answer.

Remember: the CAF requires the applicant to list the legal name(s) of household
members, not nicknames. Enter legal names on MAXIS. All names entered into MAXIS are
compared to persons already known to the system. This helps to prevent the duplication of
benefit issuance and PMI (Person Master Index) numbers if the person is already known to
the system under another name.


OTHER NAMES
If the applicant is known by any other names, they are to list them here. Other names
include maiden names, nicknames, etc.


SEX
Applicant indicates what gender they are.


RELATIONSHIP TO YOU
Applicants will not be able to complete this section as it is already auto-filled.
When completing this field for additional household members, enter the relationship of
that person to the applicant such as spouse, child, friend, etc.

BIRTH DATE
Applicant indicates their date of birth.


A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   20
MARITAL STATUS
The Applicant needs to indicate their current marital status using the options provided
above in the yellow box. This question helps you and MAXIS determine who is included in
the assistance unit, and who will be financially responsible for the assistance unit members.
All programs consider spouses financially responsible for each other.

Depending on the program, the spouse of an applicant will either be included in the
assistance unit or have the spouse’s income deemed available to the assistance unit.
When an applicant is a resident of a state hospital, regional treatment center, skilled
nursing facility or negotiated rate facility, this question establishes whether there is a
financially responsible spouse whose income and resources must be considered in the
eligibility determination. A divorce could indicate the potential for spousal support, child
support, or medical coverage. A widow/er status could indicate the potential for survivor’s
benefits.

Verification Required: No verification is required

Documentation on the WIF: Include dates of marriage, separation or divorce, or
death.

MAXIS Panel:             STAT/MEMI

References:              CM 0014.03                Determining the Assistance Unit
                         CM 0016.06                Income from Ineligible Spouse of Unit Member
                         HCPM 17.05                Determining Household Size for MA/GAMC


SOCIAL SECURITY NUMBER

The CAF requires Social Security numbers for all household members applying. In this
area, the applicant must list their Social Security number. Social Security numbers are
requested only on Page 3. On page 1 of the WIF, you will document whether or not the
applicant provided or has applied for a Social Security number for each assistance unit
member. If an applicant refuses to provide or apply for a Social Security number for an
assistance unit member, refer to Combined Manual section 0012.03 (Providing/Applying
For An SSN) to determine who will be disqualified from receiving assistance.

Note: The applicant does not have to provide verification of Social Security numbers. The
Social Security Administration compares the names and Social Security numbers entered
on MAXIS to the SSA records and verifies the information electronically. MAXIS will
generate messages on DAIL/DAIL if there are any discrepancies. To clear up the
discrepancies, follow Combined Manual section 0010.18.03.


A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   21
DATE MOST RECENTLY MOVED TO MINNESOTA?

This information is necessary to establish if the applicant is a Minnesota resident. For some
programs, applicants have to have been living in Minnesota for at least 30 consecutive
days, intend to make Minnesota their home, not have a home in another state, and be
physically present to be considered residents of this state.

Verification Required: Verify only if questionable.

Common Forms of Verification: Landlord statement, mortgage papers, lease, contract
for deed, calling the previous state of residence

Documentation on the WIF: Note why you questioned the information and how you
verified the information. If a household member moved to Minnesota within the last 12
months, document the previous state of residence.

MAXIS Panels:            STAT/MEMI, STAT/ADDR, STAT/RESI

References:              CM 0011.06                State Residence
                         CM 0011.06.03             State Residence - Excluded Time
                         CM 0011.06.09             State Residence - 30-Day Requirement
                         HCPM 13                   State Residence
                         HCPM 13.10                State Residence – GAMC and GHO
                         HCPM 13.05                State Residence – for MA/MCRE Families



ETHNICITY (optional)
Hispanic?

This question is used for statistical purposes and it is important to try and obtain this
information though the applicant is not required to answer this question.

Verification Required: No verification is required

MAXIS Panel:             STAT/MEMB

Ethnicity and Race are two separate and distinct concepts. Ethnicity is defined as a
population of human beings whose members identify with each other, usually on the basis
of a presumed common genealogy or ancestry. Ethnic groups are also often united by
common cultural, behavioral, linguistic, ritualistic, or religious traits.




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   22
Race serves to distinguish between populations or groups of people based on different sets
of characteristics which are commonly determined through social conventions. The most
widely used human racial categories are based on visible traits (especially skin color, facial
features and hair texture), and self-identification.


RACE (optional)

This is used for statistical purposes only. Applicants are not required to answer this
question. If the applicant chooses not to answer, advise the applicant that you will
code this for them based on perception. Possible discussion points that you could use to
address this subject are:
       1. We would like you to tell us your race and ethnic background so that we can
           track service quality.
       2. Please describe your racial and ethnic background in your own words.
       3. Whatever information you provide will not affect your benefits or eligibility in any
           way.
       4. Please take a moment to think about your race and culture. Our County
           gathers this information so that we can track and be sure that everyone
           receives the highest quality of services available. We want to be sure that
           who an individual is doesn’t affect the quality of services they receive.

According to the U.S. Bureau of the Census, Race can be defined as:

                       People having origins in any of the original peoples of Europe,
           White       the Middle East or North Africa. For example, includes Irish,
                       Lebanese, Arab or Polish.
    Black or African   People having origins in any of the Black racial groups of Africa.
       American         For example, includes African American, Nigerian or Haitian.
                       People having origins in any of the original peoples of North
       American        and South America (including Central America), and who
 Indian/Alaskan Native maintain tribal affiliation or community attachment. For
                       example, includes Rosebud Sioux, Chippewa, or Navajo.
                       People who have origins in any of the original peoples of the
                       Far East, Southeast Asian or the Indian subcontinent. For
         Asian
                       example, includes Asian Indian, Chinese, Filipino, Korean,
                       Burmese, Hmong, Pakistani or Thai.
 Pacific Islander/Native People who have origins in any of the original peoples of
        Hawaiian         Hawaii, Guam, Samoa, or other Pacific Islands.




Verification Required: No verification is required
A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   23
Documentation on the WIF: Indicate applicant’s response for all in the household.

MAXIS Panel:             STAT/MEMB


U.S. CITIZEN OR U.S. NATIONAL?

This question helps you and MAXIS determine the assistance unit and the types of public
assistance programs an applicant is eligible for.

Citizens are eligible for all programs. For cash and Food Support, accept the applicant's
positive statement of citizenship unless there is inconsistent information. Color, race, or
language are not valid reasons to question a statement of citizenship.

If the applicant states they or someone else in the household is not a citizen, then
citizenship status must be verified. All programs except EMA are affected by non-citizen
status.

Verification of citizenship is mandatory for all applicants and enrollees for the following
Health Care programs:
           • MinnesotaCare for families with children, including pregnant women
           • MA
           • Minnesota Family Planning.

Do not require verification of citizenship for applicants and enrollees who are:
          • Applying for or enrolled in MinnesotaCare for adults without children
          • Enrolled in or entitled to enroll in Medicare
          • Applying or enrolled in GAMC
          • Applying or enrolled in the HIV/AIDS Program
          • If someone in the household does not want to share their citizenship status or
             SSN, they can claim “non-applicant” status. This person(s) would be
             considered a “non-applicant”.

Verification Required: Non-citizen status must be verified.

Common Forms of Verification: USCIS (United States Citizenship and Immigration
Services) forms: I-94; I-551; I-766. See the Guide to Non-citizen Eligibility for Cash and
Food Support (DHS-4864) for more information.

Documentation on the WIF: Note the type of verification provided. Document in Case
Notes the type of verification provided. Note the person’s immigration status, immigration
code, Alien ID number, and any sponsor’s information.

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MAXIS Panels:            STAT/MEMI, STAT/IMIG, STAT/SPON, STAT/EATS

References:              CM 0010.18.01               Mandatory verifications – Cash Assistance
                         CM 0010.18.12               Verifying Lawful Temporary Residence
                         CM 0010.18.15               Verifying Lawful Permanent Residence
                         CM 0010.18.15.03            Lawful Permanent Residents: USCIS Class
                                                     Codes
                         CM 0010.18.21              Identify Undocumented/Non-immigrant People
                         CM 0010.18.21.03            Non-immigrant People: USCIS Class Codes
                         CM 0010.18.24               Verification - I-94 Cards
                         CM 0010.18.27               Verification - I-551 Card
                         CM 0011.03                  Citizenship and Immigration Status
                         CM 0012.03                  Non-Applicants
                         CM 0014.06                  Who Must be Excluded from Assistance Unit
                         HCPM 11.25                  Federally and State-Funded Health Care
                         HCPM 18.05                  Sponsor Deeming
                         HCPM 09.05                  Mandatory Verifications




LIST CITY, STATE AND COUNTRY OF BIRTH

Applicant needs to enter the city, state and country of birth, if known. This information
allows you to access birth records from the Minnesota Department of Health and from other
states.



WHAT PROGRAMS IS THIS PERSON APPLYING FOR?

