DCH-1181 (Rev. 12-21) Previous edition obsolete. 1

DCH-1181 COMPLETION INSTRUCTIONS

Collect the following documents (copies are acceptable):

Your child’s legal birth certificate. (Your child must be under age 18.)

Your most recently filed Michigan income tax return (MI-1040), or if a MI-1040 income tax form was not filed, you may submit a copy of your most recently filed United States (US-1040) income tax return. For new applicants only, other evidence of current year income may be used if neither a Michigan nor a U.S. income tax form was filed. Your family’s taxable income must not exceed $60,000. In situations where there is joint physical custody, both parents must submit a copy of their individual tax return.

Your child’s social security card (optional). If your child does not currently have a social security number, you may apply online for one through the Social Security Administration http://www.ssa.gov or telephone 800-772-1213. You may apply for this subsidy while you are waiting to receive a social security number.

Note: This information will be used to complete the application and will serve as proof of eligibility. Make sure to submit copies as any documents you provide will not be returned to you.

You must also contact your child’s local public school, intermediate school district or regional educational services agency and provide authorization to send or fax written verification of your child’s educational eligibility category and, if necessary, evidence of educational programming to your local county community mental health services program (CMHSP). This is the agency that provided you with this form. Please note that the only special education eligibility categories that meet FSS criteria are Severe Cognitive Impairment, Severe Multiple Impairment or Autism Spectrum Disorder AND in a program that qualifies under FSS law. Your CMHSP representative will provide you with a fax number and/or mailing address for the educational institution to use in transferring required documentation.

Other information:

If your child is currently living in a nursing home, center for persons with developmental disabilities, foster family care home or residential school, you may apply for FSS if the child is returning to your home in a very short period of time.

If your child is adopted and enrolled in the Michigan Department of Health and Human Services, Adoption Subsidy Program, you may continue to receive the monthly adoption subsidy even if your child becomes eligible for FSS payments. Your child may NOT, however, also have an open medical subsidy within the Adoption Subsidy Program. If you are unsure if your child has an open medical subsidy, you can verify this information by calling (517) 335-6443. If there is an open medical subsidy, you may wish to request closure of it as a means to meeting FSS eligibility requirements.

Line-by-line completion instructions:

1. Purpose:

Check New Applicant if this is the first time you have applied for the subsidy.

Check Annual Renewal if you are renewing eligibility.

Check Restore if there has been a gap in eligibility/payments.

Check Change of Status and write in the corresponding block number(s) to report changes in information previously provided. When reporting a change in status, you need to complete ONLY blocks 1, 2, 3 and 4 as well as the block(s) containing the information that has changed.

2. Child’s Name – First, Middle Initial, Last.

3. Child’s Date of Birth – Month/Day/Year.

4. Child’s Social Security Number. Note: You may apply for FSS at the same time that you are completing social security number registration for your child.

5. Child’s Gender – Male or Female.

6. Telephone Number – Your primary telephone number including area code.

7. Race (optional)

a) White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

b) Black or African American - A person having origins in any of the Black racial groups of Africa.

c) American Indian and Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

DCH-1181 (Rev. 12-21) Previous edition obsolete. 1

DCH-1181 COMPLETION INSTRUCTIONS

Collect the following documents (copies are acceptable):

Your child’s legal birth certificate. (Your child must be under age 18.)

Your most recently filed Michigan income tax return (MI-1040), or if a MI-1040 income tax form was not filed, you may submit a copy of your most recently filed United States (US-1040) income tax return. For new applicants only, other evidence of current year income may be used if neither a Michigan nor a U.S. income tax form was filed. Your family’s taxable income must not exceed $60,000. In situations where there is joint physical custody, both parents must submit a copy of their individual tax return.

Your child’s social security card (optional). If your child does not currently have a social security number, you may apply online for one through the Social Security Administration http://www.ssa.gov or telephone 800-772-1213. You may apply for this subsidy while you are waiting to receive a social security number.

Note: This information will be used to complete the application and will serve as proof of eligibility. Make sure to submit copies as any documents you provide will not be returned to you.

You must also contact your child’s local public school, intermediate school district or regional educational services agency and provide authorization to send or fax written verification of your child’s educational eligibility category and, if necessary, evidence of educational programming to your local county community mental health services program (CMHSP). This is the agency that provided you with this form. Please note that the only special education eligibility categories that meet FSS criteria are Severe Cognitive Impairment, Severe Multiple Impairment or Autism Spectrum Disorder AND in a program that qualifies under FSS law. Your CMHSP representative will provide you with a fax number and/or mailing address for the educational institution to use in transferring required documentation.

