Fillable Household Report Form DHS-2120-ENG


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What Is the Household Report Form?

The DHS 2120 household report form serves multiple functions for reporting household changes. From income modification to family member additions or subtractions, the form seeks to capture significant shifts that could possibly affect your assistance. Simply stated, it maintains a streamlined communication between the households and the authorities, ensuring everyone is on the same page.

Household Report Form DHS-2120-ENG Screenshot

Why is the DHS 2120 ENG essential?

Understanding the necessity of the DHS 2120 eng form is crucial for a myriad of reasons. It serves as a formal communication tool about your situation, which could ultimately impact your assistance. If there's a change in income or a member exits or enters the household, this could result in an adjustment to your benefits. To avoid surprises, timely reporting via the DHS-2120-ENG is key.

How to Fill Out MN Household Report Form

So, how do you go about this task? Here's the simplified step by step process:

  1. Start on the first page under 'Case Number' and provide your specific case number in the highlighted bar.
  2. Proceed to the 'Address Change' section. Select 'Yes' or 'No' according to your situation, and if 'Yes', fill in the necessary details regarding your new address.
  3. For the 'Rent Subsidy' section, specify if you receive any rent subsidy by choosing 'Yes' or 'No'. If 'Yes', fill in the respective details.
  4. The 'Household Members' section is broken into two parts 'Did anyone move out?' and 'Did anyone move in?'. Answer accordingly with 'Yes' or 'No' and then provide appropriate details if needed.
  5. In the 'Unearned Income' section, clarify whether you or any household member received unearned income during the report month. Choose 'Yes' or 'No'. If you select 'Yes', list down who received the money, the amount, and the date received. Remember to attach proof of income.
  6. For 'Earned Income', enter the requested details about your employment and income. 
  7. In the 'Assets' section, specify any assets and their current values.
  8. For the 'Child or Adult Care Expenses (SNAP only)' field and 'Court-ordered expenses', fill in details accordingly.
  9. In the 'Other Changes' section, mention any other significant changes that affect your household. 
  10. Moving to the 'Future Changes' section, discuss anticipated changes that could impact what you reported on this form in the next two months. Supply information on who the change applies to, the date and nature of the change.
  11. Afterward, sign your name, write the date, and provide your phone number in the designated areas.
  12. Ensure to print your name and your case number again in the respective fields.
  13. If there's a second adult in your household, have them sign and date in the appropriate locations.
  14. If someone assisted you in completing the form, they need to sign and date where indicated.
  15. If you don't have pay stubs or proof of earned income, you can have your employer fill out the 'Employer's Statement' section.

Remember to review the form to ensure all the sections are correctly filled. Make sure all the required signatures are present and the necessary documents are attached.

When to use the household report form

There are several scenarios when you will need to use the MN household report form, also known as the DHS 2120 form. This document is designed to alert the state’s Department of Human Services about any significant amendments involving your household. Here are common scenarios when you need to use the household report form:

  • Change in Household Composition: If someone moves in or out of your household, you'll need to report it. This includes children who are born or people who pass away.
  • Income Variation: If there's a significant change in your household's income, you should use the form. This could include a substantial promotion, a job loss, or the start of a new source of revenue like rental income.
  • Modification in Housing Costs: A marked rise in rent or mortgage payments, utility bills, or property taxes constitutes a change worth reporting. Conversely, if you move to a new home with lower overall costs, this should also be reported.
  • Insurance Shifts: If you, or anyone in your household, starts or stops receiving health insurance coverage, it's time to fill in the form. 
  • Addition of Major Assets: If you purchase a major asset like a car or a valuable piece of jewelry, this might need to be reported.
  • Change in Legal Status: If your application for citizenship, change in residency status, or new criminal conviction, this has to be reported.

Fillable online Household Report Form DHS-2120-ENG
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