This question identifies which types of programs are being applied for by each person. It
aids you in asking program specific questions, and in identifying which items require
verification. If the applicant makes a change to the program(s) requested during the
interview, be sure to have the changes initialed and dated by the applicant.

Verification Required: No verification is required.

Documentation on the WIF: Record if there are people who are not requesting
assistance but need to be included in the assistance unit(s). Clarify the programs the
applicant is applying for. If the applicant changes the type of program requested, be sure to
note it.



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MAXIS Panels:            STAT/TYPE, STAT/PROG

References:              CM 0014                   Assistance Units
                         CM 0014.03                Determining The Assistance Unit
                         CM 0014.06                Who Must Be Excluded From Assistance Unit
                         CM 0014.09                Assistance Units - Temporary Absence
                         HCPM 17.05                Determining Household Size for MA/GAMC
                         HCPM 17.25                Removing a Household Member
                         HCPM 17.15                Temporary Absence




LAST SCHOOL GRADE COMPLETED

School attendance may affect eligibility for certain programs. A minor child under the age of
19 and a full-time student in a secondary school or equivalent can receive MFIP/DWP.
School attendance must be monitored for MFIP minor caregivers. If they do not attend, they
may be sanctioned. For FS, student status may affect eligibility.

Verification Required: No verification is required unless school attendance is a condition
of eligibility.

Documentation on the WIF: This information should be completed by the applicant on the
CAF. No additional documentation is needed on the WIF.

MAXIS Panels:            STAT/MEMI, STAT/SCHL

References:              CM 0011.18                Students
                         CM 0012.06                Requirements for Custodial Parents under 20
                         CM 0028.12                Education Requirements




PERSON 2 LEGAL NAME (last/first/middle)

Follow the guidance outlined for Person 1. These questions must be answered for all
persons in the household whether applying for benefits or not. Additional persons may be
entered on page 8.




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10     26
CAF Page 4
Applicant must answer “Yes” or “No” to every question on page 4.

Question 1:              Does everyone in your household buy, fix or eat food with you?

This question helps you and MAXIS determine the assistance unit composition for the Food
Support Program.

Verification Required: No verification is required

Documentation on the WIF: Indicate the person(s) not included in the Food Support
assistance unit and why.

MAXIS Panel:             STAT/EATS

References:              CM 0014                   Assistance Units
                         CM 0014.03                Determining the Assistance Unit
                         CM 0014.03.06             Determining the Food Support Unit
                         CM 0022.24                FS Only Benefit for Mixed Household



Question 2:              Is anyone in the household, who is age 60 or over or disabled,
                         unable to buy or fix food due to a disability?

This question helps you and MAXIS determine the Food Support assistance unit. A “Yes”
response may result in a separate assistance unit for the elderly/disabled person and
spouse if the income of the remaining persons is at or below 165% of the Federal Poverty
Guidelines.

Verification Required: Verification is required.

Documentation on the WIF: Note whether the elderly/disabled person is a separate
assistance unit or is included in the assistance unit, and why.

MAXIS Panel:             STAT/EATS

References:              CM 0010.18.06             Verifying Disability/Incapacity-FS
                         CM 0012.15                Incapacity and Disability Determinations
                         CM 0014.03                Determining the Assistance Unit
                         CM 0014.03.06             Determining the Food Support Unit
                         CM 0019.09                GIT for Separate Elderly Disabled Units

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Question 3:              Is anyone in the household attending school?

School status includes any household member in school, from Head Start to post-
secondary education. It determines whether a dependent child's earnings are excluded for
DWP, MFIP, Food Support, and Health Care. School status and attendance affects
eligibility for MFIP minor children who have not graduated from high school. Post-
secondary student status affects eligibility for Food Support.

Verification Required: No verification required unless school attendance is a condition of
eligibility or used as a WREG exemption for FS.

Common Forms of Verification: No form of verification is required, except for caregivers
under the age of 20 without a high school diploma or GED who must attend school unless
exempt. At the intake interview, give them the Graduate to Independence/MFIP Teen
Parents Informational Brochure (DHS-2887) and the Notice of Requirement to Attend
School (DHS-2961).

Documentation on the WIF: Record if attendance is full-time or part-time, whether it was
verified and how, and what the school district number is. Note the effect on eligibility by
program. Use (DHS-2883) Request For Verification of School Attendance/Progress for
minor caregivers.

MAXIS Panels:            STAT/MEMI, STAT/SCHL

References:              CM 0011.18                Students
                         CM 0012.06                Requirements for Custodial Parents Under 20
                         CM 0028.12                Education Requirements
                         TE002.05.90.01            School District Numbers
                         TE002.05.90.02            School District Numbers
                         TE002.05.90.03            School District Numbers
                         HCPM 20.25.40             Dependent Child Income




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Question 4:              Is anyone in your household temporarily not living in your
                         home? (for example: vacation, foster care, treatment, hospital,
                         job search)

Some programs allow people to remain in the assistance unit even when temporarily out of
the home, depending on the reason for and the length of the absence.

Verification Required: Yes

Common Forms of Verification: Social worker’s statement, court papers, doctor’s
statement, Long Term Care Facility Physician’s Certification (DHS-1503), collateral contact

Documentation on the WIF: Note the reason the person is out of the home, how long the
person has been gone, and the expected date of return. Also note if Social Services is
involved.

MAXIS Panel:             STAT/REMO

References:              CM 0014.06                Who Must Be Excluded From Assistance Unit
                         CM 0014.03                Determining The Assistance Unit
                         CM 0014.09                Assistance Units - Temporary Absence
                         CM 0014.12                Units For People With Multiple Residences
                         HCPM 17.15                Temporary Absence




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   29
Question 5:              Did anyone move in or out of your home in the past 12 months?

Some household members are required to be included in the assistance unit. Some
members are optional unit members. Some programs allow people to remain in the
assistance unit even when temporarily out of the home.

Verification Required: Yes

Common Forms of Verification: Social worker’s statement, court papers, doctor’s
statement, or collateral contact.

Documentation on the WIF: Note the reason a person moved in or out of the home or if
additional forms were sent out. Also note if Social Services is involved.

MAXIS Panels: STAT/ADME, STAT/REMO

References:              CM 0014                   Assistance Units
                         CM 0014.06                Determining the Assistance Unit
                         CM 0014.09                Assistance Units – Temporary Absence
                         CM 0014.12                Units For People With Multiple Residences
                         HCPM 17.15                Temporary Absence




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   30
Question 6:              Is either parent of any child under age 19 dead or not living in the
                         home?

This question is asking for absent parent information. If one or both parent(s) is absent from
the home, the applicant must cooperate with Support and Collections (IV-D). Support and
Collections (IV-D) assists in determining paternity, collecting court ordered child support,
and pursuing medical coverage. A person does not have to be on public assistance to use
these services. The Support and Collections Division in Minnesota has a statewide
computer system called PRISM.

For all programs except Food Support, have the applicant complete the Referral to Support
and Collections (DHS-3163B). This form will assist you in completing the INFC/CSIA, B, C,
and D panels in MAXIS. The more information you collect from the applicant at the initial
interview, the less the applicant will be asked for later. Also, give the applicant
Understanding Child Support: A Handbook for Parents (DHS-3393).

Review the Cooperation with Child Support Enforcement form (DHS-2338) to see a list of
when the applicant may claim Good Cause for not cooperating with Child Support. Some
examples of verification are police reports and doctor’s statements. When an applicant
claims Good Cause, your agency will review the supporting documents and decide whether
to grant Good Cause. Your agency's decision is appealable. Good Cause can be claimed
at any time by the applicant. DHS is notified when an applicant claims Good Cause. If one
or both of the parents is deceased, investigate the possibility of RSDI benefits.

Verification Required: Yes

Common Forms of Verification: Court papers, certificate of death, divorce papers.

Documentation on the WIF: Note possible eligibility for RSDI (i.e., benefits based on
deceased parents). Note date of death, divorce or separation. Note cooperation with IV-D,
and Good Cause decision.

MAXIS Panels:            STAT/ABPS, INFC/CSIA, B, C, D

References:              CM 0012.18                Assigning Rights to Child & Medical Support
                         CM 0012.21                Responsible Relatives not in the Home
                         CM 0012.21.03             Support From Non-Custodial Parents
                         CM 0012.21.06             Good Cause Exemptions from Pursuing Support
                         CM 0025.30                Financial Responsibility, People Not in Home
                         HCPM 03.25.30             Medical Assistance for Parents – Relative
                                                   Caretakers
                         HCPM 16                   Medical Support



A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   31
Question 7:              Is anyone mentally or physically ill, disabled or blind, or not
                         able to care for themselves?

This information establishes a basis of eligibility for GA, MSA, or Health Care programs,
and provides exemptions from Employment Services requirements. It also establishes
special considerations for the Food Support program (i.e., exemption from work and
training requirements, exclusion from gross income tests, no cap on shelter deduction, and
allowance of a medical deduction).

