A verbal client statement indicating residency in Minnesota meets the verification requirement. 2.2948 3.1191 Td When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. 4 0 obj W The number of hours of employment or work program activities. /ZaDb 5.1626 Tf in SNAP deletes all policy about non-mandatory verifications and moves it to 0010.18.02.03 (Non-Mandatory Verifications SNAP) and adds a cross-reference to 0010.18.02.03 (Non-Mandatory Verifications SNAP). When used, this form also meets any monthly report requirement clients may have for cash, SNAP or health care programs. Go to the Department of Human Services' (DHS) e-Docs site and search for the form by entering the DHS form number. 0000005955 00000 n /Type /Catalog q BENEFIT LEVEL - MFIP/DWP/GA, 0022.12.01 - HOW TO CALCULATE BENEFIT LEVEL - SNAP/MSA/GRH, 0022.12.02 - BEGINNING DATE OF ELIGIBILITY, 0022.15.03 - BUDGETING LUMP SUMS IN A PROSPECTIVE MONTH, 0022.15.06 - BUDGETING LUMP SUMS IN A RETROSPECTIVE MONTH, 0022.18.03 - OVERPAYMENTS RELATING TO SUSPENDED CASES, 0022.21 - INCOME OVERPAYMENT RELATING TO BUDGET CYCLE, 0022.24 - UNCLE HARRY FOOD SUPPORT BENEFITS, 0023.09 - HOUSEHOLD FURNISHINGS AND APPLIANCES, 0024.03 - WHEN BENEFITS ARE PAID - MFIP/DWP, 0024.03.03 - WHEN BENEFITS ARE PAID - SNAP/MSA/GA/GRH, 0024.04.03.03 - BENEFIT DELIVERY METHODS--PROGRAM PROVISIONS, 0024.04.04 - CHANGES IN AUTOMATIC BENEFIT DELIVERY METHOD, 0024.06 - PROVISIONS FOR REPLACING BENEFITS, 0024.06.03 - SITUATIONS REQUIRING SNAP BENEFIT REPLACEMENT, 0024.06.03.03 - REPLACING SNAP STOLEN/LOST BEFORE RECEIPT, 0024.06.03.15 - REPLACING FOOD DESTROYED IN A DISASTER, 0024.06.03.18 - REPLACING DAMAGED SNAP CASH-OUT WARRANTS, 0024.09.01 - PROTECTIVE AND VENDOR PAYMENTS-SNAP/MSA/GA/GRH, 0024.09.09 - DISCONTINUING PROTECTIVE AND VENDOR PAYMENTS, 0024.09.12 - PAYMENTS AFTER CHEMICAL USE ASSESSMENT, 0024.12 - ISSUING AND REPLACING IDENTIFICATION CARDS, 0025.03 - DETERMINING INCORRECT PAYMENT AMOUNTS, 0025.06 - MAINTAINING RECORDS OF INCORRECT PAYMENTS, 0025.09.03 - WHERE TO SEND CORRECTIVE PAYMENTS, 0025.12.03 - OVERPAYMENTS EXEMPT FROM RECOVERY, 0025.12.03.03 - SUSPENDING OR TERMINATING RECOVERY, 0025.12.03.09 - CLAIM COMPROMISE & TERMINATION, 0025.12.06 - REPAYING OVERPAYMENTS - PARTICIPANTS, 0025.12.09 - REPAYING OVERPAYMENTS - NON-PARTICIPANTS, 0025.12.12 - ACTION ON OVERPAYMENTS - TIME LIMITS, 0025.15 - ORDER OF RECOVERY - PARTICIPANTS, 0025.18 - ORDER OF RECOVERY - NON-PARTICIPANTS, 0025.21.03 - OVERPAYMENT REPAYMENT AGREEMENT, 0025.24 - FRAUDULENTLY OBTAINING PUBLIC ASSISTANCE, 0025.24.03 - RECOVERING FRAUDULENTLY OBTAINED ASSISTANCE, 0025.24.06.03 - ADMINISTRATIVE DISQUALIFICATION HEARING, 0025.24.07 - DISQUALIFICATION FOR ILLEGAL USE OF SNAP, 0025.24.08 - SNAP ELECTRONIC DISQUALIFIED RECIPIENT SYSTEM, 0025.30 - FINANCIAL RESPONSIBILITY, PEOPLE NOT IN HOME, 0025.30.03 - CONTRIBUTIONS FROM PARENTS NOT IN HOME. 0000001233 00000 n Authorization for Release of Information About Residence and Shelter Expenses (DHS, 0004.12 (Verification Requirements for Emergency A, 0010.18.01 (Mandatory Verifications - Cash Assistance), 0010.18.02 (Mandatory Verifications - SNAP), 0017.15.15 (Income of Minor Child/Caregiver Under 20), 0010.18.02.03 (Non-Mandatory Verifications SNAP). Your report month is: 2. SERVICES SANCTIONS, 0028.30.04.03 - POST 60-MONTH SANCTIONS: 