Application For State Emergency Relief printable pdf download

Case Name:

Case Number:

Date:

APPLICATION FOR STATE

DHS Office:

EMERGENCY RELIEF

Specialist / ID:

Michigan Department of 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 DHS 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

HOW DO YOU HEAT YOUR HOME?

Natural Gas

Propane

Wood

No heat obligation

Fuel oil

Electricity

Coal

Unknown

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 DHS?

Yes

EMERGENCY NEED - Check the service(s) you are requesting and the amount needed to resolve the emergency - ATTACH PROOF

*Payment for deliverable fuel will not be made if, at the time of delivery, it is confirmed you have more than 25 percent of fuel remaining in your tank.

Eviction/relocation $

Heat $

Security Deposit

*If deliverable fuel, % remaining in tank

If this is a prepaid account, amount in account

Moving Expenses $

Mortgage

Electricity

If this is a prepaid account, amount in account

Homeowner’s Insurance $

Property Taxes

Water/Sewer $

Furnace Repair

Cooking Gas $

Burial/cremation

Home Repairs

Type of repair needed?

Migrant hospitalization

Yes → ATTACH PROOF OF CURRENT VALUE

HOUSEHOLD VEHICLE(S)

Does your household have any vehicles?

Car

Truck

Boat

Camper/trailer

Motorcycle

Other vehicle

Name(s) on Title or Registration

Make and Model

Year

Fair Market Value

Amount Owed

Yes → ATTACH PROOF OF CURRENT VALUE

HOUSEHOLD ASSETS

Does your household have any assets or joint accounts?

Cash

Money market accounts

Savings bonds, stocks or mutual funds

Patient trust fund

Checking account

Christmas club accounts

Land contact, mortgage or other note

Burial plot(s), casket, etc.

Savings account

Life Estate

payable to household member

Burial trust/funeral contract(s)

Credit union account

Life insurance

Tools and equipment, livestock or crops

Real estate

Certificate of deposit (CD)

OTHER (list)

IRA, KEOUGH, 401K or Deferred Comp. account(s)

Expect money from a lawsuit in the next 30 days

DHS-1514 (Rev. 9-13) Previous edition obsolete. MS Word

Application For State Emergency Relief

Related Articles

Related forms

Related Categories