Verification Required: Yes

Common Form of Verification: Award letter for SSI or RSDI based on disability,
certification of disability by State Medical Review Team (submit the following forms to the
SMRT: (DHS-161A or B), (DHS-1467A), (DHS-2904A), doctor’s statement, existing
certification of blindness by the state Services for the Blind.

Documentation on the WIF: Indicate the type of verification provided, the type of illness or
disability, the expected duration and effect on eligibility. Programs vary in what they will
accept for verification of disability.

MAXIS Panels:            STAT/DISA, STAT/WREG, STAT/EMPS, STAT/UNEA, STAT/PBEN

References:              CM 0010.18.05             Verifying Disability/Incapacity, Cash
                         CM 0010.18.06             Verifying Disability/Incapacity, FS
                         CM 0012.12                Applying for Other Benefits
                         CM 0012.15                Incapacity and Disability Determinations
                         CM 0013.15.03             GA Basis - Permanent Illness
                         HCPM 03.30                MA for People Who are Age 65                and
                                                   over/blind/disabled
                         HCPM 03.30.10             MA for People with Blindness
                         HCPM 03.30.15             MA for People with a Disability
                         HCPM 12                   Certification of Disability
                         HCPM 12.10                SMRT Disability Determinations




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10    32
Question 8:              Is anyone unable to work for reasons other than illness or
                         disability?

If the answer is “Yes”, then the reason must be given.

Verification Required: Yes

Common Forms of Verification: Literacy tests, battered women’s shelter statement,
court records, collateral contact, or doctor’s statement.

Documentation on the WIF: Note the barriers to employment, their duration and how they
were verified. Note whether or not you determined a basis of eligibility for GA.

MAXIS Panels:            STAT/WREG, STAT/EMPS

References:              CM 0013.15                GA Bases of Eligibility
                         CM 0028.06.10             Who Is Exempt from FSET
                         CM 0028.06.12             Who Is Exempt from FS Work Registration




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   33
Question 9:              In the last 90 days did anyone in the household:
                         • Stop working or quit a job?
                         • Ask to work fewer hours?
                         • Refuse a job offer?
                         • Go on strike?
This question is designed to determine a Food Support program disqualification for a
voluntary quit within the 60 days before application. It is also used to identify assistance
units which are subject to monthly reporting because of recent work history (work within 90
days before application). Be careful not to disqualify someone for a voluntary quit that
occurred more than 60 days before application.

A striker is defined as an employee who is involved in a work stoppage, slowdown or
interruption of work whether or not the employee voted for the strike. Strike status can
affect eligibility for DWP, MFIP, and Food Support. If the PWE in the Food Support
household is on strike, determine if the assistance unit would have been eligible before the
strike. If yes, count their pre-strike earnings as if they were still receiving it.

Verification Required: Yes

Common Forms of Verification: Employer’s statement, separation notice, collateral
statement, applicant’s statement, re-employment insurance records, union statement,
media reports.

Documentation on the WIF: Note if the person who left a job was the principal wage
earner according to the Food Support program definition. Note when and why the applicant
left the job. Note if this was voluntary quit, and if there was Good Cause. Indicate if a
period of ineligibility was applied, and the time it covered. Note if the striker is the PWE.
Indicate pre-strike earnings and how this was verified.

MAXIS Panels:            STAT/STWK, STAT/DISQ, STAT/WREG, STAT/STRK

References:              CM 0007                   Reporting
                         CM 0012                   Procedural Eligibility
                         CM 0028.30.09             Refusing or Terminating Employment
                         CM 0004.03                Emergency Aid Eligibility – Cash Assistance
                         CM 0011.15                Strikers
                         CM 0014.06                Who Must be Excluded from Assistance Unit
                         CM 0028.18.03             Suitable Work/Unsuitable Work




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10     34
Question 10:             Has anyone in the household been injured or had an accident in
                         the past 72 months?

This refers to injuries or accidents of household members. If yes, update STAT/ACCI with
information given to you by the applicant. Benefit Recovery (BRS) will send a Medical
Service Questionnaire (DHS-2237A) to the applicant to be completed and returned. BRS
will monitor its return. This question is about Third Party Liability. Third Party Liability refers
to the potential for medical coverage other than Medical Assistance. This pertains to MA
and MCRE, including automatic coverage. Applicants agree to assign their rights, to third
party payment to your agency, when they sign the CAF.

Verification Required: No

Common Forms of Verification: An accident report, lawyer’s statement, court records

Documentation on the WIF: Note if the (DHS-2237A) form was completed and submitted
to the DHS Benefit Recovery Unit. Indicate the date of the injury and circumstances.
Include the accident report file date. Include information on the effects of the injury or
accident. Provide all information about a pending settlement including date of hearing(s), an
offer of out-of-court settlement being received and considered, etc.

MAXIS Panel:             STAT/ACCI

MMIS Panel:              Complete the TKEY sequence of panels.

References:              CM 0012.27                Cooperating To Get Tort Liability Payments
                         HCPM 15.15                Third Party Liability




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10     35
Question 11:             Is anyone in the household on a diet prescribed by a doctor?

The MSA program provides a cash supplement to support certain special diets. The diet
must be prescribed by a physician for a medical condition listed in CM 0023.12.
In MAXIS, case note the Special Diet amount allowed.

Verification Required: Yes

Common Forms of Verification: Doctor’s statement

Documentation on the WIF: All member(s) with the special diet, and the type of special
diet prescribed. Document the type and date of verification provided.

MAXIS Panel:             STAT/DIET

Reference:               CM 0023.12                Special Diets




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   36
What do you own?


Questions 12 and 13 deal with assets.

Assets are defined as real and personal property owned wholly or in part by the applicant.
Real property is land, all buildings, structures, improvements, or other fixtures on it
belonging or pertaining to the land and all mines, minerals, fossils, and trees on or under it.
Real property is considered non-liquid.

Personal property is an asset that isn't real property. This includes liquid assets such as
cash, checking accounts, savings accounts, stocks and bonds. It also includes such items
as vehicles, jewelry, and contracts for deed.

Keep in mind that excluded assets can vary by program. Refer to Combined Manual
section 0015 and Health Care Programs Manual section 19 for full information on assets. If
an assistance unit has assets within program limits, the unit is asset eligible. If the unit's
countable assets are over program limits, the unit is ineligible. Excess assets are a bar to
initial and ongoing eligibility.

You will determine the equity value of certain types of assets. To determine the equity
value, deduct encumbrances from the Fair Market Value (FMV) or Estimated Market Value
(EMV) of the asset. Fair Market Value is the price an asset sells for using current market
trends for similar property in similar condition. Estimated Market Value is the county
assessor's assigned value of real estate used to levy property taxes. An encumbrance is
the amount owed on the property, or a penalty which would be required if an asset is
liquidated. Equity is the FMV or EMV minus encumbrance.

Applicants who disagree with your determination of asset value or asset availability have
the right to rebuttal. The applicant can provide verification to support a claim of lower value
than the one you assigned to the asset. For example, you determine the value of a vehicle
based on the NADA (National Automobile Dealers' Association) book. The applicant can
claim a lower value because the car was in an accident and is not now drivable. If
verification can be provided of this (a picture, a dealer's statement, etc.), use the lower
value.




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   37
Question 12:             Does anyone in the household own, or is anyone buying, any
                         of the following?
                         • Cash (see below)
                         • Accounts such as checking, savings, debit cards, money
                             market, trust funds, annuities, certificates of deposit (CD),
                             retirement funds (see below)
                         • Life insurance or burial accounts (see below)
                         • Vehicles such as cars, trucks, campers, motorcycles (see
                             below)
                         • Stocks, bonds, contracts for deed or other securities (see
                             below)
                         • Land, buildings, life estates, houses, mobile homes (see
                             below)
                         • Other assets such as tools, livestock, boats, motors, trailers,
                             farm implements, snowmobiles (see below)
                         • Sponsor’s assets (see below)


Cash
This refers to cash an applicant has in his or her pocket or purse, in a piggy bank at home,
etc. This includes the cash of children. This is declaratory only. All programs count cash as
an available asset.

Verification Required: No verification is required.

Common Forms of Verification: No forms of verification are required.

Documentation on the WIF: Note total cash available to the household.

MAXIS Panel:             STAT/CASH

References:              CM 0015                   Assets
                         CM 0015.03                Asset Limits
                         HCPM 19                   Assets




Bank accounts
Include items such as checking, savings, debit cards, money market, trust funds, annuities,
certificates of deposit (CD), or retirement funds. These are considered liquid assets. All
programs are affected by liquid assets.

A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   38
Verification Required: Yes

Common Forms of Verification: Bank statements, (DHS-2243) (Consent for Release of
Information About Assets)

Documentation on the WIF: Note the account number, the verification provided, the
equity for all accounts, etc., and other listed personal property. Note the balance and
balance date of each account. Note if the asset is jointly owned, unavailable, or excluded.
Note if account is interest-bearing, and if so, the next date interest is paid.

