MFIP & DWP Employment Services: Child Care Assistance Forms and Resources

Job counselors assist their Minnesota Family Investment Program (MFIP) clients to fill out requests for child care assistance.  Child care assistance provided through Hennepin County helps many clients to complete job search, education, work and other activities in the MFIP program.  Click on the links below for a copy of the form.

State of Minnesota forms

• Authorization for Release of Information About Residence and Shelter Expenses  DHS-2852
• Change Report Form DHS-4794
• Child Care Addendum  DHS-5223D
• Child Care Assistance Redetermination (DHS 5274-ENG) 11/08
• Client Statement of Good Cause (DHS-2338)
• Do You Need Help Paying for Child Care? (DHS-3551) 
• Minnesota Child Care Assistance Program Application (DHS-3550)
• Parent Acknowledgement When Choosing a Legal Unlicensed Provider (DHS- 5367)
• Parent Request for In-Home Child Care (DHS-6475)  4/12
• Referral to Support and Collections (DHS-3163B)
• Understanding Child Support--A Handbook for Parents (DHS-3393)

Hennepin County forms

• Checklist for Child Care Application -- DWP  2/13  (Replaces Initial CCA Application Packet)
• Checklist for Child Care Application -- MFIP 2/13  (Replaces Initial CCA Application Packet)
• Child Care Assistance Biweekly Sliding Fee Schedule (rev. 10/12)
• Child Care Plan HC12362A (rev. 05/13)
• Child Care Plan Instructions (rev. 3/09)
• Common Child Care Questions - DWP  (rev. 4/12)
• Common Child Care Questions - MFIP (rev. 4/12)
• HSPHD Notice of Privacy Practices Form
• Important Information About Child Care - DWP  (rev. 4/12)
• Language Block
• Notice and Release
• Work Verification Form (rev. 7/12)

Resources and Reference:

• MEC2 Screens--Quick Reference Guide for ESPs. (2/13)
• Resources for Child Caring   Thinksmall.org .  (3/12)
• School Hours 2012-2013