Application For State Emergency Relief - Dhs-1514 printable pdf download

Case Name:

Case Number:

Date:

APPLICATION FOR STATE

MDHHS Office:

EMERGENCY RELIEF

Specialist / ID:

Michigan Department of Health and Human Services

Phone:

Fax:

Individual ID:

I hereby make application for the State Emergency Relief (SER) Program. I understand that the following information will be used in the

determination of my eligibility for SER. I also understand that there may be a delay in processing if there is missing information. If this

application is for burial services, I understand that it must be received by the MDHHS office in my area no later than 10 business days after

the burial, cremation or donation takes place. For energy related emergencies, the SER crisis season runs from November 1 through

May 31. Requests for those services will be denied June 1 through October 31.

HOUSEHOLD INFORMATION – Attach extra pages if you need to include additional members

List everyone who lives in your home, including adults and children temporarily absent due to illness or employment. People are considered

members of your household if they sleep and keep their belongings in your home. Be sure to include the date of birth and citizenship status for

each member. If you are applying for burial assistance only, list the deceased first.

Name

Relationship to you

Social Security number

Date of birth

Citizen?

SELF

Yes

HOUSEHOLD ADDRESS

Address (Number and street name, Apt., etc.)

City

State

Zip code

MAILING ADDRESS, if different than above

Address (Number and Street Name, Apt., etc.)

City

State

Zip code

CONTACT INFORMATION

Phone number to reach you

Contact name and number to leave messages

Email address

Has anyone ever been convicted of a drug-related felony that occurred after August 22, 1996?

Yes



Yes

If yes, who?

Convicted more than once?

Is anyone in violation of probation or on parole?

Yes



If yes, who?

HOW DO YOU HEAT YOUR HOME?

Natural Gas

Propane

Wood

No heat obligation

Fuel oil

Electricity

Coal

Unknown

Has your electricity been turned off?

Yes, date service was turned off:

Have you received a past due or shut off notice for your electricity?

Yes, when is electric service scheduled to be turned off:

Has your heat been turned off or have you run out of your only heating fuel source?

Yes, date heat was turned off or when fuel ran out:

Have you received a past due or shut off notice for your heat or are you at risk of running out of your household heating fuel?

Yes, number of days until fuel runs out or date service is scheduled to be shut off:

HOME HEATING CREDIT - Did you receive the Home Heating Credit in the last 6 months?

Yes, month received

HAVE YOU OR DO YOU CURRENTLY RECEIVE OTHER BENEFITS FROM MDHHS?

Yes

HAVE YOU RECEIVED ENERGY ASSISTANCE (Example: MEAP) FROM ANOTHER AGENCY OR THROUGH A PROVIDER-

Application For State Emergency Relief - Dhs-1514

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