• Using DHS Forms and Applications
The DHS forms and applications listed here are only a portion of those available. Visit your local DHS Office for forms or applications not available through the Internet. The following documents are in PDF format. To view or print PDF files, you will need Adobe Acrobat Reader. If you do not already have Reader installed on your computer, it is available free of charge from Adobe's web site.

• Assistance Application (DHS-1171)
A packet containing an application for assistance, an information booklet and a filing form.

• Important Things About Programs and Services - DHS Pub-1010 

• Request for Central Registry Clearance - DHS-194 

• Solicitud de Asistencia - DHS-1171-SP

• Documento de Archivo - DHS-1171-F-SP 

• Original License Application Packet
Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Day Care Aide Provider Application - DHS-220-A 

• Solicitud del Ayudante de Cuidado - DHS-220-A-SP 

• Relative Care Provider Application - DHS-220-R 

• Solicitud del Cuidador Familiar - DHS-220-R-SP 

• Energy Supplier Participation Agreement - DHS-355 

• Adult Services Application - DHS-390 

• Adult Foster Care License Limited Liability Company Governmental Organization and Corporate Application - BCAL-569-C 

• Adult Foster Care License Individual Application - BCAL-569-I 

• Supplemental Application for State Emergency Relief - DHS-1514 

• Plan First! Family Planning Program Application - MSA-1582 

• Insurance Assistance Program and Insurance Assistance Program-Plus Application - DHS-1661 

• Retroactive Medicaid Application - DHS-3243 

• Solicitud Para Medicaid Retroactivo - DHS-3243-SP 

• Medicaid Application Patient of Nursing Home - DHS-4574 

• Solicitud para Medicaid Paciente de Asilo - DHS-4574-SP 

• Child Development and Care Application - DHS-4583 

• Solicitud de Desarrollo y Cuidado de Niños - DHS-4583-SP 

• Voter Registration Application and Michigan Driver License/Personal Identification Card Address Change Form NSP-0938-B 

• Solicitud de Registración del Votante,Forma para Cambiar Dirección de Licencia de Manejar de MI/Tarjeta de Identificación Personal NSP-938B-SP 

• Notification to Court of Jurisdiction and Child's Lawyer Guardian Ad Litem - DHS-867 

• Request for Medical Subsidy for An Adopted Child DHS-1341-A 

• Adult Former Sibling Statement to Release Information to Adult Adoptee DHS-1917 

• Release of Information to Adult Adoptee by Brother/Sister as proxy for Deceased Parent - DHS-1918 

• Parent's Consent/Denial to Release Information to Adult Adoptee - DHS-1919 

• Release of Information Authorization Adult Adoptee DHS-1920 

• Request by Adult Adoptee for Identifying Information - DHS-1925 

• Medical Needs - DHS-54-A 

• Adult Services Application - DHS-390 

• Personal Care Services Provider Log - DHS-721 

• Home Help Payment Schedule - DHS-1356 

• Insurance Assistance Program and Insurance Assistance Program-Plus Application - DHS-1661 

• Assistance Application (DHS-1171)
A packet containing an application for assistance, an information booklet and a filing form.

• Solicitud de Asistencia - DHS-1171-SP

• Documento de Archivo - DHS-1171-F-SP 

• Financial Assistance Payment Schedule - DHS-1111 

• Change Report - DHS-2240 

• Informe de Cambio - DHS-2240-SP 

• Retroactive Medicaid Application - DHS-3243 

• Solicitud Para Medicaid Retroactivo - DHS-3243-SP 

• DHS-1546-AR, Provider's Child Care Daily Time and Attendance Record. 

• Registro De Asistencia Y Tiempo Diario Del Proveedor De Cuidado De Niños - DHS-1546-SP 
Provider's Child Care Daily Time and Attendance Report- DHS-1546-SP

• Verificacion del Proveedor del Cuidado del Nino-DHS-4025-SP 

• Child Care Provider Verification-DHS-4025 

• Day Care Aide Provider Application - DHS-220-A 

• Solicitud del Ayudante de Cuidado - DHS-220-A-SP 

• Relative Care Provider Application - DHS-220-R 

• Solicitud del Cuidador Familiar - DHS-220-R-SP 

• Child Development and Care Parent Record - DHS-641 (Word)
Child Development and Care Parent Need Hours Worksheet

• Hoja de Trabajo Con Horarios Necesarios Para Padres con Niños en Desarrollo Y Cuidado Infantil - DHS-641-SP (Word)
Child Development and Care Parent Need Hours Worksheet

• Assistance Application (DHS-1171)
A packet containing an application for assistance, an information booklet and a filing form.