2-PARENT PROVISIONS, 0028.30.06 - SANCTIONS FOR NOT MEETING SNAP WORK RULE, 0028.30.09 - REFUSING OR TERMINATING EMPLOYMENT, 0028.30.12 - SANCTION NOTICE FOR MINOR CAREGIVER, 0028.33 - EMPLOYMENT SERVICES/SNAP E&T NOTICE REQUIREMENTS, 0029.03.06 - FAMILY SUPPORT GRANT PROGRAM, 0029.03.09 - CONSUMER SUPPORT GRANT PROGRAM, 0029.03.18 - RELATIVE CUSTODY ASSISTANCE PROGRAM, 0029.06.03 - SUPPLEMENTAL SECURITY INCOME PROGRAM, 0029.06.06 - RETIREMENT, SURVIVORS AND DISABILITY INSURANCE, 0029.06.21 - UNITED STATES REPATRIATION PROGRAM, 0029.06.24.03 - TRIBAL TANF - MILLE LACS BAND OF OJIBWE, 0029.06.24.06 - TRIBAL TANF - RED LAKE BAND OF CHIPPEWA INDIANS, 0029.07.03 - MINNESOTA STATE FOOD BENEFITS, 0029.07.09 - WOMEN, INFANTS AND CHILDREN (WIC) PROGRAM, 0029.07.12 - COMMODITY SUPPLEMENTAL FOOD PROGRAM, 0029.07.15 FOOD DISTRIBUTION PROGRAM-INDIAN RESERVATION, 0029.20.09 - FAMILY HOMELESS PREVENTION ASSISTANCE, 0029.27 - LOW INCOME HOME ENERGY ASSISTANCE PROGRAM, 0029.31 - CHILD CARE RESOURCE AND REFERRAL, 0030.03.01.01 - INELIGIBLE FOR OTHER CASH PROGRAMS, 0030.03.09 - DETERMINING RCA GROSS INCOME, 0030.03.16 - PROCESSING REPORTED CHANGES - RCA, 0030.03.18 - RCA OVERPAYMENTS AND UNDERPAYMENTS, 0030.12.03 - RCA POST-SECONDARY EDUCATION/TRAINING, 0030.12.06 - RCA EMPLOYMENT SERVICES GOOD CAUSE CLAIMS. 0000007685 00000 n Click Done after twice-checking all the data. 0 0 9.96 9 re Household Report Form - Fill Out and Sign Printable PDF Template | signNow 0000001677 00000 n endstream endobj 425 0 obj <>/Subtype/Form/Type/XObject>>stream 0000007179 00000 n EMC BENEFIT LEVEL - MFIP/DWP/GA, 0022.12.01 - HOW TO CALCULATE BENEFIT LEVEL - SNAP/MSA/GRH, 0022.12.02 - BEGINNING DATE OF ELIGIBILITY, 0022.15.03 - BUDGETING LUMP SUMS IN A PROSPECTIVE MONTH, 0022.15.06 - BUDGETING LUMP SUMS IN A RETROSPECTIVE MONTH, 0022.18.03 - OVERPAYMENTS RELATING TO SUSPENDED CASES, 0022.21 - INCOME OVERPAYMENT RELATING TO BUDGET CYCLE, 0022.24 - UNCLE HARRY FOOD SUPPORT BENEFITS, 0023.09 - HOUSEHOLD FURNISHINGS AND APPLIANCES, 0024.03 - WHEN BENEFITS ARE PAID - MFIP/DWP, 0024.03.03 - WHEN BENEFITS ARE PAID - SNAP/MSA/GA/GRH, 0024.04.03.03 - BENEFIT DELIVERY METHODS--PROGRAM PROVISIONS, 0024.04.04 - CHANGES IN AUTOMATIC BENEFIT DELIVERY METHOD, 0024.06 - PROVISIONS FOR REPLACING BENEFITS, 0024.06.03 - SITUATIONS REQUIRING SNAP BENEFIT REPLACEMENT, 0024.06.03.03 - REPLACING SNAP STOLEN/LOST BEFORE RECEIPT, 0024.06.03.15 - REPLACING FOOD DESTROYED IN A DISASTER, 0024.06.03.18 - REPLACING DAMAGED SNAP CASH-OUT WARRANTS, 0024.09.01 - PROTECTIVE AND VENDOR PAYMENTS-SNAP/MSA/GA/GRH, 0024.09.09 - DISCONTINUING PROTECTIVE AND VENDOR PAYMENTS, 0024.09.12 - PAYMENTS AFTER CHEMICAL USE ASSESSMENT, 0024.12 - ISSUING AND REPLACING IDENTIFICATION CARDS, 0025.03 - DETERMINING INCORRECT PAYMENT AMOUNTS, 0025.06 - MAINTAINING RECORDS OF INCORRECT PAYMENTS, 0025.09.03 - WHERE TO SEND CORRECTIVE PAYMENTS, 0025.12.03 - OVERPAYMENTS EXEMPT FROM RECOVERY, 0025.12.03.03 - SUSPENDING OR TERMINATING RECOVERY, 0025.12.03.09 - CLAIM COMPROMISE & TERMINATION, 0025.12.06 - REPAYING OVERPAYMENTS - PARTICIPANTS, 0025.12.09 - REPAYING OVERPAYMENTS - NON-PARTICIPANTS, 0025.12.12 - ACTION ON OVERPAYMENTS - TIME LIMITS, 0025.15 - ORDER OF RECOVERY - PARTICIPANTS, 0025.18 - ORDER OF RECOVERY - NON-PARTICIPANTS, 0025.21.03 - OVERPAYMENT REPAYMENT AGREEMENT, 0025.24 - FRAUDULENTLY OBTAINING PUBLIC ASSISTANCE, 0025.24.03 - RECOVERING FRAUDULENTLY OBTAINED ASSISTANCE, 0025.24.06.03 - ADMINISTRATIVE DISQUALIFICATION HEARING, 0025.24.07 - DISQUALIFICATION FOR ILLEGAL USE OF SNAP, 0025.24.08 - SNAP ELECTRONIC DISQUALIFIED RECIPIENT SYSTEM, 0025.30 - FINANCIAL RESPONSIBILITY, PEOPLE NOT IN HOME, 0025.30.03 - CONTRIBUTIONS FROM PARENTS NOT IN HOME. in general provisions updates the name and hyperlink for the Verification Request Form (DHS-2919). n CF 1042 (11-14) Title: HENNEPIN COUNTY Subject ( Author: Shari Sellner Last modified by: Anne C . hbbd```b``"wH`j Document in MAXIS CASE/NOTEs the identity information obtained from SOLQ as a "Verify MN interface". A verbal client statement indicating residency in Minnesota meets the verification requirement. l(i`_Vh5F,mXB7sJK~A."ak&MaWtyB\"#upI7HD6 .Qpfv \#ba=Jzc0%FFA(=Z(pK4V:pT"#nQ $F_Mq~$\b7 .QpQ $FF#Lzup! in SNAP adds a new last paragraph to not request verification of earned income of an elementary, secondary, or GED student IF the student is in school at least half-time, is under age 18, and is working. Forms / Minnesota Department of Employment and Economic Development Home Programs and Services Dislocated Worker Program For Counselors and Service Providers Forms Forms Here we offer these frequently requested forms and tools. The participant's last day of employment was 01/13 and received the last check 1/13. EDAK 3641DIAL BrochureBrochure explaining how use the Dakota Information Access Line (DIAL) system. This can be verified with the income verifications that are provided by the client. Registered unlicensed individuals, as part of renewing their registration, must provide verification of their employment by a licensed contractor or registered employer during the registration period. endstream endobj 422 0 obj <>/Subtype/Form/Type/XObject>>stream ^ey$>PzVjP~64$b*a`?H"4{p1 j X 1300.0170 STOP WORK ORDER. in SNAP under sub-heading ABAWDs in the 3rd bullet adds and deletes language and cross-references for clarity. Also see 0010.18.01 (Mandatory Verifications - Cash Assistance) for additional MFIP provisions relating to citizenship and immigration status. See 0011.24 (Time-limited SNAP Recipients) for more information on counted months used in another state. Authorization to Release Employment Information - Minnesota: Fill out You do not have to sign this form if either the requesting organization or the organization supplying the information is left blank. CASES, 0022.09 - WHEN TO SWITCH BUDGET CYCLES - CASH, 0022.09.03 - WHEN TO SWITCH BUDGET CYCLES - SNAP, 0022.12 - HOW TO CALC. FAX: 612-321-3488. << The participant's last day of employment was 01/13 and received the last check 1/13. W - This form is used to designate an authorized representative of your choosing who can communicate with Economic Assistance. Use the Verification Request Form (DHS-2919) (PDF) to request needed verification. Also see 0010.18.01 (Mandatory Verifications - Cash Assistance) for additional MFIP provisions relating to citizenship and immigration status. 