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Free Michigan Verification Student Template in PDF

The Michigan Verification Student form is a document used to confirm a student's enrollment, attendance, and academic progress for individuals receiving or applying for public assistance. This form is essential for the Family Independence Program, as full-time school attendance is required for children aged 6 to 18 to maintain eligibility for benefits. Schools are asked to complete the form and return it to the Department of Human Services to ensure that assistance remains uninterrupted.

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The Michigan Verification Student form plays a crucial role in the process of verifying student enrollment, attendance, and academic progress for individuals receiving or applying for public assistance. This form is particularly significant for participants in the Family Independence Program, as it mandates that children aged 6 to 18 must attend school full-time to maintain their benefits. The form requires completion by a school official, who must provide detailed information about the student’s enrollment status, attendance patterns, and the type of educational program they are involved in. Additionally, the form includes provisions for the release of information, ensuring that the Department of Human Services (DHS) can assess eligibility for assistance. While the school administration's cooperation is requested, there is no penalty for refusal to complete the form; however, failure to provide the necessary information may result in adverse outcomes for the client. The form also emphasizes the importance of accessibility under the Americans with Disabilities Act, inviting individuals to communicate their needs to local DHS offices. Overall, the Michigan Verification Student form serves as a vital tool for ensuring that students receive the support they need while navigating the public assistance system.

Form Example

ENTER ADDRESSEE NAME ENTER ADDRESSEE CARE OF

ENTER ADDRESSEE PO BOX OR STREET ENTER ADDRESSEE CITY/STATE/ZIP

Case Name:
Case Number:
Date:
DHS Office:
Specialist / ID:	/
Phone:
Fax:
Individual ID:

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. AUTHORITY: Act 280 of 1939, as amended, and Title IV and XIX of the Social Security Act.

COMPLETION: The school administration's voluntary cooperation is requested.

PENALTY: None for the school administration’s refusal to fill out form. However, failure of school to provide information may result in denial, reduction, or loss of assistance for client.

VERIFICATION OF STUDENT INFORMATION

Student Name

Student’s Birthdate

Date Completed

CLIENT INSTRUCTIONS & RELEASE OF INFORMATION:

•It is necessary to verify school enrollment, attendance and progress for students who are receiving or applying for public assistance. For the Family Independence Program, all children between the ages of 6-18 are expected to be attending school full-time or benefits may be denied, reduced, or terminated.

•This form must be completed by the school. Sign below, then take or mail the form and the return envelope to the school.

• It is your responsibility to have the form completed and returned to your worker by	or your
benefits may be denied, reduced, or terminated.

To school official: You are authorized to release the information requested below to the Department of Human Services.

Client Signature

Date

INSTRUCTIONS FOR SCHOOL OFFICIAL:

We are requesting your help in verifying enrollment, attendance and progress of the above-referenced student. Please complete the information on the back of this form and return it to our office. A stamped self-addressed envelope has been enclosed for that purpose.

TO BE COMPLETED BY SCHOOL OFFICIAL:

	1.	Name of School

	Address of School					City

	2.	Name of Responsible Person With Whom the Student is Residing				3. Relationship to Student

	4.	Address of Student's Home				City

	5.	Enrollment Status:
		FULL TIME STUDENT	HALF TIME STUDENT	LESS THAN HALF TIME			NOT CURRENTLY ENROLLED
	6.	Attendance:					Since (Give Date)
		REGULARLY ATTENDING	ATTENDING SOMETIMES	NOT ATTENDING
	If not regularly attending, is absence due to disability or periods of extended illness?				Yes	No
DHS-3380 (Rev. 10-12) Previous edition obsolete. MS Word				1

Case Name

Case Number

Specialist

7. Type of Program

K-12

8.Curriculum or Major

9.Degree Being Pursued:

HIGH SCHOOL DIPLOMA

					VOCATIONAL TRADE OR TECHNICAL TRAINING
	COLLEGE OR UNIVERSITY				YES	NO	Is a High School diploma/GED Required for this program
Participating in Work Study				School Year/Term/Semester Begin Date				End Date
		YES	NO

	ASSOCIATE OF ARTS DEGREE			NOT APPLICABLE				Expected Date of Completion/Graduation
	B.A./B.S			OTHER (Specify)

21 Day Compliance Test

Complete if box is checked

10. Has the child regularly attended all school days for the past 21 calendar days?

Yes

11. Comments

12. Signature of School Official

Title

Phone Number

Date

DHS-3380 (Rev. 10-12) Previous edition obsolete. MS Word

▼ Michigan Verification Student PDF Form

Document Specs

Fact Name	Details
Purpose	The Michigan Verification Student form is used to verify school enrollment, attendance, and progress for students receiving or applying for public assistance.
Governing Laws	This form is governed by Act 280 of 1939, as amended, and Title IV and XIX of the Social Security Act.
Client Instructions	Clients must ensure the form is completed by the school and returned to their worker to avoid denial or reduction of benefits.
School's Role	School officials are requested to complete the form and verify the student's enrollment and attendance.
Compliance	Schools are encouraged to cooperate voluntarily, but there is no penalty for refusal to complete the form.
Age Requirement	Children aged 6-18 are expected to attend school full-time to qualify for assistance under the Family Independence Program.
ADA Compliance	The Department of Human Services will accommodate individuals with disabilities as per the Americans with Disabilities Act.

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