ࡱ> '` _bjbj .3  6$6$6$8n$\$$ vh%4.)D)D)D)**l5+8sStttttt$rwhytu -**--t D)D)nu`111-X D) D)s1-s11h PlD)% PoV6$-dlj,nmu< vjzG.@zXPlz ^lm+h+J1,<[,0m+m+m+tt1dm+m+m+ v---- D6$ 6$   GUARDIANSHIP ASSISTANCE CASE OPENING REQUESTMichigan Department of Human ServicesINSTRUCTIONS:Assigned worker COMPLETES this entire form. Guardian and assigned worker sign page 2.Child s Name (Last, First, Middle) FORMTEXT      Child s BirthdateChild s Social Security NumberChild s RaceChild s Sex FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Payments can only be issued in one guardian name. Choose one guardian payee by checking the Payee box next to one name below.Guardian Parent Name (Last, First, Middle)PayeeGuardian Name, if more than one (Last, First, Middle)Payee FORMTEXT       FORMCHECKBOX  FORMTEXT       FORMCHECKBOX Social Security Number of Above GuardianSocial Security Number of Above Guardian FORMTEXT       FORMTEXT      Home Address (Number and Street)CityStateZip FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      Mailing Address (if different from above, or P.O. Box)CityStateZip FORMTEXT       FORMTEXT       FORMTEXT      FORMTEXT      Home Phone NumberWork or Other Phone NumberWhose Number? (name) FORMTEXT       FORMTEXT       FORMTEXT      1. Type of AssistanceGuardianship Order Date FORMCHECKBOX  Guardianship Assistance FORMCHECKBOX  Medical Subsidy FORMCHECKBOX  Nonrecurring Expenses FORMTEXT      2. Criminal HistoryDoes any adult (age 18 or over) in the household have felony convictions for any of the following:Child abuse or neglect, spousal abuse Crime against children, including pornographyViolence, rape, sexual assault, homicide Within the last five years: physical assault, battery, or a drug related offense FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes, name and relationship FORMTEXT      4. Medical Coverage for Child (Other than Medical Subsidy) FORMCHECKBOX  Medicaid FORMCHECKBOX  Insurance FORMCHECKBOX  Children s Special Health Care Services FORMCHECKBOX  No insurance coverage for childInsurance Company N24L$ 4 > P R v z   L N ^ f h x ~ Ӷjh'UjDh'Uh'jh'Uh(,hlKhHjhl]hUmHnHujh$Uh$jh$Uhjhth~g5OJQJh~ghph9#hq<h4F-5^`qh $Ifgd~g<kdX$$Ifl4y,y,4 lalf4 $Ifgd9#<kd$$Ifl4y,y,4 lalf4 $Ifgd9#^^x z ul/<kdf$$Ifl4y,y,4 lalf4 $IfgdlK<kd$$Ifl4Py,y,4 lalf4$$If^a$gdq<<kd$$Ifl4y,y,4 lalf4  N h $IfgdlK<kdF$$Ifl4y,y,4 lalf4 $IfgdlK " $IfgdlKukd$$Ifl4\ <Z!y,    4 lalf4     $ & b h j z    " 2    " $ & ( D F H J L ` b d n ÿҘ컐zjh'Ujhl]hUjhlKUjh'UhlKCJOJQJhjhhlK5>*hlKhq<h(,jh'Uh'h'h(,5jhl]hUmHnHujh'Uj,h'U0" $ " x C:. $$Ifa$gdlK $IfgdlK<kd$$Ifl4Py,y,4 lalf4 $IfgdlKukd $$Ifl4\ <Z!y,    4 lalf4 & J r tk_k_ $$Ifa$gdlK $IfgdlKukd$$Ifl4\<)y,4 lalf4 $$Ifa$gdlK $IfgdlKn p r t *:>@TVXbdfh|~  024>@BDXZ\dfhjϫϖϋπjl h'Uj h'Uj h'UhlKCJOJQJj h'Ujhl]hUmHnHujl h'Uh'hq<hlK5OJQJjthl]hUjhlKUhlKjh'U2 <>0Okd $$Ifl40<y,<=4 lalf4 $IfgdlKukd$$Ifl4\<)y,4 lalf4>f $IfgdlKOkdT $$Ifl40<y,<=4 lalf4 $Ifgdg VBh $Ifgdg Vukd $$Ifl4\<Z!!