Other information:

If your child is currently living in a nursing home, center for persons with developmental disabilities, foster family care home or residential school, you may apply for FSS if the child is returning to your home in a very short period of time.

If your child is adopted and enrolled in the Michigan Department of Health and Human Services, Adoption Subsidy Program, you may continue to receive the monthly adoption subsidy even if your child becomes eligible for FSS payments. Your child may NOT, however, also have an open medical subsidy within the Adoption Subsidy Program. If you are unsure if your child has an open medical subsidy, you can verify this information by calling (517) 335-6443. If there is an open medical subsidy, you may wish to request closure of it as a means to meeting FSS eligibility requirements.

Line-by-line completion instructions:

1. Purpose:

Check New Applicant if this is the first time you have applied for the subsidy.

Check Annual Renewal if you are renewing eligibility.

Check Restore if there has been a gap in eligibility/payments.

Check Change of Status and write in the corresponding block number(s) to report changes in information previously provided. When reporting a change in status, you need to complete ONLY blocks 1, 2, 3 and 4 as well as the block(s) containing the information that has changed.

2. Child’s Name – First, Middle Initial, Last.

3. Child’s Date of Birth – Month/Day/Year.

4. Child’s Social Security Number. Note: You may apply for FSS at the same time that you are completing social security number registration for your child.

5. Child’s Gender – Male or Female.

6. Telephone Number – Your primary telephone number including area code.

7. Race (optional)

a) White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.

b) Black or African American - A person having origins in any of the Black racial groups of Africa.

c) American Indian and Alaska Native - A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment.

DCH-1181 (Rev. 12-21) Previous edition obsolete. 2

d) Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

e) Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

f) Some other race.

g) Unknown.

8. Name of public school that signed the Multi-Disciplinary Evaluation Team (MET) report.

9. Parent/Guardian Name (First, Middle Initial, Last) THE PERSON LISTED IN THIS BOX WILL BE THE SOLE PAYEE FOR FSS PAYMENTS. If you desire both parents’/guardians’ names on the check then select “Another Payee” and the other parent/guardian must complete block 20.

10. Parent/Guardian Social Security Number – Enter the SSN of the person listed in block 9.

11. Print the address where the child resides (must be same as parent/guardian- only one address may be listed).

12. Has the child’s residence changed in the last year? If yes, enter previous city name.

13. Is your child adopted? Check yes or no.

14. If your child is adopted, check yes or no indicating if the child is receiving a medical subsidy through the Michigan Department of Health and Human Services Adoption Subsidy Program.

15. Check the bracket corresponding to the taxable income amount displayed on line 16 on your most recently filed Michigan income tax form (MI-1040). If a Michigan income tax form was not filed, you will be required to complete a Michigan Department of Treasury 4095 form to prove that you did not file a Michigan income tax form. Your CMHSP will guide you in this process. (Note: if joint physical custody, both parents’ incomes must be reported.

16. Confirm yes or no that the child lives in Michigan with one or both of the persons listed in blocks 9 and 20. If no, fill in the month and year the child left the family home.

17. If no is marked in block 16, indicate whether the child is temporarily living with another relative.

18. It is important to read and understand all the items listed. Your signature in block 19 (and 20 if another payee is listed) indicates that you understand and agree to all bulleted items.

Questions about the information displayed in this block can be directed to the agency representative providing you with this form.

19. Signature of the person named in block 9. Be sure to include the date of signature.

20. If “another payee” was selected in block 9, the other parent/guardian must complete block 20.

The bottom portion of the application is for CMHSP use.

NEXT STEPS: Take or send this completed application along with a copy of your most recently filed Michigan income tax form, a copy of your child’s legal birth certificate and a copy of your child’s social security card to the CMHSP representative that gave this paperwork to you. You must also contact your child’s public school, intermediate school district or regional services educational agency to give them permission for the sharing of documentation with the CMHSP. The CMHSP representative will give you a fax number or mailing address that the school can use to send the required educational information.

DCH-1181 (Rev. 12-21) Previous edition obsolete. 2

d) Asian - A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

e) Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

f) Some other race.

g) Unknown.

