Request For New PAN Card Or/ And Changes Or Correction in PAN Data Permanent Account Number (PAN) Please read Instructions ‘h’ & ‘i’ for selecting boxes on left margin of this form.
Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
Bureau of Hospitals and Behavioral Health Administration
Adult
Adoption
Adoption Facilitator Clearing House Record, DHS-4746 Adoption Facilitator Clearing House Record, - DHS-4746
Cash Assistance
Refugee Family Self-Sufficiency Plan
Addressing employment related service needs to help families become self-supporting. With the assistance and input of the refugee client, the refugee contractor must complete this plan within 30 days of receiving the referral, and send a completed and signed copy to the local MDHHS office within 5 days of completion.
Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
Child Care
Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
Child Support
Child Support Response Form - e842 If you are receiving public assistance, complete this form to provide additional information to your caseworker.
Apply for Child Support Online If you are not receiving public assistance, apply for Child Support Services online.
IV-D Child Support Services Application/Referral - DHS-1201 If you are not receiving public assistance, apply for Child Support Services with this paper form.
Solicitud Para Servicios de Sostenimento de Ninos (IV-D)/Recomendacion - DHS-1201-SP Si usted no está recibiendo asistencia pública, rellene este formulario para solicitar los servicios de Mantenimiento de Hijos
Children's Protective Services
Report of Actual or Suspected Child Abuse or Neglect - DHS-3200
Complete this form within 72 hours of calling in a suspicion of abuse or neglect.
Earned Income Tax Credit (EITC)
Emergency & Energy
Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
Food Assistance
Assistance Application (MDHHS-1171)
A packet containing an application for assistance, an information booklet and a filing form. The best way to apply for assistance is online using MI Bridges. If you need to use this paper application, keep in mind that you'll need to print and complete the application, and then take it to your local MDHHS office.
Interstate Compact
Interstate Compact on Juveniles Petition for Requisition to Return a Runaway Juvenile - DHS-1908 ICJ Form A
Interstate Compact on Juveniles Out of State Travel Permit and Agreement to Return - DHS-3034 ICJ Travel Permit
Interstate Compact on Juveniles Requisition for Escapee/Absconder/Juvenile Charged Delinquent (Rendition Amendment) - DHS-3036 ICJ Juvenile Rights
Interstate Compact on Juveniles Consent for Voluntary Return by Runaway, Escapee or Absconder - DHS-3037 ICJ Form III
Interstate Compact on Juveniles Parole or Probation Investigation Request - DHS-3038 ICJ Form IV
Interstate Compact on Juveniles Parolee/Probationer Report to Receiving State - DHS-3039 ICJ Form V
Interstate Compact on Juveniles Application for Services and Waiver - DHS-3040 ICJ Form 1A-VI
Licensing - Adult Foster Care & Homes for the Aged
Tan Form 49b Pdf
Licensing - Child Welfare
Report of Actual or Suspected Child Abuse or Neglect - DHS-3200
Complete this form within 72 hours of calling in a suspicion of abuse or neglect.
Native American Affairs (NAA) & Indian Outreach Services (IOS)
Relative Licensing
DHS-972 Relative Agreement for Placement and Licensure Rev 05/17
Medical Services
Health Coverage & Help Paying Costs Application - DCH-1426
The Michigan Department of Health and Human Services offers several medical assistance programs. Each program covers different groups of people and each program has different eligibility requirements.
Other
Tan Correction Form
Safe Delivery
Voluntary Medical Background Form - DHS-4819
If the surrendering parent wishes to provide information about their medical background, this information would assist with the newborn's care.
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Forma Voluntaria de Antecedentes Medicos para un Recien Nacido Entregado - DHS-4819-SP La Forma Voluntaria de Antecedentes Médicos para un Recién Nacido Entregado es llenada por el Proveedor de Servicios de Emergencia.
Voluntary Release for Adoption - DHS-4820
The Voluntary Release for Adoption of a Surrendered Newborn by Parent form is a written affirmation that the surrendering parent voluntary released their parental rights to their newborn child.