Michigan PDF Forms
Homepage ➼ Free Michigan Verification Student Template in PDF
Structure

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

No

11. Comments

12. Signature of School Official

Title

Phone Number

Date

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

2
▼ 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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