8. Name of public school that signed the Multi-Disciplinary Evaluation Team (MET) report.

9. Parent/Guardian Name (First, Middle Initial, Last) THE PERSON LISTED IN THIS BOX WILL BE THE SOLE PAYEE FOR FSS PAYMENTS. If you desire both parents’/guardians’ names on the check then select “Another Payee” and the other parent/guardian must complete block 20.

10. Parent/Guardian Social Security Number – Enter the SSN of the person listed in block 9.

11. Print the address where the child resides (must be same as parent/guardian- only one address may be listed).

12. Has the child’s residence changed in the last year? If yes, enter previous city name.

13. Is your child adopted? Check yes or no.

14. If your child is adopted, check yes or no indicating if the child is receiving a medical subsidy through the Michigan Department of Health and Human Services Adoption Subsidy Program.

15. Check the bracket corresponding to the taxable income amount displayed on line 16 on your most recently filed Michigan income tax form (MI-1040). If a Michigan income tax form was not filed, you will be required to complete a Michigan Department of Treasury 4095 form to prove that you did not file a Michigan income tax form. Your CMHSP will guide you in this process. (Note: if joint physical custody, both parents’ incomes must be reported.

16. Confirm yes or no that the child lives in Michigan with one or both of the persons listed in blocks 9 and 20. If no, fill in the month and year the child left the family home.

17. If no is marked in block 16, indicate whether the child is temporarily living with another relative.

18. It is important to read and understand all the items listed. Your signature in block 19 (and 20 if another payee is listed) indicates that you understand and agree to all bulleted items.

Questions about the information displayed in this block can be directed to the agency representative providing you with this form.

19. Signature of the person named in block 9. Be sure to include the date of signature.

20. If “another payee” was selected in block 9, the other parent/guardian must complete block 20.

The bottom portion of the application is for CMHSP use.

NEXT STEPS: Take or send this completed application along with a copy of your most recently filed Michigan income tax form, a copy of your child’s legal birth certificate and a copy of your child’s social security card to the CMHSP representative that gave this paperwork to you. You must also contact your child’s public school, intermediate school district or regional services educational agency to give them permission for the sharing of documentation with the CMHSP. The CMHSP representative will give you a fax number or mailing address that the school can use to send the required educational information.

DCH-1181 (Rev. 12-21) Previous edition obsolete. See instructions on Pages 1 and 2

FAMILY SUPPORT SUBSIDY PROGRAM 1. Purpose New Applicant Annual Renewal Michigan Department of

Health and Human Services Restore Change of Status (Enter block #s that have changed):____________

2. Child’s name (first, middle initial, last) 3. Date of Birth (m/dd/yy) 4. Child’s SSN

5. Gender 6. Primary Telephone No. 7. Race (see instructions for codes)

8. Name of public school signing MET report

Male Female

9. Parent/Guardian name (first, middle initial, last) Another payee (If yes fill 10. Parent/Guardian SSN

Yes No in block 20) IMPORTANT: If found eligible, Family Support Subsidy checks will be mailed to this address.

11. Parent/Guardian Address (number & street) City State Zip Code

12. Has your family moved in the last year? No Yes Previous city:

13. Is your child adopted? 14. If yes, is your child receiving a medical subsidy through the Adoption

No Yes Subsidy Program? No Yes

15. What is your taxable income as listed (line 16) on your most recently filed Michigan income tax form?

(If joint physical custody, both parent’s incomes must be reported.)

$19,999 or Less $20,000 - $44,999 $45,000 - $60,000 Over $60,000

16. Does your child currently live in Michigan with one or both of the parents/guardians listed? Yes No If no, date child left the family home: Month:_______ Year_______

17. Does your child temporarily live with a relative?

Yes No

18. PARENT/GUARDIAN CERTIFICATION:

I agree to notify my county Family Support Subsidy coordinator within two weeks of any changes in information reported on this form.

I understand that a change in status can include name, address, living arrangement, an open medical subsidy, a more recent tax return with a taxable income of more than $60,000, or a change in the child's educational eligibility category and/or programming.

I understand that this program requires a yearly renewal near or during my child's birth month and that I must contact my community mental health services program to start the renewal process.

There is a two-month grace period following my child's birth month in which I may renew the subsidy without penalty.

If I fail to reapply within the renewal period or grace period, I will not receive compensation for any payments I may have missed if my child is later found eligible. The new eligibility period will start and payments will resume the month following receipt of a complete packet of renewal information.