4.9716 TL Q 0000006074 00000 n PARENT/GUARD. f 0000020915 00000 n Verify eligibility factors at initial application. The process is simple and automated, and most employees are verified within 24 hours. /Tx BMC 409 0 obj <> endobj 0000024995 00000 n >> Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than . /Tx BMC GEN 335 General Assistance Advanced Age Form - This form is used to verify a person meets the advanced age guidelines for General Assistance. >> endobj Case Name: Case Number: 15. >> Paperwork can also be submitted by email to EADocs@co.anoka.mn.us. ET Date and reason of employment termination, and date last paid. /ZaDb 5.1626 Tf n /H [ 0000001041 0000000192] 1300.0170 - MN Rules Part - Minnesota GEN 280 Drug Felony Release form - This form is used to allow Economic Assistance to obtain information regarding drug test results. 0026.12.12 - WHEN NOT TO GIVE ADDITIONAL NOTICE, 0026.12.15 - WHEN TO GIVE RETROACTIVE OR NO NOTICE, 0026.12.21 - VOLUNTARY REQUEST FOR CLOSURE NOTICE, 0026.15 - NOTICE OF DENIAL, TERMINATION, OR SUSPENSION, 0026.21 - NOTICE OF CHANGE IN ISSUANCE METHOD, 0026.24 - NOTICE OF RELATIVE CONTRIBUTION. 0 0 Td Forms - Dakota County, Minnesota 0000021573 00000 n Q 0 0 9.96 9 re in general provisions in the 2nd paragraph in the 3rd bullet adds and deletes information. Applying for MNsure Helpful Information - This document gives you step by step instructions for completing an online MNsure application. PDF Individual Electrical License Exam Application - Minnesota Below is a list of frequently requested Human services forms. The verification must be in existing files. endstream endobj 427 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream SERV. See 0010.18 (Mandatory Verifications) for mandatory verifications that apply to all programs. n >> 1 1 7.96 7 re q Verification Forms: DHS-2146 Authorization for Release of Employment Information - This form is completed by an employer to verify employment start, stop, or wage change. OF MINOR CRGVR, 0016.18.01 - 200 PERCENT OF FEDERAL POVERTY GUIDELINES, 0016.21 - INCOME OF SPONSORS OF IMMIGRANTS WITH I-134, 0016.21.03 - INCOME OF SPONSORS OF LPRS WITH I-864, 0016.27 - INCOME FROM SPOUSES WHO CHOOSE NOT TO APPLY, 0016.33 - INCOME OF INELIGIBLE NON-CITIZENS, 0016.39 - INCOME OF TIME-LIMITED RECIPIENTS, 0017.03 - AVAILABLE OR UNAVAILABLE INCOME, 0017.09 - CONVERTING INCOME TO MONTHLY AMOUNTS, 0017.12 - DETERMINING IF INCOME IS EARNED OR UNEARNED, 0017.15.03 - CHILD AND SPOUSAL SUPPORT INCOME, 0017.15.12 - INFREQUENT, IRREGULAR INCOME, 0017.15.15 - INCOME OF MINOR CHILD/CAREGIVER UNDER 20, 0017.15.18 - EMPLOYMENT, TRAINING, AND NATIONAL SERVICE INCOME, 0017.15.33.03 - SELF-EMPLOYMENT, CONVERT INC. TO MONTHLY AMT, 0017.15.33.24 - SELF-EMPLOYMENT INCOME FROM FARMING, 0017.15.33.27 - SELF-EMPLOYMENT INCOME FROM ROOMER/BOARDER, 0017.15.33.30 - SELF-EMPLOYMENT INCOME FROM RENTAL PROPERTY, 0017.15.36 - STUDENT FINANCIAL AID INCOME, 0017.15.36.03 - WHEN TO BUDGET STUDENT FINANCIAL AID, 0017.15.36.06 - IDENTIFYING TITLE IV OR FEDERAL STUDENT AID, 0017.15.36.09 - STUDENT FINANCIAL AID DEDUCTIONS, 0017.15.42 - INTEREST AND DIVIDEND INCOME, 0017.15.45.03 - HOW TO DETERMINE GROSS RSDI, 0017.15.48 - DISPLACED HOMEMAKER PROGRAM INCOME, 0017.15.51 - PAYMENTS RESULTING FROM DISASTER DECLARATION, 0017.15.54 - CAPITAL GAINS AND LOSSES AS INCOME, 0017.15.57 - PAYMENTS TO PERSECUTION VICTIMS, 0017.15.63 - RELATIVE CUSTODY ASSISTANCE GRANTS, 0017.15.78 - NATIONAL AND COMMUNITY SERVICE PROGRAMS, 0017.15.84 - CONTRACTS FOR DEED AS INCOME, 0018.06.06 - PLAN TO ACHIEVE SELF-SUPPORT (PASS), 0018.12.03 - ALLOWABLE