DWP / MFIP FORMS

When you select a link (internet address underlined) a seperate window will open containing the form listed. The Office of Job Training webpage will remain open along with any forms you select until you close them.  This will allow you to have more than one form open and available at a time.  All DHS forms (edocs internet address) will be the most recent versions automatically. 

Form Name Internet Address
Agency Checklist (02/05/2013)

AdultDLWKR_DWP_MFIP_FSS_checklist

Consent to Share Wage

CONSENT TO SHARE WAGE revision 11 09.pdf

Disparity Project Referral _site_components/files/FormUpdated%20DISPARITY%20PROJECT%20REFERRAL.pdf

Do you have a Disability? (DHS 4133)

MFIP requires this topic be discussed each time you update the EP.
DHS-4133-ENG

DWP Expectations DWP EXPECTATIONS.pdf
DWP/MFIP Observation Checklist DHS-3483-ENG
DWP/MFIP Status Update DHS-3165-ENG

 

BELOW are the "paper" Employment Plan (EP) sections for printing. 
There are 12 sections.  These forms are also fillable on-line.

EP - First/signature page (DHS 4209) DHS-4209-ENG
EP - Employment  (DHS 4209A) DHS-4209A-ENG
EP - Job Search (DHS 4209B) DHS-4209B-ENG
EP -  Unpaid Work (DHS 4209C) DHS-4209C-ENG
EP -  Education (DHS 4209D) DHS-4209D-ENG
EP -  Family Safety (DHS 4209E) DHS-4209E-ENG
EP- Child Care or Transportation(DHS4209H) DHS-4209H-ENG
EP - Health (DHS 4209I) DHS-4209I-ENG
EP -  Housing (DHS 4209J) DHS-4209J-ENG
EP -  Personal/Family (DHS 4209K) DHS-4209K-ENG
EP - Legal Issues (DHS 4209L) DHS-4209L-ENG
EP - County/State Social Services (DHS 4209M) DHS-4209M-ENG
  
Employment Services Responsibilities, Rights and Consent (DHS 3172) DHS-3172-ENG
FSS Pre-Sanction Checklist (DHS 6075) DHS-6075-ENG
I-9 Employment Eligibility Verification i-9.pdf
   
MFIP/DWP Weekly Job Search Activity Log (DHS 5784) DHS-5784-ENG
MFIP Expectations MFIP EXPECTATIONS.pdf
MFIP Notice of Intent to Sanction (DHS 3175)  eDHS-3175-ENG
MFIP Self-Screen (DHS 3482) DHS-3482-ENG
MFIP Self-Screen Scoring Form (DHS 3482A) DHS-3482A-ENG
MFIP Brief Screening Tool for Special Learning Needs (DHS 3504) DHS-3504-ENG
MFIP Brief Screening Tool Questions for client Client is to view these questions while you read and score them from Form DHS 3504. 
Print these questions on green paper for the client.
MFIF Screening Tool Questions for client with DHS 3504 rev04_8_2009.pdf
MFIP Overview Notice of Requirement to Attend (DHS 2929) DHS-2929-ENG
MFIP Provider Change Request (St. Louis County - 3/5/2012) MFIP_Provider_Change_Request
MFIP Time Limits DHS-3498-ENG
Minnesota Transition Application (DHS 5223E)

Use this application to apply for MFIP and the Work Benefit (WB) program for clients who currently receive benefits from the DWP or have received DWP within the last 30 days. 


DHS-5223E-ENG
"Opting out" of the Cash Portion of MFIP DHS-3356-ENG
Request for Medical Opinion (DHS/SLC/NEMN-2114A) Medical Opinion Single 06 2013
Request for Medical Opinon for Family Member Needing Care Medical Opinion Family Needing Care 06 2013

Request for Training (08/10/11) Client completes

Request for Training Northeast Minnesota FINAL.pdf
Request for Training Guide (09/01/2011) for client Request for Training Guide
Request for Training Evaluation (8/10/11) Counselor completes Request for Training Evaluation NEMN Final.pdf
   
Request for Verification of School Attendance/Progress  (DHS 2883)

Can use for under 20 high school students.
DHS-2883-ENG

Sanction Tracking (2/20/2012) Sanction Tracking
STOP Welfare Fraud (DHS 4748) DHS-4748-ENG
Self-Assessment (All Programs) 10/15/2010 _site_components/files/self_assessment_10_15_2010(1).pdf
Self-Employment Business Plan (DHS 6200) DHS-6200-ENG
Self-employment Report Form (DHS 3336) DHS-3336-ENG
Tennessen Warning Notice and Notice to the Public (2/12/10) Tennessen Warning 07 09 2013
Post-SecondaryStudy Time Verification Letter for hours of unsupervised study time.  (Required for MFIP WPR) Training Verification Letter
Work Activity Verification Log (week) (DHS 4897) DHS-4897-ENG
Work Activity Verification Log (month - agency form)  (2/7/2011) Work Activity Verification Log Agency.pdf

Work Benefit Program
(DHS 5837)

DHS-5837-ENG

"Work will always pay" (bulletin 11-11-01 effective 05/12/11)

dhs16_161648.pdf


The Northeast Minnesota Office of Job Training is a Minnesota WorkForce Center partner.
Email us at info@jobtrainingmn.org

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