I agree that subsidy dollars received will be used to meet the special needs of my child/family.

I declare that this information is complete and true to the best of my knowledge.

I understand that providing false information or failing to provide notice of a change in required information may result in denial of eligibility, repayment of any amount inappropriately received and perjury penalties as provided by law.

19. Parent/Guardian signature Date

20. Other Payee (Parent/Guardian signature) Other Payee (printed name) Other Payee SSN Date

THIS SECTION IS FOR CMHSP USE ONLY – DO NOT WRITE BELOW THIS LINE

Child’s current education eligibility category:

21. Severe Cognitive Impairment: If Severe Cognitive Impairment, does the documentation include written verification from the public school that the child’s latest intellectual assessment shows development at a rate of 4.5 or more standard deviations below the mean? Yes No

22. Autism Spectrum Disorder: If Autism Spectrum Disorder, does the child’s special education programming fall under any of the following options?

1) Severe Cognitive Impairment Program (R340.1738) .................................... Yes No

2) Severe Multiple Impairments Program (R340.1748) ..................................... Yes No

3) Autism Spectrum Disorder Program (R340.1758) ........................................ Yes No

23. Severe Multiple Impairment

Is this family eligible for the one-time double subsidy payment to prepare for the child’s return to home?

Yes No

Has this child been in an out-of-home placement during the past 12 months? Yes No If yes, enter the date child returned home: Month:_______________________ Year:_______________ Type of out-of-home placement: Group Home Foster Care Other (explain):_____________ Complete application packet received date (M/DD/YY) Effective Date (M/DD/YY) Expiration Date (M/DD/YY)

Eligible CMHSP authorized signature Date CMHSP Board No.

Yes No (Due to block #):_____

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

AUTHORITY: Sections 155-161 of PA 258 of 1974, as amended.

COMPLETION: Is voluntary for a new application, but is required for annual renewal, change of status or restore to active status.

DCH-1181 (Rev. 12-21) Previous edition obsolete. See instructions on Pages 1 and 2

FAMILY SUPPORT SUBSIDY PROGRAM 1. Purpose New Applicant Annual Renewal Michigan Department of

Health and Human Services Restore Change of Status (Enter block #s that have changed):____________

2. Child’s name (first, middle initial, last) 3. Date of Birth (m/dd/yy) 4. Child’s SSN

5. Gender 6. Primary Telephone No. 7. Race (see instructions for codes)

8. Name of public school signing MET report

Male Female

9. Parent/Guardian name (first, middle initial, last) Another payee (If yes fill 10. Parent/Guardian SSN

Yes No in block 20) IMPORTANT: If found eligible, Family Support Subsidy checks will be mailed to this address.

11. Parent/Guardian Address (number & street) City State Zip Code

12. Has your family moved in the last year? No Yes Previous city:

13. Is your child adopted? 14. If yes, is your child receiving a medical subsidy through the Adoption

No Yes Subsidy Program? No Yes

15. What is your taxable income as listed (line 16) on your most recently filed Michigan income tax form?

(If joint physical custody, both parent’s incomes must be reported.)

$19,999 or Less $20,000 - $44,999 $45,000 - $60,000 Over $60,000

16. Does your child currently live in Michigan with one or both of the parents/guardians listed? Yes No If no, date child left the family home: Month:_______ Year_______

17. Does your child temporarily live with a relative?

Yes No

18. PARENT/GUARDIAN CERTIFICATION:

I agree to notify my county Family Support Subsidy coordinator within two weeks of any changes in information reported on this form.

I understand that a change in status can include name, address, living arrangement, an open medical subsidy, a more recent tax return with a taxable income of more than $60,000, or a change in the child's educational eligibility category and/or programming.

I understand that this program requires a yearly renewal near or during my child's birth month and that I must contact my community mental health services program to start the renewal process.

There is a two-month grace period following my child's birth month in which I may renew the subsidy without penalty.

If I fail to reapply within the renewal period or grace period, I will not receive compensation for any payments I may have missed if my child is later found eligible. The new eligibility period will start and payments will resume the month following receipt of a complete packet of renewal information.

I agree that subsidy dollars received will be used to meet the special needs of my child/family.

I declare that this information is complete and true to the best of my knowledge.

I understand that providing false information or failing to provide notice of a change in required information may result in denial of eligibility, repayment of any amount inappropriately received and perjury penalties as provided by law.