• Solicitud de Asistencia - DHS-1171-SP

• Documento de Archivo - DHS-1171-F-SP 

• Provider's Child Care Daily Time and Attendance Record - DHS-1546 

• Change Report - DHS-2240 

• Informe de Cambio - DHS-2240-SP 

• Child Development and Care Application - DHS-4583 

• Solicitud de Desarrollo y Cuidado de Niños - DHS-4583-SP 

• In Home Care Certification - DHS-167 (Word)

• In Home Care Certification - DHS-167 

• Basic Grant Certification - DHS-168 

• Basic Grant Certification - DHS-168 (Word)

• Monthly Report on Foster Care Under the Family Division of the Circuit Court - DHS-207 

• Monthly Report on Foster Care Under the Family Division of the Circuit Court - DHS-207 (Word)

• County Child Care Budget Summary - DHS-2091 

• County Child Care Budget Summary - DHS-2091 (Word)

• In Home Care Summary - DHS-2093 

• In Home Care Summary - DHS-2093 (Word)

• In Home Care/Basic Grant Budget Detail Report - DHS-2094 

• In Home Care/Basic Grant Budget Detail Report - DHS-2094 (Word)

• Basic Grant Summary - DHS-2095 

• Basic Grant Summary - DHS-2095 (Word)

• In Home Care Addendum for DHS-206B - DHS-2396 

• In Home Care Addendum for DHS-206B - DHS-2396 (Word)

• In Home Care/Basic Grant Program Component Report/Request - DHS-4471 

• In Home Care/Basic Grant Program Component Report/Request - DHS-4471 (Word)

• Child Care Fund Summary Report - DHS-4472 

• Child Care Fund Summary Report - DHS-4472 (Word)

• IV-D Child Support Services Application/Referral - DHS-1201 

• DHS Child Support Form and Publication Order Form - DHS-Pub 1454 

• Solicitud Para Servicios de Sostenimento de Ninos (IV-D)/Recomendacion - DHS-1201-SP 

• Request for Central Registry Clearance, DHS-0194 

• Relative Search Information - DHS-988 (WORD)

• Relative Response Form - DHS-989 (WORD)

• Relative Notification Form Letter for CPS and Foster Care - DHS-990 (WORD)

• Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 

• State of Michigan Sudden & Unexplained Child Death Scene Investigation Form 

• Your EITC refund belongs to you 

• Su reembolso de EITC pertenece a usted 

• You Earned It! You Keep It, Michigan! - DHS-1111-06-02 

• Earned Income Tax Credit Temporary Assistance for Needy Families (TANF) - DHS-3043 

• Asistencia Federal Temporal a Familias Necesitadas (TANF) Determinación de Elegibilidad - DHS-3043-SP 

• Assistance Application (DHS-1171)
A packet containing an application for assistance, an information booklet and a filing form.

• Solicitud de Asistencia - DHS-1171-SP

• Energy Supplier Participation Agreement - DHS-355 

• Supplemental Application for State Emergency Relief - DHS-1514 

• Solicitud Para Ayuda de Emergencia del Estado - DHS-1514-SP 

• Assistance Application (DHS-1171)
A packet containing an application for assistance, an information booklet and a filing form.

• Solicitud de Asistencia - DHS-1171-SP

• Documento de Archivo - DHS-1171-F-SP 

• Change Report - DHS-2240 

• Informe de Cambio - DHS-2240-SP 

• Assessment for Determination of Care for Children in Foster Care Ages 0-12 - DHS-470 

• Assessment for Determination of Care for Children in Foster Care Ages 13+ - DHS-470-A 

• Local DHS Office Review and Recommendation Specialized Foster Care Request - DHS-596 

• Private Child Placing Agency Specialized Foster Care Request Cover Sheet - DHS-597 

• Regional Review Team Review Form - DHS-598 

• Check List for Licensing Relative Caregivers - DHS-973 

• Relative Search Information - DHS-988 (WORD)

• Relative Response Form - DHS-989 (WORD)

• Relative Notification Form Letter for CPS and Foster Care - DHS-990 (WORD)

• Department/Foster Parent Agreement - DHS-1798 

• Assessment for Determination of Care for Medically Fragile Children in Foster Care DHS-1945 

• Unauthorized Leave Report to Court/Law Enforcement DHS 3198-A 

• Clothing Inventory Checklist DHS-3377 

• SCAO approved Juvenile Court Forms

• Interstate Compact on Juveniles Petition for Requsition to Return a Runaway Juvenile - DHS-1908 
ICJ Form A