MAXIS Panel:             STAT/ACCT

References:              CM 0015                   Assets
                         CM 0015.03                Asset Limits
                         CM 0015.06                Availability of Assets
                         CM 0015.06.03             Availability of Assets With Multiple Owners




Life insurance or burial accounts
Burial plans/accounts/funds/contracts are funds prepaid or designated for funeral
expenses. All programs have some provision for excluding part or all these items.

Verification Required: Varies by program. Refer to the CM for each program’s verification
requirements.

Common Forms of Verification: Contract, a statement from a funeral home/cemetery,
bank statement, purchase agreement, or copy of insurance policy.

Documentation on the WIF: Note the specific type of asset, its current value, how it was
verified, and how specific programs will be affected. Note if it is excluded and why. Note the
policy number, the verification received, the date of the verification, and the face value and
equity value of all policies.

MAXIS Panels:            STAT/OTHR, STAT/SECU

References:              CM 0015.21                Excluded Assets - Burial Spaces
                         CM 0015.24                Excluded Assets - Burial Contracts
                         CM 0015.51                Evaluation of Insurance Policies
                         HCPM 19.25.40             Burials and Life Insurance




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10     39
Vehicles
Use the NADA book to determine the vehicle's value. The listed trade-in value is used for
MSA, MA and GAMC. The listed loan value is used for DWP, MFIP, Food Support and GA.
Do not assign extra value for specially equipped vehicles. Some programs also consider a
vehicle's equity.
Verification Required: Yes. DWP, MFIP, MSA, & GA require verification of ownership.

Common Forms of Verification: NADA book, dealer’s statement, lender’s statement,
title, registration.

Documentation on the WIF: Note the trade-in or loan values and how it was verified.
Indicate the balance owed as of a specific date. Note if the vehicle is excluded and why.
Indicate amounts counted by specific programs.

MAXIS Panel:             STAT/CARS

References:              CM 0015.39                Excluded Assets - Vehicles
                         CM 0015.54                Evaluation of Vehicles
                         HCPM 19.25.25             Vehicles




Stocks, bonds, annuities, etc.
All programs are affected by these types of assets. See the note below for U.S. saving
bond verification.

Verification Required: Yes

Common Forms of Verification: Consent for Release of Information about Assets (DHS-
2243), broker's statement

Documentation on the WIF: Note whether the account has a single owner or is jointly
owned. Note if a joint owner is in or out of the assistance unit. Note the availability of the
asset. If the asset is a contract for deed, note if there is a balloon payment and if yes the
date that payment is due. Note whether you counted or excluded the asset. NOTE: If
making a photocopy of a savings bond, alter the size of the copy. It is illegal to make an
exact size copy.

MAXIS Panel:             STAT/SECU




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   40
References:              CM 0002.31                Glossary: (Honoraria) Income Producing
                                                   Assets
                         CM 0015.09                Excluded Assets for Self Support
                         CM 0015.27                Excluded Assets - Income
                         CM 0015.42                Excluded Assets - Liquid Assets
                         HCPM 19.10                Excluded Assets




Real estate property
All programs exclude an applicant's homestead from the asset limits. Non-homestead
property may be excluded for other reasons, which vary by program.

Verification Required: Yes, if non-homestead

Common Forms of Verification: A property tax statement, purchase agreement,
title/deed, county assessor/recorder.

Documentation on the WIF: Indicate if this property is excluded, and why. If not excluded,
note the equity value and how it was verified. Note the date the value was effective. Note
the date a repayment agreement is signed, the date it expires, and if the property is for
sale. If the property is owned jointly, note if it is jointly owned by someone within or outside
the assistance unit. Note if the property is unavailable, why it is unavailable, and how this
was verified.

MAXIS Panel:             STAT/REST

References:              CM 0015.12                Excluded Assets - Real Property
                         CM 0015.12.03             Excluded Assets - Homestead
                         CM 0015.12.06             Repayment Agreements on Real Property
                         CM 0015.57                Evaluation of Real Property



Other assets
Some of these items such as tools or equipment necessary for employment are excluded
by some programs. Ownership of these assets affects all programs.

Verification Required: Yes, except for Food Support.

Common Forms of Verification:                    Purchase agreement, bank/lender's statement,
appraisal, NADA.


A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   41
Documentation on the WIF: Indicate the specific type of resource, the current value, the
amount owed as of what date, and how you verified it. Note how the item is used. Note if it
is excluded for a specific program, and why. Note amounts counted toward asset limits.

MAXIS Panel:             STAT/OTHR

References:              CM 0015                   Assets
                         CM 0015.09                Excluded Assets for Self Support
                         HCPM 19.10.10             Self-Support Excluded Assets




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   42
Question 13:             Has anyone in the household given away, sold or traded
                         anything of value in the past 60 months? (for example: real
                         estate property, bank accounts, annuities, vehicles, etc.) Note:
                         Include any transfers made by a spouse not living with you.

This question is used to determine if a transfer of assets has taken place and if so, whether
it was a proper or improper transfer. Transfers made to establish or maintain eligibility for
public assistance result in a period of ineligibility. Some examples of transfers are gifts,
sales, or trades.

The question asks for information going back 60 months because that is the longest period
which affects a program. MA looks at up to 60 months before application. MFIP, DWP, and
GA look at 12 months prior to application and Food Support looks at three months prior to
application.

Verification Required: Yes

Common Forms of Verification: Bank statement(s), collateral contact, or an applicant’s
statement.

Documentation on the WIF: Carefully and completely document all information that
pertains to transfers. Note the reason the transfer was made, and to whom. Note if the
transfer is considered improper, and why. Note if adequate compensation was or was not
received for the transferred asset. Note when the transfer occurred and its effect on specific
programs. Note the Verification provided. Note all attempts by the applicant to regain
improperly transferred property. If you assign a period of ineligibility, include your
calculations, and the end date of the ineligibility.

MAXIS Panel:             STAT/TRAN

References:              CM 0015.69                Asset Transfers
                         CM 0015.69.03             Asset Transfers from Spouse to Spouse
                         CM 0015.69.06             Improper Asset Transfers
                         CM 0015.69.09             Improper Transfer Ineligibility
                         CM 0015.69.12             Improper Transfers - Onset of Ineligibility
                         HCPM 19.40                Transfers
                         HCPM 19.45                Asset Assessments




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10     43
              CHECKPOINT




1. Do liquid assets have to be verified for all programs?




2. What form do you use to get a release of information about assets?




3. How many months prior to application does each program look at the potential for an
improper transfer?




4. If the applicant answers “yes” to question 6, what do you give the client to complete?




5. On what two MAXIS panels do you record school information?




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   44
What kinds of income do you have?

Questions 14 through 19 deal with income.

Income is defined as cash or an in-kind benefit whether earned or unearned, received by or
available to an applicant or participant that is not an asset. In-kind income is defined as
payment for a service in a form other than money, or receipt of non-cash gifts or non-cash
contributions such as gift cards, food, or clothing.



Question 14:             Has anyone in the household had a job or been self-employed
                         in the past 12 months?

This question is targeted for an applicant’s recertification. The CAF is also used for the
recertification. All programs are affected by earned income. It is important to look carefully
at all earned income or self-employed income, determine pay dates and amounts, and
examine all the income an applicant has received in the past 12 months.
Verification Required: Yes

Common Forms of Verification: Pay Stubs/Tip Report, Employer's Statement, tax forms,
business records, receipts/bills or a Self-Employment Report Form (DHS-3336).

Documentation on the WIF: Note the dates the applicant was paid. Note the amount of
each check. Note the last pay date if the income is non-recurring. Note any discrepancies
in pay dates and clarify information on possible tips or commissions. Note the types and
dates of verification provided. Note if it is excluded due to age and student status.

MAXIS Panel:             STAT/JOBS

References:              CM 0007.03                Monthly Reporting - Cash
                         CM 0007.03.01             Monthly Reporting - FS
                         CM 0010.18                Mandatory Verifications
                         CM 0016                   Income from People not in the Unit
                         CM 0017                   Determining Gross Income
                         CM 0017.12                Determining If Income Is Earned Or Unearned
                         CM 0017.12.06             Earned Income
                         CM 0018                   Determining Net Income
                         CM 0018.06                Work Expense Deductions
                         CM 0018.18                Earned Income Disregards
                         CM 0022.06                How and When to Use Retrospective Budgeting




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   45
Question 15:             Does anyone in the household have a job or expect to get
                         income from a job this month or next month? Note: Include
                         income from Work Study and paid internships. Include free
                         benefits or reduced expenses received for work (shelter, food,
                         clothing, etc.).

All programs are affected by earned income. It is important to look carefully at all earned
income, determine pay dates and amounts, and examine all the information available to
you. For example, you can check year-to-date totals on pay stubs to determine if all
paychecks have been reported to you.