19. Parent/Guardian signature Date

20. Other Payee (Parent/Guardian signature) Other Payee (printed name) Other Payee SSN Date

THIS SECTION IS FOR CMHSP USE ONLY – DO NOT WRITE BELOW THIS LINE

Child’s current education eligibility category:

21. Severe Cognitive Impairment: If Severe Cognitive Impairment, does the documentation include written verification from the public school that the child’s latest intellectual assessment shows development at a rate of 4.5 or more standard deviations below the mean? Yes No

22. Autism Spectrum Disorder: If Autism Spectrum Disorder, does the child’s special education programming fall under any of the following options?

1) Severe Cognitive Impairment Program (R340.1738) .................................... Yes No

2) Severe Multiple Impairments Program (R340.1748) ..................................... Yes No

3) Autism Spectrum Disorder Program (R340.1758) ........................................ Yes No

23. Severe Multiple Impairment

Is this family eligible for the one-time double subsidy payment to prepare for the child’s return to home?

Yes No

Has this child been in an out-of-home placement during the past 12 months? Yes No If yes, enter the date child returned home: Month:_______________________ Year:_______________ Type of out-of-home placement: Group Home Foster Care Other (explain):_____________ Complete application packet received date (M/DD/YY) Effective Date (M/DD/YY) Expiration Date (M/DD/YY)

Eligible CMHSP authorized signature Date CMHSP Board No.

Yes No (Due to block #):_____

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

AUTHORITY: Sections 155-161 of PA 258 of 1974, as amended.

COMPLETION: Is voluntary for a new application, but is required for annual renewal, change of status or restore to active status.

MDHHS

Michigan Department of

Health and Human Services Restore Change of Status (Enter block #s that have changed):____________

2. Child’s name (first, middle initial, last) 3. Date of Birth (m/dd/yy) 4. Child’s SSN

5. Gender 6. Primary Telephone No. 7. Race (see instructions for codes)

8. Name of public school signing MET report

Male Female

9. Parent/Guardian name (first, middle initial, last) Another payee (If yes fill 10. Parent/Guardian SSN

Yes No in block 20) IMPORTANT: If found eligible, Family Support Subsidy checks will be mailed to this address.

11. Parent/Guardian Address (number & street) City State Zip Code

12. Has your family moved in the last year? No Yes Previous city:

13. Is your child adopted? 14. If yes, is your child receiving a medical subsidy through the Adoption

No Yes Subsidy Program? No Yes

15. What is your taxable income as listed (line 16) on your most recently filed Michigan income tax form?

(If joint physical custody, both parent’s incomes must be reported.)

$19,999 or Less $20,000 - $44,999 $45,000 - $60,000 Over $60,000

16. Does your child currently live in Michigan with one or both of the parents/guardians listed? Yes No If no, date child left the family home: Month:_______ Year_______

17. Does your child temporarily live with a relative?

Yes No

18. PARENT/GUARDIAN CERTIFICATION:

I agree to notify my county Family Support Subsidy coordinator within two weeks of any changes in information reported on this form.

I understand that a change in status can include name, address, living arrangement, an open medical subsidy, a more recent tax return with a taxable income of more than $60,000, or a change in the child's educational eligibility category and/or programming.

I understand that this program requires a yearly renewal near or during my child's birth month and that I must contact my community mental health services program to start the renewal process.

There is a two-month grace period following my child's birth month in which I may renew the subsidy without penalty.

If I fail to reapply within the renewal period or grace period, I will not receive compensation for any payments I may have missed if my child is later found eligible. The new eligibility period will start and payments will resume the month following receipt of a complete packet of renewal information.

I agree that subsidy dollars received will be used to meet the special needs of my child/family.

I declare that this information is complete and true to the best of my knowledge.

I understand that providing false information or failing to provide notice of a change in required information may result in denial of eligibility, repayment of any amount inappropriately received and perjury penalties as provided by law.

19. Parent/Guardian signature Date

20. Other Payee (Parent/Guardian signature) Other Payee (printed name) Other Payee SSN Date

THIS SECTION IS FOR CMHSP USE ONLY – DO NOT WRITE BELOW THIS LINE

Child’s current education eligibility category:

21. Severe Cognitive Impairment: If Severe Cognitive Impairment, does the documentation include written verification from the public school that the child’s latest intellectual assessment shows development at a rate of 4.5 or more standard deviations below the mean? Yes No

22. Autism Spectrum Disorder: If Autism Spectrum Disorder, does the child’s special education programming fall under any of the following options?