• Detention Order - DHS-1909 

• Recommendation and Assurance for Pre-Adoption and Requirement Certification - DHS-3005 

• Interstate Compact on Juveniles Out of State Travel Permit and Agreement to Return - DHS-3034 
ICJ Travel Permit

• Runaway Juvenile Requisition - DHS-3035 
ICJ Form 1

• 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

• Interstate Compact Placement Request - DHS-4332 

• Interstate Compact Report on Child's Placement Status - DHS-4333 

• ICPC Financial/Medical Plan - DHS-4334 

• Interstate Compact Checklist - DHS-4335 

• Original License Application Packet
Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Downloading Resident Records/Forms
The forms marked with a (* ) are required and must be used unless prior written approval for a specific substitute form has been granted. All other forms on this page are intended to assist the licensee in demonstrating compliance with the record keeping requirements specified in the Adult Foster Care Licensing Rules.

• AFC Forms Request 

• AFC Sample Starter Packet 

• E-Score Sample Packet 

• Request for Modification of Terms of License 

• Finding the Total Resident Score 

• Finding the Staff Shift Score 

• Finding the Home's Evacuation Difficulty Score 

• Worksheet for Rating Residents 

• Worksheet for Calculating Evacuation Difficulty Score 

• Resident Register - BCAL-0535 

• Adult Foster Care License Limited Liability Company Governmental Organization and Corporate Application - BCAL-569-C 

• Adult Foster Care License Individual Application - BCAL-569-I 

• Homes for the Aged Application for Licensure, BCAL-1600 

• Homes for the Aged, Certificate of Appointment for Authorized Representative, BCAL-1603 

• HFA Administrator Appointment 

• Certification of Specialized Programs Application - BCAL-1609 
Must currently be licensed to be certified

• Resident Funds Record Part 1(*) - BCAL-2318 

• Resident Funds Record Part II(*) - BCAL-2319 

• Assessment Plan for AFC Residents - BCAL-3265

• Resident Care Agreement(*) - BCAL-3266 

• AFC Resident Medication Record - BCAL-3267 

• Resident Weight Record - BCAL-3485 

• Medical Clearance Request - BCAL-3704 

• Resident Health Care Appraisal(*) - BCAL-3947 

• AFC Incident/Accident Report(*) - BCAL-4607 

• AFC/HFA Sample Corrective Action Plan - BCAL-0414 

• Request for Modification of the Terms of the License/Registration 

• Child Care Forms Request 

• Original License Application Packet
Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Annual Compliance Certification for School Age Programs Exempt from Inspections 

• Request for Modification of the Terms of the License/Registration 

• Fire/Tornado Drill Record - BCAL-4594 (Word)

• Request for Central Registry Clearance, DHS-0194 

• Child Care Center Compliance Record, Part 8 - BCAL-722 
Part 8. Fire Safety Mainetance

• Notification of Changes in Status-Family and Group Child Care Home - BCAL-1485 

• Employee Notification to Child Care Center of Arraignment - BCAL-1486 

• Child Care Center Compliance Record, Part 1 - BCAL-1888 
Part 1. General Provisions

• Child Care Center Compliance Record, Part 2 - BCAL-1889 
Part 2. Infants/Young Toddler/Older Toddler

• Child Care Center Compliance Record, Part 3 and 5 - BCAL-1890 
Parts 3 and 5. Additional Provisions (School-Age/Swimming)

• Child Care Center Compliance Record, Part 6 - BCAL-1891 
Part 6. Transportation Provision

• Corrective Action Plan - BCAL 1894 

• Assistant Caregiver Certifications - BCAL-4595 

• Lead Caregivers: Child Care Centers - BCAL-5000

• Driver Verification - BCAL-5039 

• Child Care Center Record Requirements - BCAL-5041 

• Self-Certification Transportation Rules - BCAL-5044 

• Field Trip Driver Certification - BCAL-5046 

• Playground Inspection Certification Summary - BCAL-5047 

• Preparing Your License Renewal Fire Safety Inspection - BCAL-5048 

• Infant/Toddler Primary Caregivers Documentation 

• Medication Permission and Instructions for Child Care Homes/Child Care Centers - BCAL-1243 

• Permiso e Instrucciones Para la Medicación Para Casas de Cuidado/Guarderias - OCAL-1243-SP 

• Licensing Record Clearance Request - BCAL 1326 

• Health Appraisal - MDCH/BCAL-3305 

• Medical Clearance Request - BCAL-3704 

• Child Information Record - BCAL-3731 

• Documento de Información del Niño Estado de Michigan - OCAL-3731-SP 

• Child Information Record - OCAL 3731-AR (Arabic) 