Assistance units which receive earned income are required to report monthly on a
Household Report Form (DHS-2120).

Verification Required: Yes

Common Forms of Verification: Pay Stubs/Tip Report, Employer's Statement.

Documentation on the WIF: Note the dates the applicant is paid and the pay-period
ending date if provided. Note the amount of each check for the 1st, 2nd, and ongoing
months. Note the last pay date if the income is non-recurring. Note any discrepancies in
pay dates and clarify information on possible tips or commissions. Note the types and dates
of verification provided. Note if it is excluded due to age and student status.

MAXIS Panel:             STAT/JOBS

References:              CM 0007.03                Monthly Reporting - Cash
                         CM 0007.03.01             Monthly Reporting - FS
                         CM 0010.18                Mandatory Verifications
                         CM 0016                   Income from People not in the Unit
                         CM 0017                   Determining Gross Income
                         CM 0017.12                Determining If Income Is Earned Or Unearned
                         CM 0017.12.06             Earned Income
                         CM 0018                   Determining Net Income
                         CM 0018.06                Work Expense Deductions
                         CM 0018.18                Earned Income Disregards
                         CM 0022.06                How and When to Use Retrospective Budgeting
                         HCPM 20                   Income




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   46
Question 16:             Is anyone in the household self-employed or does anyone expect
                         to get income from self-employment this month or next month?
                         Examples:
                         • Product sales
                         • Crop Reserve Program (CRP)
                         • Personal services
                         • Farming
                         • Paper route
                         • In-home day care
                         • Roomers/boarder
                         • Property rental
                         • Taxi driver
                         • Other
People are self-employed when they work for themselves. They are responsible for their
own work schedule. They do not have taxes or FICA withheld by an employer and they do
not have coverage under an employer's liability or Worker's Compensation Insurance.

Allowable expenses vary by program, so check the Combined Manual or Health Care
Programs Manual for program-specific information. The individual programs also have
different rules to cover the pro-ration of receipts and expenses over more than one month,
and to determine whether the self-employment is earned or unearned income.

Calculating self-employment income can be difficult and error prone. Make sure to
document all of your steps very clearly and completely. Be sure to write extensive notes.

Verification Required: Yes

Common Forms of Verification: Tax forms, business records, receipts/bills, Self-
Employment Report Form (DHS-3336).

Documentation on the WIF: Note the type of self-employment, all income and expenses,
and how net income was determined for each program (which expenses were allowed).
Indicate budgeting method. Note type of verification provided. Include all calculations. If any
of the income is excluded, indicate why. Indicate if it is earned or unearned.

MAXIS Panels:            STAT/BUSI, STAT/RBIC




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   47
References:              CM 0010.18.09             Verifying Self-Employment Income/Expenses
                         CM 0015.09                Excluded Assets for Self Support
                         CM 0017.15.33             Self-Employment Income
                         CM 0017.15.54             Capital Gains and Losses as Income
                         CM 0028.30.09             Refusing or Terminating Employment
                         CM 0029.33                Self-Employment Investment
                                                   Demonstration (SEID)
                         HCPM 20                   Income




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   48
CAF Page 5
Applicant must answer yes or no to every question on page 5.




Question 17:             Do you expect any changes in income, expenses or work hours?


If applicant marks yes, ask what type of changes in income, expenses or work hours they
are expecting.

Verification Required: Yes

Common Forms of Verification: Pay Stubs/Tip Report, Employer's Statement, Tax
forms, business records, receipts/bills, Self-Employment Report Form (DHS-3336).

Documentation on the WIF: Record the applicant’s changes and indicate the verification
provided by the applicant or requested.

MAXIS Panels:            STAT/JOBS, STAT/BUSI

References:              CM 0017.12                Determining If Income Is Earned Or Unearned
                         CM 0017.15                Specific Types of Income
                         CM 0017.15.09             Income From Tribal Land
                         CM 0017.15.12             Infrequent, Irregular Income
                         CM 0017.15.21             Tax Credit and Refund Income
                         HCPM 20                   Income




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   49
Question 18:             Has anyone in the household applied for or does anyone get any
                         of the following types of income?
                         • Social Security (RSDI)
                         • Supplemental Security Income (SSI)
                         • Veteran benefits (VA)
                         • Unemployment Insurance
                         • Workers’ Compensation
                         • Retirement benefits
                         • Tribal payments
                         • Child support or spousal support
                         • Other unearned income
This is income from sources other than employment or training, referred to as unearned
income. The verification requirements vary by program. The applicant must answer either
yes or no for each type of unearned income listed.

Verification Required: Yes

Common Forms of Verification: Award Letters, court orders, copy of check stubs,
SDX/BENDEX, SVES, unemployment insurance check stubs

Documentation on the WIF: Indicate the type of income, dates received, and the
verification provided. Note the date of the verification. Note the amount expected in the 1st,
2nd and ongoing months, and identify non-recurring income. Note date of receipt of
anticipated income. Note if the income is excluded or counted, and if excluded, indicate
why. Note any referrals you made for other potential benefits. If the applicant claims no
income, specify how you confirmed this, particularly if expenses are being paid.

MAXIS Panels:            STAT/UNEA, STAT/PBEN

References:              CM 0012.12                Applying for Other Benefits
                         CM 0017.12                Determining If Income Is Earned Or Unearned
                         CM 0017.12.03             Unearned Income
                         CM 0017.15                Specific Types of Income
                         CM 0017.15.09             Income From Tribal Land
                         CM 0017.15.12             Infrequent, Irregular Income
                         CM 0017.15.21             Tax Credit and Refund Income
                         HCPM 20                   Income




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   50
Question 19:             Does anyone in the household have or expect to get any loans,
                         scholarships or grants for attending school?

This question pertains to post-secondary education. Each program looks at school income
differently. Expenses that can be deducted from such income vary depending on the
program and the type of financial aid. The program that is most affected by student status
is Food Support.

Title IV financial aid includes grants and loans for students which are authorized by the
Federal Higher Education Act (Title IV), and are funded by the U.S. Dept. of Education.
Non-Title IV aid is either state or federally funded, but not under Title IV.

DHS issues a bulletin that provides information on every post-secondary school in
Minnesota. This bulletin indicates whether the school is an institution of higher learning,
what a part- or full-time schedule is, general expenses, and so on. This information is used
to determine a student's eligibility for Food Support.

Verification Required: Yes

Common Forms of Verification: Financial Aid Information (DHS-2646), public
assistance/financial aid form, financial aid award letters or fee statements.

Documentation on the WIF: Indicate the type, source and amount of student income, and
the period the income is intended to cover. Note the type of verification provided and the
information it included. Indicate whether expenses are allowable or not, and the period they
are intended to cover. Note if the income is excluded for a specific program. Indicate if the
student is eligible or ineligible for Food Support.

MAXIS Panel:             STAT/STIN

References:              CM 0010.18.30             Verifying Student Income and Expenses
                         CM 0011.18                Students
                         CM 0015.33                Excluded Assets - Student Financial Aid
                         CM 0017.15.18             Work Force Investment Act (WIA) Income
                         CM 0017.15.36             Student Financial Aid Income
                         CM 0017.15.36.09          Student Financial Aid Deductions
                         HCPM 20.05                Excluded Income




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   51
              CHECKPOINT




1. What information regarding self-employment do you document on the WIF?




2. What information do you document on the WIF regarding earned income?




3. What are some examples of unearned income?




4. What form must monthly reporters complete and submit?




5. How do you verify employment?




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   52
What kinds of expenses do you have?


Questions 20 through 26 deal with expenses and deductions.

Deductions are defined as an amount of income not counted in the computation of a
person's income because of its use or intended use for certain specific expenses. For
example, the Food Support program allows a deduction for an applicant’s shelter cost(s).
Each program has its own set of allowable deductions, and amounts allowed for those
deductions.

Work-related expenses are defined as the amount withheld or paid for: state and federal
income taxes; FICA; mandatory retirement fund deductions; dependent care costs;
transportation costs to and from work at the amount allowed by the IRS for personal car
mileage; costs of work uniforms, union dues, and medical insurance premiums; costs of
tools and equipment used on the job; $2 per work day for the costs of meals eaten during
employment; public liability insurance required by an employer when an automobile is used
in employment and the cost is not reimbursed by the employer; and the amount paid by an
employee from personal funds for business costs not reimbursed by the employer. Work
expenses affect all programs. Check the Combined Manual for program specific expenses.




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   53
Question 20:             Does your household have the following housing expenses?
                         • Rent (include mobile home lot rental)
                         • Mortgage/contract for deed payment
                         • Association fees
                         • Homeowner’s insurance (if not included in mortgage)
                         • Real estate taxes (if not included in mortgage)
                         • Room and/or meals
This question gathers information about the applicant's monthly shelter costs. Shelter costs
affect most programs. The Food Support program allows the costs to be used as a
deduction only if the applicant pays someone outside of the unit. The maximum monthly
shelter deduction is $459. Shelter cost’s are used to determine the amount of the DWP
grant and affects the amount of the MFIP grant if the applicant is living in subsidized
housing. In addition, DWP applicants and some MFIP recipients must have their shelter
expenses vendored. In these situations, shelter costs must be verified.