$y,< X4 lalf4j~ "68:DFHJ^`blnprDFH\^`ɿɿ}r}jhUjhUhCJOJQJhj h'Ujh'Uj$h'Ujh'Uhg VCJOJQJhg VhlKCJOJQJhlKjhl]hUmHnHujh'Uj h'Uh',  $IfgdlKukdT$$Ifl4\<Z!!$y,< X4 lalf4 Hp $Ifgdg Vukd$$Ifl4\<Z!!$y,< X4 lalf4D $IfgdlKukd$$Ifl4\<Z!!$y,< X4 lalf4DFn0bkdZ$$Ifl4F<Z!y,<      4 lalf4 $Ifgdg Vbkd.$$Ifl4F<Z!y,<      4 lalf4`jlnp"$@BDFtvx   滷jhl]hUjhl]hUhlKjhl]hUjhg VUhq<h1$hg Vh5OJQJjhHUjrhjUhjjhjUhjhUjhl]hUmHnHu0 "v \OFF $Ifgdg V $If^gd5Okd$$Ifl40Z!y,Z! 4 lalf4  $Ifgd1$<kd*$$Ifl4y,y,4 lalf4 $IfgdlK "$.04:^bhnpz|9:   ./9:  ¾ʺζʪʟʪʔʌ}ތun hJRchq<h5TOJQJjhVUhVjhVUjhl]hUj<hl]hUjh5TUhh5hjhHhHh5T>*h5Thhg Vh1$hlKjhl]hUmHnHujhUjthHU+ 24\^s6<kd$$Ifl4y,y,4 lalf4  $Ifgd1$ukd$$Ifl4\ Z!y,   4 lalf4 $Ifgd^:h{kYG$ & F<$Ifa$gd5$ & F<$Ifa$gd5$ & F$Ifa$gd5$ & F<$Ifa$gd5Okd"$$Ifl40#y,#4 lalf4 x$If^xgdH$If]^gdH.=Okd$$$Ifl40y,k+4 lalf4 x$If^xgd5T$If]^gd5TOkd$$Ifl40<y,<=4 lalf4.q4<kd$$Ifl4y,y,4 lalf4 t$If^gd5Tbkd$$Ifl4F@ +y,@ M     4 lalf4 x$If^xgd5T $IfgdVtoffff $Ifgd$<kd$$Ifl4y,y,4 lalf4  $Ifgd$<kd>$$Ifl4y,y,4 lalf4 $Ifgd$ "tvPP@PBPVPXPZPdPfPhPjP~PPPPPPPPPPPQQQ Q0Q2QNQj#hl]hUj#hl]hUj!hq<Ujhl]hUmHnHuj:!hq<UU hhq<jjhl]hUjhl]hUj~hl]hUjhl]hUjhq<Uhq<3P>P@P0Okd $$Ifl40<y,<=4 lalf4 $Ifgd$ukd$$Ifl4\hy, 4 lalf4ame #1Insurance Policy Number FORMTEXT       FORMTEXT      Coverage/Policy Type FORMCHECKBOX  Major Medical FORMCHECKBOX  Dental FORMCHECKBOX  Vision FORMCHECKBOX  Catastrophic OnlyInsurance Company Name #2Insurance Policy Number FORMTEXT       FORMTEXT      Coverage/Policy Type FORMCHECKBOX  Major Medical FORMCHECKBOX  Dental FORMCHECKBOX  Vision FORMCHECKBOX  Catastrophic OnlyInsurance Company Name #3Insurance Policy Number FORMTEXT       FORMTEXT      Coverage/Policy Type FORMCHECKBOX  Major Medical FORMCHECKBOX  Dental FORMCHECKBOX  Vision FORMCHECKBOX  Catastrophic OnlyDISTRIBUTION:ORIGINAL  DHS Subsidy Office, Central Office Make a copy to retain for your records To the best of my knowledge, the following information is accurate and complete.Guardian (s) Signature(s)DateAssigned Worker SignatureDateTelephone NumberAgency Name FORMTEXT       FORMTEXT      INSTRUCTIONS:Attach a copy of: The JC 91, Order Appointing Juvenile Guardian. Send the original of this form and all attachments to: MICHIGAN DEPARTMENT OF HUMAN SERVICES SUBSIDY OFFICE 235 S GRAND AVE SUITE 413 PO BOX 30037 LANSING MI 48909 Retain a copy for your records.AUTHORITY: Act 260 of 2008, as amended. COMPLETION: Mandatory. PENALTY: Failure to comply may result in inability to open case.Department of Human Services (DHS) 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 a DHS office in your area.     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