Application For State Emergency Relief - Dhs-1514 (Page 4 of 4) in pdf

Case Name

Case Number

Specialist

Notes:

If you are not already registered to vote at your current address, would you like to register to vote?

Yes

NOTE: If you do not check either box, MDHHS will assume you have decided not to register to vote at this time.

Checking “yes” does not register you to vote. If you check “yes” or do not respond, a voter registration application

will be forwarded to you.

Applying or deciding to register to vote will not affect the amount of help that you will be provided by this department. If you

would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help

is yours. You may fill out the voter registration application form in private. If you believe that someone has interfered with your

right to: register to vote, decline to register to vote, privacy in deciding whether to register or in applying to register to vote, or

choose your own political party or other political preference, you may file a complaint with Michigan Secretary of State, PO Box

20126, Lansing, MI 48901-0726.

HEARINGS:

If you believe any action of the department is incorrect, or if the decision to approve or deny your application is not made within

10 (ten) days of the application date, you have the right to a hearing. A request for a hearing must be in writing, signed by you

or your authorized representative, and received by the Michigan Department of Health and Human Services within 90 days

following the date of this form. Hearing requests should be sent to your local MDHHS office in your area. You are entitled to

representation by an attorney or other person of your choice. However, the department does not pay for any legal expenses.

Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, religion, age, national

origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading,

writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to an MDHHS office in your area.

AUTHORITY: Act 280, P.A. 1939, as amended (sections 400.6, 400.14, 400.24, 400.68 MCL); 45 CFR 283, 120(b); Low Income Home Energy Assistance Act

of 1981, as amended; MCL 400.10; Administrative Codes Rules 400.7001-400.7049

COMPLETION: Required

PENALTY: Denial of SER.

DHS-1514 (Rev. 11-15) Previous edition obsolete.