1) Severe Cognitive Impairment Program (R340.1738) .................................... Yes No

2) Severe Multiple Impairments Program (R340.1748) ..................................... Yes No

3) Autism Spectrum Disorder Program (R340.1758) ........................................ Yes No

23. Severe Multiple Impairment

Is this family eligible for the one-time double subsidy payment to prepare for the child’s return to home?

Yes No

Has this child been in an out-of-home placement during the past 12 months? Yes No If yes, enter the date child returned home: Month:_______________________ Year:_______________ Type of out-of-home placement: Group Home Foster Care Other (explain):_____________ Complete application packet received date (M/DD/YY) Effective Date (M/DD/YY) Expiration Date (M/DD/YY)

Eligible CMHSP authorized signature Date CMHSP Board No.

Yes No (Due to block #):_____

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

AUTHORITY: Sections 155-161 of PA 258 of 1974, as amended.

COMPLETION: Is voluntary for a new application, but is required for annual renewal, change of status or restore to active status.

DCH-1181 (Rev. 12-21) Previous edition obsolete. See instructions on Pages 1 and 2

FAMILY SUPPORT SUBSIDY PROGRAM 1. Purpose New Applicant Annual Renewal Michigan Department of

Health and Human Services Restore Change of Status (Enter block #s that have changed):____________

2. Child’s name (first, middle initial, last) 3. Date of Birth (m/dd/yy) 4. Child’s SSN

5. Gender 6. Primary Telephone No. 7. Race (see instructions for codes)

8. Name of public school signing MET report

Male Female

9. Parent/Guardian name (first, middle initial, last) Another payee (If yes fill 10. Parent/Guardian SSN

Yes No in block 20) IMPORTANT: If found eligible, Family Support Subsidy checks will be mailed to this address.

11. Parent/Guardian Address (number & street) City State Zip Code

12. Has your family moved in the last year? No Yes Previous city:

13. Is your child adopted? 14. If yes, is your child receiving a medical subsidy through the Adoption

No Yes Subsidy Program? No Yes

15. What is your taxable income as listed (line 16) on your most recently filed Michigan income tax form?

(If joint physical custody, both parent’s incomes must be reported.)

$19,999 or Less $20,000 - $44,999 $45,000 - $60,000 Over $60,000

16. Does your child currently live in Michigan with one or both of the parents/guardians listed? Yes No If no, date child left the family home: Month:_______ Year_______

17. Does your child temporarily live with a relative?

Yes No

18. PARENT/GUARDIAN CERTIFICATION:

I agree to notify my county Family Support Subsidy coordinator within two weeks of any changes in information reported on this form.

I understand that a change in status can include name, address, living arrangement, an open medical subsidy, a more recent tax return with a taxable income of more than $60,000, or a change in the child's educational eligibility category and/or programming.

I understand that this program requires a yearly renewal near or during my child's birth month and that I must contact my community mental health services program to start the renewal process.

There is a two-month grace period following my child's birth month in which I may renew the subsidy without penalty.

If I fail to reapply within the renewal period or grace period, I will not receive compensation for any payments I may have missed if my child is later found eligible. The new eligibility period will start and payments will resume the month following receipt of a complete packet of renewal information.

I agree that subsidy dollars received will be used to meet the special needs of my child/family.

I declare that this information is complete and true to the best of my knowledge.

I understand that providing false information or failing to provide notice of a change in required information may result in denial of eligibility, repayment of any amount inappropriately received and perjury penalties as provided by law.

19. Parent/Guardian signature Date

20. Other Payee (Parent/Guardian signature) Other Payee (printed name) Other Payee SSN Date

THIS SECTION IS FOR CMHSP USE ONLY – DO NOT WRITE BELOW THIS LINE

Child’s current education eligibility category:

21. Severe Cognitive Impairment: If Severe Cognitive Impairment, does the documentation include written verification from the public school that the child’s latest intellectual assessment shows development at a rate of 4.5 or more standard deviations below the mean? Yes No

22. Autism Spectrum Disorder: If Autism Spectrum Disorder, does the child’s special education programming fall under any of the following options?

1) Severe Cognitive Impairment Program (R340.1738) .................................... Yes No

2) Severe Multiple Impairments Program (R340.1748) ..................................... Yes No

3) Autism Spectrum Disorder Program (R340.1758) ........................................ Yes No

23. Severe Multiple Impairment

Is this family eligible for the one-time double subsidy payment to prepare for the child’s return to home?