SNAP MEDICAL EXPENSES, 0018.15.03 - SHELTER DEDUCTION - HOME TEMPORARILY VACATED, 0018.33 - CHILD AND SPOUSAL SUPPORT DEDUCTIONS, 0018.39 - PRIOR AND OTHER INCOME REDUCTIONS, 0018.42 - INCOME UNAVAILABLE IN FIRST MONTH, 0019.03 - GROSS INCOME TEST - WHAT INCOME TO USE, 0019.09 - GIT FOR SEPARATE ELDERLY DISABLED UNITS, 0020.03 - PEOPLE EXEMPT FROM NET INCOME LIMITS, 0020.06 - CHOOSING THE ASSISTANCE STANDARD TABLE, 0022 - BUDGETING AND BENEFIT DETERMINATION, 0022.03 - HOW AND WHEN TO USE PROSPECTIVE BUDGETING, 0022.03.01 - PROSPECTIVE BUDGETING - PROGRAM PROVISIONS, 0022.03.01.03 - PROSPECTIVE BUDGETING - SNAP PROVISIONS, 0022.03.03 - INELIGIBILITY IN A PROSPECTIVE MONTH - CASH, 0022.03.04 - INELIGIBILITY IN A PROSPECTIVE MONTH - SNAP, 0022.06 - HOW AND WHEN TO USE RETROSPECTIVE BUDGETING, 0022.06.03 - WHEN NOT TO BUDGET INCOME IN RETRO. for more information on counted months used in another state. DHS 2952 Authorization for Release of Information About Residence and Shelter Expenses - This form is used to allow a landlord or homeowner information about your shelter expense. DHS 3543 Request for Payment of Long Term Care Services - This form is for people currently open on Medical Assistance (MA) that need waiver services, assisted living services, or nursing home services paid. endstream endobj 415 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Residency in Minnesota, unless verification cannot be obtained because the people are homeless, migrant farmworkers, or newly arrived in Minnesota. This form is for clients who have a six-month renewal for health care eligibility or a six-month report for the Supplemental Nutrition Assistance Program (SNAP) due. Counted TLR months used in another state. /Tx BMC 2.7962 2.7525 Td GEN 262 Special Diets - This form is used to provide information regarding diets prescribed by a doctor. endstream endobj 435 0 obj <>/Subtype/Form/Type/XObject>>stream This information can be obtained from the client's Employment Services Provider. MANDATORY VERIFICATIONS - dhs.state.mn.us 0000019279 00000 n f endstream endobj 439 0 obj <>/Subtype/Form/Type/XObject>>stream /Root 3 0 R ET /MediaBox [0 0 612 792] _ ! 2 0 obj Verification of participation is required every 12 months or when there is a change in the clients participation, whichever comes first. updates cross-references to 0007.03.02 (Six-Month Reporting) only due to section title changes. << Truework allows you to complete employee, employment and income verifications faster. 0000019329 00000 n W Student course of study if attending a post-secondary institution. Verify at the point of employment termination for participants, and for any employment terminated within 60 days of application for applicants. Other Items to Consider. It looks like your browser does not have JavaScript enabled. Email us at compliance.mdhr@state.mn.us or call 651-539-1095. This is valid for 1 year or when I withdraw it in writing. Household Report Form Case number: How to fill out this form: 1. If no other form of verification is available or if the client chooses to use a form to verify residence or shelter expenses, you may use the Authorization for Release of Information About Residence and Shelter Expenses (DHS-2952) (PDF). Unless questionable, a verbal statement from the client meets the verification requirement. Minnesota Employment Verification Form - signNow /Tx BMC /Contents 6 0 R The following list includes the most commonly requested forms. We would like to show you a description here but the site won't allow us. in SNAP in the 2nd paragraph clarifies to allow the listed verifications only if an applicant/participant wants a deduction from their income for them. /Tx BMC endstream endobj 413 0 obj <>/Subtype/Form/Type/XObject>>stream MFIP/DWP Commonly Used eDocs Forms - dhs.state.mn.us "H`DH.