Use Shelter Expense and Residence Form (DHS-2952), if the applicant is unable to provide
another form of verification.

Verification Required: Yes

Common Forms of Verification: (DHS-2952), mortgage statement, contract, rent receipt,
lease agreement or tax statements.

Documentation on the WIF: Note the shelter costs for the current and next month and
the type and date of verification provided. If the expense is shared, indicate the amount the
applicant is responsible for. Note the name of the person/agency that payment is made to.

MAXIS Panel:             STAT/SHEL

References:              CM 0008.03                Changes - Obtaining Information
                         CM 0015.12                Excluded Assets - Real Property
                         CM 0015.57                Evaluation of Real Property
                         CM 0018.15                Shelter Deductions
                         CM 0018.15.06             Averaging Shelter Costs
                         CM 0022.12                How to Calculate the Benefit Level –
                                                   MFIP/DWP/GA




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   54
Question 21:             Does your household have the following utility expenses any
                         time during the year?
                         • Heating/air conditioning
                         • Electricity
                         • Cooking fuel
                         • Garbage removal
                         • Water and sewer
                         • Phone/cell phone
The applicant must check yes or no for each utility expense listed. The utility costs a unit is
responsible for are part of the shelter expense. Deduct utility costs when the unit is billed
for utilities separately from the rent or mortgage payment.

During the Food Support interview, review the actual and standard utility options with the
applicant. When an applicant checks yes to the ‘Heating/air conditioning’ expense and
chooses the standard utility deduction, ask if the air conditioning is actually used. A unit
incurs a cooling expense ONLY if it must pay electrical costs for operating an air
conditioning system or a room air conditioner and there is a reasonable expectation the unit
will use air conditioning. A unit incurs a heating expense ONLY if it must pay for the actual
fuel used for its primary source of heat.

A unit may choose between the standard or actual utility deduction only at initial
certification, recertification or when a unit moves. The unit may switch between the
standard utility allowance and/or actual utility deductions only at recertification or when the
unit changes residence. Only verify actual utility expenses if the unit wishes to claim
expenses in excess of the standard utility deduction in order to allow these expenses as a
deduction.

Do not allow a deduction when expenses are reimbursed by a source outside the unit,
except when the expenses are reimbursed by the Low Income Home Energy Assistance
Program or payments vendored from the applicant's funds. Households that receive HUD
utility reimbursements and Farmers Home Administration (FMHA) Rental Assistance
Program utility reimbursements may not claim the standard utility deduction unless they
incur or are expected to incur heating or cooling costs exceeding the excluded HUD utility
reimbursement amount in any month of the certification period.

The Food Support program allows utility expenses as part of its shelter deduction. Allow the
single utility standard of $305 only for the following:
       • Units that incur expenses for heating and/or cooling
       • Units on the Low Income Home Energy Assistance Program (LIHEAP),
            regardless of whether they incur expenses for heating and/or cooling. This
            standard includes heating, cooling, electricity, water, sewer, garbage, and phone.

A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   55
For units billed for neither heating nor cooling:
      • Deduct the electric standard of $80 per month for units billed for electricity.
      • Deduct the phone standard of $28 per month for units billed for phone service.
           Do not allow actual phone expenses. NOTE: The phone standard can be
           allowed for cell phone expenses when the unit is billed monthly, and the cell
           phone is their only phone.

For DWP, applicants must verify their actual utility expenses to determine the DWP grant.
The utility expenses for a DWP applicant are entered on STAT/ACUT. If the DWP applicant
will also be on Food Support, they could potentially have a STAT/HEST and STAT/ACUT. If
they have a phone, we allow a flat $35 phone allowance which is recorded on STAT/ACUT.
Utility expenses are vendored for DWP applicants.

Verification Required: For Food Support, only if the applicant chooses actual utility costs.
For DWP, utility expenses are verified at initial application and do not have to be verified
every month unless the amount has changed. For MFIP, verify shelter costs if required for
vendor payments or as part of the family maintenance needs.

Common Forms of Verification: Billing statement

Documentation on the WIF: Indicate the type of utility expense the applicant has and the
amount of their current bill; person(s) who is billed and how much each person pays, if
utility costs are shared. Note whether or not the applicant has a central or window air
conditioner and whether or not they use it. Clarify with the applicant if they want to use the
Standard utility amount or Actual utility costs when figuring their Food Support benefits. Be
sure you are able to explain the difference between the two amounts. Indicate verifications
received or requested.

MAXIS Panels:            STAT/ACUT, STAT/HEST

References:              CM 0010.18.01             Mandatory Verifications – Cash Assistance
                         CM 0018.15.09             Utility Deductions
                         CM 0018.15.12             Actual Utility Deductions
                         CM 0018.15.18             Standard Utility Allowance
                         CM 0022.12                How to Calculate the Benefit Level –
                                                   MFIP/DWP/GA




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10   56
Question 22              Do you or anyone living with you have costs for care of a child or
                         an ill or disabled adult because you or they were working,
                         looking for work or going to school?
                         Note: The Child Care Fund may pay child care costs. Ask your
                         financial worker for more information.

All programs except WB, GA, GRH and MSA (Blind only) allow an ongoing deduction for
dependent care. DWP and MFIP allow the dependent care deduction only when applying
the initial eligibility test for applicant units. However, each program allows a different
maximum amount.

Verification Required: No

Common Forms of Verification: Day Care Provider’s Statement, Child Care Verification
form, cancelled checks/receipts.

Documentation on the WIF: Note the expense(s), for whom the care is paid, and the
reason for the care. Note the relationship of the provider to the assistance unit. Note the
amount expected for the 1st, 2nd, and ongoing months, particularly any changes which are
expected. Note how the information was verified. Note the amount allowed for each
program authorized.

MAXIS Panel:             STAT/DCEX

References:              CM 0008.06.18                      Change in Participant’s Age
                         CM 0017.15.36.09                   Student Financial Aid Deduction
                         CM 0018                            Determining Net Income
                         CM 0018.09                         Dependent Care Deduction
                         CM 0028.06.10                      Who Is Exempt from FSET
                         CM 0028.18                         Good Cause for Failure to Comply
                         CM 0028.30.09                      Refusing or Terminating Employment
                         HCPM 21.50.60                      Dependent Care Deduction




A Financial Worker's Guide to the Combined Application and Worker Interview Forms   04/07/10     57
Question 23:             Does anyone in the household pay court-ordered child support,
                         spousal support, child care support, medical support or
                         contribute to a tax dependent who does not live in your home?

This refers to payments specifically ordered by the court. For some programs these
payments are allowed as a deduction from the income of someone whose income is
counted.

Verification Required: Yes

Common Forms of Verification: Court documents, cancelled check/money order,
receipts, tax forms, a collateral statement, pay stubs or PRISM.

Documentation on the WIF: Note the type and amount of court ordered expense, the
period covered, and how this was verified. Indicate who the support/alimony is for, who is
responsible for payment, and if the payments are current.

MAXIS Panel:             STAT/COEX

References:              CM 0016                   Income from People Not In the Unit
                         CM 0018.30                Allocations
                         HCPM 17.05                Determining the Household Size for MA/GAMC
                         HCPM 21.50.65             Child Support Deduction




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Question 24:             Does anyone in the household have expenses related to work,
                         training or job search, such as transportation, meals or
                         uniforms? Ask your financial worker if these expenses apply to
                         the programs you are requesting.

MSA, GA, GRH and MA allow certain actual work expenses.

Verification Required: Yes, if actual expenses are allowed.

Common Forms of Verification: Employer’s statement, pay stubs or receipts, a tax table,
standard mileage allowance, standard meal allowance.

Documentation on the WIF: Note the name of the employed person, the type of expense,
the monthly amount, and how these expenses were verified. Note the amount allowed for
each program.

MAXIS panel:             STAT/WKEX

References:              CM 0004.21                Emergency Aid for Employment                Related
                                                   Expense
                         CM 0018.06                Work Expense Deductions
                         CM 0028.16                Support Services
                         CM 0028.30.09             Refusing or Terminating Employment
                         HCPM 21.50.45             Work Expense Deduction




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Question 25a:            Does anyone in your household currently have health insurance,
                         long-term care insurance, or prescription drug coverage?

Applicants must report any health insurance plans or sources of medical support that might
be available (Third Party Liability). Complete the Health Insurance Information Form (DHS-
1922B) to report other coverage to the DHS Benefit Recovery Unit. The must cooperate in
determining if health insurance plans are cost effective, i.e., if the payments made under
the policy are greater than the cost of the insurance premium.