Yes No

Has this child been in an out-of-home placement during the past 12 months? Yes No If yes, enter the date child returned home: Month:_______________________ Year:_______________ Type of out-of-home placement: Group Home Foster Care Other (explain):_____________ Complete application packet received date (M/DD/YY) Effective Date (M/DD/YY) Expiration Date (M/DD/YY)

Eligible CMHSP authorized signature Date CMHSP Board No.

Yes No (Due to block #):_____

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

AUTHORITY: Sections 155-161 of PA 258 of 1974, as amended.

COMPLETION: Is voluntary for a new application, but is required for annual renewal, change of status or

CMSHP

Michigan Department of

Health and Human Services Restore Change of Status (Enter block #s that have changed):____________

2. Child’s name (first, middle initial, last) 3. Date of Birth (m/dd/yy) 4. Child’s SSN

5. Gender 6. Primary Telephone No. 7. Race (see instructions for codes)

8. Name of public school signing MET report

Male Female

9. Parent/Guardian name (first, middle initial, last) Another payee (If yes fill 10. Parent/Guardian SSN

Yes No in block 20) IMPORTANT: If found eligible, Family Support Subsidy checks will be mailed to this address.

11. Parent/Guardian Address (number & street) City State Zip Code

12. Has your family moved in the last year? No Yes Previous city:

13. Is your child adopted? 14. If yes, is your child receiving a medical subsidy through the Adoption

No Yes Subsidy Program? No Yes

15. What is your taxable income as listed (line 16) on your most recently filed Michigan income tax form?

(If joint physical custody, both parent’s incomes must be reported.)

$19,999 or Less $20,000 - $44,999 $45,000 - $60,000 Over $60,000

16. Does your child currently live in Michigan with one or both of the parents/guardians listed? Yes No If no, date child left the family home: Month:_______ Year_______

17. Does your child temporarily live with a relative?

Yes No

18. PARENT/GUARDIAN CERTIFICATION:

I agree to notify my county Family Support Subsidy coordinator within two weeks of any changes in information reported on this form.

I understand that a change in status can include name, address, living arrangement, an open medical subsidy, a more recent tax return with a taxable income of more than $60,000, or a change in the child's educational eligibility category and/or programming.

I understand that this program requires a yearly renewal near or during my child's birth month and that I must contact my community mental health services program to start the renewal process.

There is a two-month grace period following my child's birth month in which I may renew the subsidy without penalty.

If I fail to reapply within the renewal period or grace period, I will not receive compensation for any payments I may have missed if my child is later found eligible. The new eligibility period will start and payments will resume the month following receipt of a complete packet of renewal information.

I agree that subsidy dollars received will be used to meet the special needs of my child/family.

I declare that this information is complete and true to the best of my knowledge.

I understand that providing false information or failing to provide notice of a change in required information may result in denial of eligibility, repayment of any amount inappropriately received and perjury penalties as provided by law.

19. Parent/Guardian signature Date

20. Other Payee (Parent/Guardian signature) Other Payee (printed name) Other Payee SSN Date

THIS SECTION IS FOR CMHSP USE ONLY – DO NOT WRITE BELOW THIS LINE

Child’s current education eligibility category:

21. Severe Cognitive Impairment: If Severe Cognitive Impairment, does the documentation include written verification from the public school that the child’s latest intellectual assessment shows development at a rate of 4.5 or more standard deviations below the mean? Yes No

22. Autism Spectrum Disorder: If Autism Spectrum Disorder, does the child’s special education programming fall under any of the following options?

1) Severe Cognitive Impairment Program (R340.1738) .................................... Yes No

2) Severe Multiple Impairments Program (R340.1748) ..................................... Yes No

3) Autism Spectrum Disorder Program (R340.1758) ........................................ Yes No

23. Severe Multiple Impairment

Is this family eligible for the one-time double subsidy payment to prepare for the child’s return to home?

Yes No

Has this child been in an out-of-home placement during the past 12 months? Yes No If yes, enter the date child returned home: Month:_______________________ Year:_______________ Type of out-of-home placement: Group Home Foster Care Other (explain):_____________ Complete application packet received date (M/DD/YY) Effective Date (M/DD/YY) Expiration Date (M/DD/YY)

Eligible CMHSP authorized signature Date CMHSP Board No.