• Child in Care Statement/Receipt - BCAL-3900 

• Declaración/Recibo de Niños en Cuidado - BCAL-3900-SP 

• Training Record Family/Group Child Care Homes - BCAL-4590 

• Incident, Accident, Illness, Death or Fire Report - BCAL-4603 

• Child Care Center Compliance Record, Part 9 - BCAL-4668 
Part 9. Environmental Health/Sanitation Maintenance

• Staffing Plan: Child Care Centers - BCAL-5001 

• Child Care Licensee Designee - BCAL-5003 

• School Building Fire Inspection Certification - BCAL-5043 

• Child Welfare Licensing Form Request 

• Original License Application Packet
Adult Foster Care, Child Day Care, Child Caring Institution, or Child Placing Agency

• Application for Child Care Plan Review - BFS-13 

• Court Operated Facility Rules Review Worksheets

• Child Caring Institution Rules Review Worksheets

• Special Investigation Report - OCAL-259 

• Health History Record - OCAL-353 

• Child Caring Institution Application, BCAL-1074 

• Licensing Record Clearance Request - BCAL 1326 

• Licensing Clearance Record Request - BCAL 1326CW 

• Children's Foster Home Rules Compliance Record - BCAL-3080 

• Report of Actual or Suspected Child Abuse or Neglect - DHS-3200 

• Child Information Record - BCAL-3731 

• Documento de Información del Niño Estado de Michigan - OCAL-3731-SP 

• Child Information Record - OCAL 3731-AR (Arabic) 

• Foster Home Reference Questionnaire OCAL-3739 

• Medical Emergency Care Authorization OCAL-3978 

• Emergency Telephone Numbers - OCAL-4234 

• Incident, Accident, Illness, Death or Fire Report - BCAL-4603 

• Relative/Unrelated Caregiver/Guardianship Home Study Outline - DHS-197 (Word)

• Initial Relative Safety Screen - DHS-588 (Word)

• Waiver of Foster Home Licensure-Relative Caregiver - DHS-875 (Word)

• Relative Agreement for Placement and Licensure - DHS-972

• Initial Foster Home/Adoption Evaluation - BCAL-3130 (Word)
NOTE: This form MUST be saved to your personal computer in order to do spell check and save inputted text.

• Assistance Application (DHS-1171)
A packet containing an application for assistance, an information booklet and a filing form.

• Solicitud de Asistencia - DHS-1171-SP

• Documento de Archivo - DHS-1171-F-SP 

• Irrevocable Funeral Contract Certification - DHS-8-A 

• Deductible Report - DHS-114A 

• Informe de Deducible - DHS-114A-SP 

• Plan First! Family Planning Program Application - MSA-1582 

• Change Report - DHS-2240 

• Informe de Cambio - DHS-2240-SP 

• Retroactive Medicaid Application - DHS-3243 

• Solicitud Para Medicaid Retroactivo - DHS-3243-SP 

• Medicaid Application Patient of Nursing Home - DHS-4574 

• Assets Declaration, Patient and Spouse - DHS-4574-B 

• Declaración de Bienes Paciente y Esposo/a - DHS-4574-B-SP 

• Request for Hearing - DHS-18 

• Hearing Request Withdrawal - DHS-18-A 

• Certification of Translation for Non-English Speaking Applicants or Recipients - DHS-848 

• Request for Emergency Shelter Temporary Assistance for Needy Families (TANF) DHS-3041-ES (PDF) - For homeless shelter providers ONLY 

• Information About Your Baby's Social Security Card DHS-4557 

• Voter Registration Application and Michigan Driver License/Personal Identification Card Address Change Form NSP-0938-B 

• Solicitud de Registración del Votante,Forma para Cambiar Dirección de Licencia de Manejar de MI/Tarjeta de Identificación Personal NSP-938B-SP 

• Safe Delivery of Newborns Tracking Information - DHS-850 

• Voluntary Medical Background Form - DHS-4819
The Voluntary Medical Background Form for a Surrendered Newborn is completed by the emergency service provider.

• 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.

• Entega Voluntaria Para Adopcion De Un Recien Nacido Por Parte De Un Padre - DHS-4820-SP 

• Employer or Volunteer Agency Central Registry Clearance DHS-640 

• Employer or Volunteer Agency Central Registry Clearance DHS-640 (Word)

• Registration for Ongoing Volunteers - DHS-1182-A 

• Registration for Short Term Volunteers - DHS-1182-B 

• Registration for Group Volunteers - DHS-1182-C