It is a condition of MA eligibility that the applicant enrolls or remains in an available cost-
effective health plan. Your agency will pay the cost-effective premiums for the applicant.
HCPM 15.10.05 lists some policies that are easily determined cost-effective by your
agency. If you are unable to determine cost-effectiveness based on this HCPM section,
submit a completed Health Insurance Premium -- Cost Effectiveness Review (DHS-2841),
to the Benefit Recovery Unit.

Verification Required: Yes

Common Forms of Verification: Employer’s statement, copy of insurance policy

Documentation on the WIF: Note the name of the insurance plan and cost of the
premium. Note the type of verification provided. Note if there is access to other insurance
coverage the applicant does not currently have. Note if the plan is cost-effective, or if you
have submitted the (DHS-2841). Note the date you submitted the (DHS-2841) to DHS, and
any response.

MAXIS Panels:            STAT/HCRE, STAT/INSA

MMIS Panel:              Complete the TKEY sequence of panels.

References:              CM 0012.18                Assigning Rights to Child & Medical Support
                         CM 0012.21.03             Support from Non-Custodial Parents
                         HCPM 15                   Insurance and Third Party Liability
                         HCPM 15.10.05             MA and GAMC Cost-Effective Insurance




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Question 25b:            Does anyone in your household have Medicare Part A, B or D?

Medicare is a federal health insurance program for people who are age 65 and over,
disabled or blind, or have permanent kidney failure. Three types of Medicare coverage are
available: Part A, Part B, and Part D. Part A covers hospital care, hospice care, and home
health care. Part B covers doctors’ services, X-rays, lab services, and medical supplies.
Part D is optional and covers prescription drug costs.

If applicants are 65 and over, disabled or blind, or have permanent kidney failure, and do
not have Medicare, refer them to the Social Security Administration. Use (DHS-3439)
(Minnesota Health Care Programs Medicare Buy-in Referral Letter) to refer a person to
apply for Medicare. This is a requirement for health care eligibility.

If an elderly or disabled applicant has applied for Food Support and has Medicare, it may
be possible for your agency to pay the Medicare premiums for the applicant once eligibility
is determined. There is a standard premium for Medicare Part A/B coverage. This standard
premium amount changes every year on January 1 which is commonly referred to as the
COLA (cost of living adjustment) increase. Some people are not eligible to pay the standard
premium under certain circumstances and may have a Medicare premium amount that is
not the standard amount.

Verification Required: Yes

Common Forms of Verification: Award letter, Medicare Card, SVES

Documentation on the WIF: Note if you made a referral to the SSA, and the date of the
referral. If the applicant has Medicare, note which type of benefits they are receiving (for
example Part A, Part B, and/or Part D. Note the claim number and the premiums paid by
the applicant, also the begin and end dates of eligibility. Note if the premiums are different
from the standard Medicare premium amount, and why.

MAXIS Panels:            STAT/MEDI, STAT/PBEN, STAT/FMED

References:              HCPM 04.40       Medicare
                         HCPM 03.30       MA for People Who are Age 65 or Older, Blind,
                                          or Disabled
                         HCPM 06.15       Applying for Other Benefits
                         HCPM 15.10.05.20 Cost Effective Reimbursement
                         CM 0018.12       Medical Deductions
                         CM 0018.12.03    Allowable Food Support Medical Expense




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Question 26:             For the following programs you will need to provide proof of
                         your medical expenses:

                         Food Support applicants or recipients: To get a medical
                         deduction, you must provide proof of all medical bills incurred
                         by anyone in your household who is disabled or 60 years or
                         older. Do not bring medical bills that are being paid for by any
                         health care program, insurance or someone not living with
                         you.

                         Health care program applicants or recipients: Some health care
                         programs may pay for health care you received up to three
                         months before you apply for help. Bring proof of any medical
                         bills you or any household member incurred in the last three
                         months.


The programs affected by medical bills are Food Support and Health Care. This information
is used to determine retroactive medical assistance coverage. It may also be used to
determine if a medical spenddown is met.

Medical bills also are used as an expense in the Food Support budget if the person who
incurred the costs is disabled or aged. This is an error prone area which requires clear and
complete documentation.

Verification Required: Yes

Common Forms of Verification: Doctor bills, hospital bills, pharmacy bills

Documentation on the WIF: For Food Support: indicate the person who is elderly or
disabled. Note if the expense is recurring or one time only. If the expense is recurring, note
how often it occurs or is billed. Note if there is a payment schedule. Note the amount
allowed as a deduction. Note any reasons for not allowing a specific expense.

For MA/GAMC: Indicate if the applicant wishes retroactive medical coverage, and for what
period of time (can go up to three months before the month of application). Note the
amount the applicant is responsible for. Indicate if the (DHS-1844) was used to list
additional expenses. Note if there is a spenddown, and if so when the spenddown is met.
Note the date that medical eligibility starts (for example the month of application, or within
the three prior months). Note if they are not eligible for retroactive medical coverage and
why. Note if there are bills which will not be paid by MA. Indicate the verification which was
viewed, its date, and which expense it verified.



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MAXIS Panels:            STAT/FMED, STAT/BILS

References:              CM 0018.12                Medical Deductions
                         CM 0018.12.03             Allowable Food Support Medical Expenses
                         HCPM 24                   Medical Spenddowns
                         HCPM 24.15.15             H Bills
                         HCPM 24.15.20             M Bills
                         HCPM 24.15.25             P Bills
                         HCPM 24.15.30             R Bills




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              CHECKPOINT




1. What program(s) allow actual work expenses as a deduction?




2. Who is entitled to a medical deduction?




3. What is the maximum monthly shelter deduction for the Food Support program?




4. The Food Support program allows utility expenses as part of its shelter deduction.
   What is the single utility standard amount? For units billed for neither heating or
   cooling, what is the electric and phone standard amounts?




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CAF Pages 6 and 7
These pages contain the applicant’s penalty warnings and qualification questions, medical
assignment of benefits, assignment of support, an authorization for release of medical
information and fraud prevention investigation, employment services registration and
perjury and general declarations.

The applicant must read all pages. If the applicant is unable to read and/or understand
these assignments and penalty warnings, it is up to county staff to explain them to the
applicant. The applicant has the option on the top of page 6 to indicate if they need help
reading or understanding the information.

Page 6 also contains the penalty warnings and qualification questions. The applicant will
need to answer yes or no to these questions. The questions are:

1.      Has a court or any other civil or administrative process in Minnesota or any other
        state found anyone in the household guilty or has anyone been disqualified from
        receiving public assistance for breaking any of the rules above?

2.      Has anyone in the household been convicted of making fraudulent statements about
        their place of residence to get cash or medical benefits from more than one state?

3.      Is anyone in your household hiding or running from the law to avoid prosecution,
        being taken into custody, or to avoid going to jail for a felony?

4.      Has anyone in your household been convicted of a drug felony since July 1, 1997?

5.      Is anyone in your household currently violating a condition of parole, probation or
        supervised release?


If the applicant has checked yes to any of these questions, they will then need to list the
household member(s) and which question(s) they pertain to. These questions are asked to
determine if an individual(s) is ineligible or will be terminated from assistance for a certain
period of time, or subject to special requirements. Note: GAMC applicants who use the
CAF must also complete the Required Questions for GAMC (DHS-3423) at the time of
application to confirm that they meet certain legal and other criteria. Some of the required
questions are included on the CAF, but not all of them.

Verification required: Verify only if questionable




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Common forms of Verification: Admission on CAF, results of random drug testing, court
documents.

Documentation on the WIF: Indicate the applicant’s admission and any offenses and
indicate how you verified this.

MAXIS panel: STAT/DISQ

References:              CM 0011.27                Criminal Conviction
                         CM 0011.27.03             Drug Felons
                         CM 0011.27.06             Parole Violators
                         CM 0011.27.09             Fleeing Felons
                         CM 0014.06                Who Must Be Excluded From Assistance Unit
                         HCPM 03.50.15             Legal Factors for GAMC


The remainder of page 6 contains information for the applicant regarding medical
assignment of benefits and assignment of support.

Page 7 contains authorizations for release of medical and information for fraud investigation
purposes. If the applicant is applying for either cash or Food Support, when they sign the
application, they are automatically registered for employment services. This includes
everyone in the home the county approves to receive assistance.

Keep in mind that anyone in the household may apply and sign the CAF Page 1. But after
you determine which applicants are members of a unit, there are certain people who must
sign the CAF. Each program has specific requirements, for example, both parents in a two-
parent DWP and MFIP household must sign. Each person signing is signing the fraud
statement.

You may find more than one assistance unit in the same household. Applicants have the
right to use the same CAF to apply for more than one assistance unit. An example would
be two single-parent siblings who live together and eat together. They would be one Food
Support assistance unit, if applying only for Food Support; but two DWP and MFIP units, if
applying for cash assistance. If both units choose to apply on the same CAF, both
caregivers would need to sign the CAF, and you would copy the CAF for the case record of
the second MFIP unit. It is up to the applicants to decide if they want to use the same CAF
or complete an additional one. Note their decision on the WIF.