~ "9H0:@X,r,bb{5 I& |##(9$L @/b /Tx BMC W Tips on how to complete the Stop working form online: To get started on the form, use the Fill camp; Sign Online button or tick the preview image of the document. in SNAP deletes to verify disability exemption from work registration. Minneapolis, MN 55487-0718. See 0010.18.06 (Verifying Disability/Incapacity SNAP). - Participants of Refugee Cash Assistance (RCA) when they are working with a Refugee Employment Services Provider. You may also mail any paperwork to our mailing address listed on this page. /F1 10 0 R /L 0000026108 GEN 260 Sponsor Release of Information - This form is used to allow Economic Assistance to communicate with the client's sponsor. endstream BT startxref /ExtGState << EMC 481 0 obj <>/Filter/FlateDecode/ID[<6D1378B16692F9479C354AD2C049B183>]/Index[409 149]/Info 408 0 R/Length 206/Prev 521012/Root 410 0 R/Size 558/Type/XRef/W[1 3 1]>>stream 1 1 7.96 7 re Verify the exemptions listed below at application time and/or when a change occurs. 0000006779 00000 n * 4. DOC Hennepin County 0000025069 00000 n EMC Verify the following for all programs: Inconsistent information. Verify the exemptions listed below at application time and/or when a change occurs. 0000025773 00000 n DHS 2338 Cooperation with Child Support EnforcementForm that client completes about cooperating with child support to receive public assistance. For more information about running SAVE, see 0010.18.11.03 (Systematic Alien Verification (SAVE)). FREE 13+ Work Verification Forms in PDF | Ms Word - sampleforms SNAP Application Packet - This packet provides SNAP program information to people applying for SNAP benefits. DHS 2402-ENG Change Report FormReporting form used by clients to report income, asset, and circumstance changes usually on a non-scheduled basis. You must verify that the client is complying with Refugee Employment Services. endobj If the injury/disability is expected to last indefinitely, verification is only needed once. The locations accepting paperwork including vehicle tab renewals, property tax documents, child support and economic assistance applications, and reporting forms are: Paperwork that CANNOT be accepted at drop boxes are documents related to legal service, litigation, or court matters. PDF DHS-2120-ENG 9-17 Household Report Form - 83rd Minnesota Legislature 2 36 0000006987 00000 n In MFIP, DWP deletes all previous provisions and adds new provisions. Identity may be verified through a document, or if a document is not available a collateral contact can be used. Return this form no . endstream endobj 426 0 obj <>/ProcSet[/PDF/Text]>>/Subtype/Form/Type/XObject>>stream Fill out and return this form or your benefits may be late or stop. You must verify that the client is cooperating with the work requirements of this program. /ID [<1b285431b6d97f0b3d25c629171a4448>