Yes No (Due to block #):_____

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

AUTHORITY: Sections 155-161 of PA 258 of 1974, as amended.

COMPLETION: Is voluntary for a new application, but is required for annual renewal, change of status or restore to active status.

DCH-1181 (Rev. 12-21) Previous edition obsolete. See instructions on Pages 1 and 2

FAMILY SUPPORT SUBSIDY PROGRAM 1. Purpose New Applicant Annual Renewal Michigan Department of

Health and Human Services Restore Change of Status (Enter block #s that have changed):____________

2. Child’s name (first, middle initial, last) 3. Date of Birth (m/dd/yy) 4. Child’s SSN

5. Gender 6. Primary Telephone No. 7. Race (see instructions for codes)

8. Name of public school signing MET report

Male Female

9. Parent/Guardian name (first, middle initial, last) Another payee (If yes fill 10. Parent/Guardian SSN

Yes No in block 20) IMPORTANT: If found eligible, Family Support Subsidy checks will be mailed to this address.

11. Parent/Guardian Address (number & street) City State Zip Code

12. Has your family moved in the last year? No Yes Previous city:

13. Is your child adopted? 14. If yes, is your child receiving a medical subsidy through the Adoption

No Yes Subsidy Program? No Yes

15. What is your taxable income as listed (line 16) on your most recently filed Michigan income tax form?

(If joint physical custody, both parent’s incomes must be reported.)

$19,999 or Less $20,000 - $44,999 $45,000 - $60,000 Over $60,000

16. Does your child currently live in Michigan with one or both of the parents/guardians listed? Yes No If no, date child left the family home: Month:_______ Year_______

17. Does your child temporarily live with a relative?

Yes No

18. PARENT/GUARDIAN CERTIFICATION:

I agree to notify my county Family Support Subsidy coordinator within two weeks of any changes in information reported on this form.

I understand that a change in status can include name, address, living arrangement, an open medical subsidy, a more recent tax return with a taxable income of more than $60,000, or a change in the child's educational eligibility category and/or programming.

I understand that this program requires a yearly renewal near or during my child's birth month and that I must contact my community mental health services program to start the renewal process.

There is a two-month grace period following my child's birth month in which I may renew the subsidy without penalty.

If I fail to reapply within the renewal period or grace period, I will not receive compensation for any payments I may have missed if my child is later found eligible. The new eligibility period will start and payments will resume the month following receipt of a complete packet of renewal information.

I agree that subsidy dollars received will be used to meet the special needs of my child/family.

I declare that this information is complete and true to the best of my knowledge.

I understand that providing false information or failing to provide notice of a change in required information may result in denial of eligibility, repayment of any amount inappropriately received and perjury penalties as provided by law.

19. Parent/Guardian signature Date

20. Other Payee (Parent/Guardian signature) Other Payee (printed name) Other Payee SSN Date

THIS SECTION IS FOR CMHSP USE ONLY – DO NOT WRITE BELOW THIS LINE

Child’s current education eligibility category:

21. Severe Cognitive Impairment: If Severe Cognitive Impairment, does the documentation include written verification from the public school that the child’s latest intellectual assessment shows development at a rate of 4.5 or more standard deviations below the mean? Yes No

22. Autism Spectrum Disorder: If Autism Spectrum Disorder, does the child’s special education programming fall under any of the following options?

1) Severe Cognitive Impairment Program (R340.1738) .................................... Yes No

2) Severe Multiple Impairments Program (R340.1748) ..................................... Yes No

3) Autism Spectrum Disorder Program (R340.1758) ........................................ Yes No

23. Severe Multiple Impairment

Is this family eligible for the one-time double subsidy payment to prepare for the child’s return to home?

Yes No

Has this child been in an out-of-home placement during the past 12 months? Yes No If yes, enter the date child returned home: Month:_______________________ Year:_______________ Type of out-of-home placement: Group Home Foster Care Other (explain):_____________ Complete application packet received date (M/DD/YY) Effective Date (M/DD/YY) Expiration Date (M/DD/YY)

Eligible CMHSP authorized signature Date CMHSP Board No.

Yes No (Due to block #):_____

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

AUTHORITY: Sections 155-161 of PA 258 of 1974, as amended.

COMPLETION: Is voluntary for a new application, but is required for annual renewal, change of status or

PARENT / GUARDIAN

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