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A complete application is a signed and dated CAF with all questions answered. If an
Authorized Representative filled out the CAF, his/her signature would go where indicated
as well as the date the form was filled out.

As a Financial Worker, you must sign page 7 of the CAF and fill in the date the CAF
was received.

If the applicant fails to return the CAF or does not come in for an interview, the application
will be denied 30 days following the date the CAF Page 1 was received in your agency.

Documentation on the WIF: Indicate if the Rights and Responsibilities (R&R) were
reviewed with the applicant (the tear off page on the CAF), if you gave or discussed with
the applicant the Family Violence Referral (DHS-3323). Also indicate if you gave the
applicant the Domestic Violence Information brochure (DHS-3477) as well as the Notice of
Privacy Practices (DHS-3979) and a Change Report Form (DHS-2402). The Change
Report Form is required for Food Support, and strongly recommended for all other
programs. Note if you gave the applicant an ADA brochure (DHS-4133) and the Important
Information sheet (DHS-5223B).

References:              CM 0005.12.06             Who Must Sign applications
                         CM 0007.15                Unscheduled Reporting Of Changes - Cash
                         CM 0007.15.03             Unscheduled Reporting Of Changes - FS
                         CM 0025.24                Fraudulently Obtaining Public Assistance
                         CM 0028.03.06             Determining the FS Principal Wage Earner




CAF Page 8

Page 8 is used for additional information that the applicant may have, i.e. additional
household members. There is also a large space available for additional details. Be sure to
check the back page for information from the applicant.

Documentation on the WIF: Indicate whether or not the applicant had to use page 8 and
what type of information was given.




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FORMS RELATED TO DETERMINING ELIGIBILITY


DHS-2919A&B              Verification Request Form
DHS-2243                 Consent for Release of Information About Assets
DHS-2243A                General Consent for Release of Information
DHS-2952                 Consent for Release of Information About Residence and Shelter
                         Expenses
DHS-1503                 Long Term Care Facility Physician Certification
DHS-161A                 Request for Adult Medical Examination
DHS-161B                 Request for Child Medical Examination
DHS-1467A                State Medical Review Team Determination of Disability
DHS-2904A                Children’s Activities of Daily Living
DHS-3163B                Referral to Support and Collections
DHS-2338                 Cooperation with Child Support Enforcement/Statement of Good
                         Cause
DHS-2646                 Financial Aid Information Form
DHS-2120                 Household Report Form
DHS-2402                 Change Report Form
DHS 3336                 Self-Employment Report Form
DHS-2237                 Medical Service Questionnaire
DHS-3439                 Minnesota Health Care Programs Medicare Buy-in Referral Letter
DHS-1844                 Medical Expenses Form
DHS-1922B                Third Party Liability Resource Information
DHS-2841                 Referral For Cost Effective Health Insurance Review
DHS-2883                 Request for Verification of School Attendance / Progress
DHS-4864                 Guide to Non-citizen Eligibility for Cash and Food Support




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ADDITIONAL INFORMATION

A complete list of all forms is available online at www.dhs.state.mn.us
- click on Forms (e-Docs)

Use the search engine to access the most current versions of DHS documents. The forms
will be fillable on-line, and workers will be able to save the completed form to their
computers/county networks if they have Adobe Reader 7.0 or a later version. This is
especially important for workers who choose to complete the WIF on-line as a part of the
interview so they do not lose what they have completed if there is a power issue during the
interview process. Workers can maintain the completed WIF electronically and/or as a
printed form in the s file as long as the form is available to anyone who needs access to
review the case. Along with the development of a new Combined Application Form a new
CAF Addendum (DHS-5223C) and the CAF Child Care Addendum (DHS-5223D) have
been developed that are laid out consistent with the DHS-5223 format.


The application forms can also be found at the following direct links:

Combined Application Form (DHS-5223)
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5223-ENG
Worker Interview Form (WIF) (DHS-5223A)
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5223A-ENG
CAF Important Information sheet (DHS-5223B)
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5223B-ENG
Combined Application - Addendum (DHS-5223C)
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5223C-ENG
Combined Application - Child Care Addendum (DHS-5223D)
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5223D-ENG
MFIP Transition Application Form (DHS-5223E)
http://edocs.dhs.state.mn.us/lfserver/Legacy/DHS-5223E-ENG




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GLOSSARY


A
ADDENDUM: The Combined Application - Addendum (cash, Food Support, and Health
Care) (DHS-5223C), used to add people to an existing assistance unit.


C
COMBINED APPLICATION FORM (CAF): The Combined Application Form (DHS-5223)
is the form on which people apply for multiple assistance programs including: cash
assistance, Food Support, Emergency Programs, and Health Care.

COMBINED MANUAL (CM): The Combined Manual (CM) gives financial workers a
complete, authoritative, concise set of provisions to determine eligibility for the cash and
food programs and to issue applicant benefits on MAXIS.



D
DIVERSIONARY WORK PROGRAM (DWP): DWP is a short-term, work focused program
for families applying for cash benefits. It provides a maximum of 4 consecutive months in a
12-month period, of necessary services and supports to families which will lead to
unsubsidized employment, increase economic stability, and reduce the risk of needing
longer term assistance under MFIP.



E
EMERGENCY GENERAL ASSISTANCE (EGA): An assistance program available to units
who are ineligible for Emergency Minnesota Supplemental Aid and who are in an
emergency situation.

EMERGENCY MEDICAL ASSISTANCE (EMA): A program meeting the emergency
medical needs of people ineligible for Medical Assistance.

EMERGENCY MINNESOTA SUPPLEMENTAL AID (EMSA): A program meeting the
emergency needs of Minnesota Supplemental Aid participants.




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F
FOOD SUPPORT EMPLOYMENT AND TRAINING (FSET): An employment and training
program for some Food Support participants.

FOOD SUPPORT (FS): Benefits issued under the Food Support Program for the purchase
of food.

FOOD SUPPORT PROGRAM: Minnesota’s name for the Food Stamp Program, a United
States Department of Agriculture program that issues benefits in the form of electronic
benefits to increase food purchasing power.



G
GENERAL ASSISTANCE (GA): A program providing financial assistance and services to
people who are unable to provide for themselves.

GENERAL ASSISTANCE MEDICAL CARE (GAMC): A program authorized under
Minnesota Statutes 256D.03 to provide medical care to people receiving GA, or ineligible
for medical coverage through MSA or MA as long as ineligibility for MA is not due to
program non-compliance. People on GAMC may be eligible for MINNESOTACARE but
may not be covered on both programs at the same time.

GROUP RESIDENTIAL HOUSING (GRH): A state-funded program that provides at a
minimum, room and board for unrelated people who live in certain licensed or registered
group living arrangements and who receive SSI or would be eligible for SSI except for
excess income and are blind, age 65 or older, or disabled and age 18 or older, or meet a
category of eligibility under the GA program.




M
MAXIS: Minnesota's statewide automated eligibility system for public assistance programs.

MEDICAL ASSISTANCE (MA): The program established under Title XIX of the Social
Security Act and Minnesota Statutes 256B providing for health care to needy people.

MINNESOTACARE (MCRE): A premium-based health care coverage program for
uninsured Minnesota residents who meet the income guidelines.




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MINNESOTA FAMILY INVESTMENT PROGRAM (MFIP): Minnesota's Family Assistance
program. The program is both TANF and state-funded. MFIP benefits provide cash and
food benefits to eligible applicants.

MINNESOTA FOOD ASSISTANCE PROGRAM (MFAP): For DWP participants who do
not qualify for federally funded Food Support due to non-citizen status and who are age 50
or older; and for Non-citizens who do not receive MFIP and who do not qualify for federally
funded Food Support due to citizenship requirements, and who are age 50 or older. They
must meet all other Food Support eligibility requirements, and unless exempt or deferred,
are subject to work provisions as well as FSET participation requirements. The amount of
state-funded benefits will be equal to the amount of benefits that would have been received
under the federal Food Support program if citizenship requirements were met. It will be
referred to in MAXIS as the State Food Amount.

MINNESOTA SUPPLEMENTAL AID (MSA): A state-funded program that provides cash
assistance to SSI recipients, blind people, people age 65 or older, and DISABLED
people who are age 18 and older.



P
PERSONAL RESPONSIBILITY AND WORK OPPORTUNITY AND RECONCILIATION
ACT (PRWORA): An agreement signed into law on 8-22-96 which eliminated the federal
entitlement program of Aid to Families with Dependent Children and created a new
program called Temporary Assistance for Needy Families (TANF). PRWORA provides
block grants to states to offer time-limited cash assistance. It also made major changes in
the Food Support Program.



T
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) GRANT: A federal grant
which replaced the AFDC program in Minnesota.




W
WORKER INTERVIEW FORM (WIF): The Worker Interview Form (DHS-5223A) is a
document designed for you to record information given in the application interview.




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