Get MI DHS-1514 2018-2024

You may fill out the voter registration application form in private. If you believe that someone has interfered with your right to register to vote decline to register to vote privacy in deciding whether to register or in applying to register to vote or choose your own political party or other political preference you may file a complaint with Michigan Secretary of State PO Box 20126 Lansing MI 48901-0726. Case Name Case Number Date APPLICATION FOR STATE EMERGENCY RELIEF MDHHS Office / Specialist / ID Michigan Department of Health and Human Services Phone Fax Individual ID I hereby make application for the State Emergency Relief SER Program. I understand that the following information will be used in the determination of my eligibility for SER. I also understand that there may be a delay in processing if there is missing information. If this application is for burial services I understand that it must be received by the MDHHS office in my area no later than 10 business days after the burial cremation or donation takes place. For energy related emergencies the SER crisis season runs from November 1 through May 31. Requests for those services will be denied June 1 through October 31. HOUSEHOLD INFORMATION Attach extra pages if you need to include additional members List everyone who lives in your home including adults and children temporarily absent due to illness or employment. People are considered members of your household if they sleep and keep their belongings in your home. Be sure to include the date of birth and citizenship status for each member. If you are applying for burial assistance only list the deceased first. Name Relationship to you Social Security number Date of birth SELF Citizen Yes No HOUSEHOLD ADDRESS Address Number and street name Apt. etc* City State Zip code MAILING ADDRESS if different than above CONTACT INFORMATION Phone number to reach you Contact name and number to leave messages Email address Has anyone ever been convicted of a drug-related felony that occurred after August 22 1996 If yes who Convicted more than once Is anyone in violation of probation or on parole HOW DO YOU HEAT YOUR HOME Natural Gas Propane Wood No heat obligation Fuel oil Electricity Coal Unknown Has your electricity been turned off Yes date service was turned off Have you received a past due or shut off notice for your electricity Yes when is electric service scheduled to be turned off Has your heat been turned off or have you run out of your only heating fuel source Yes date heat was turned off or when fuel ran out Yes number of days until fuel runs out or date service is scheduled to be shut off HOME HEATING CREDIT - Did you receive the Home Heating Credit in the last 6 months Yes month received HAVE YOU OR DO YOU CURRENTLY RECEIVE OTHER BENEFITS FROM MDHHS HAVE YOU RECEIVED ENERGY ASSISTANCE Example MEAP FROM ANOTHER AGENCY OR THROUGH A PROVIDERst SPONSORED PROGRAM SINCE OCTOBER 1 If yes from which agencies/provider s EMERGENCY NEED - Check the service s you are requesting and the amount needed to resolve the emergency - ATTACH PROOF Payment for deliverable fuel will not be made if at the time of delivery it is confirmed you have more than 25 percent of fuel remaining in your tank.