Forms
Public Assistance Forms
SNAP Application Packet:
SNAP Application Packet - This packet provides SNAP program information to people applying for SNAP benefits.
Release Forms:
DHS 2243 Authorization for Release of Information about Assets - This form is used to allow a bank or other financial institution to share information about your assets.
DHS 2952 Authorization for Release of Information About Residence and Shelter Expenses - This form is used to allow a landlord or homeowner information about your shelter expense.
DHS 3549 General Consent/Authorization for Release of Information (PDF) - This form allows you to give Economic Assistance the authority to share specific information with another person or agency.
DHS 7823 Authorization to Obtain Information from AVS - This form allows the Account Validation Service to provide information about your assets for the MA program to Anoka County.
Verification Forms:
DHS-2146 Authorization for Release of Employment Information - This form is completed by an employer to verify employment start, stop, or wage change.
DHS-8620 Request for Special Diet Information - This form is used to provide information regarding diets prescribed by a doctor.
Probate Forms:
DHS 5893 Application for Certificate of Clearance for Medical Assistance Claim - Transfer on Death Deed (PDF) - This form is used to request a Certificate of Clearance when the property was transferred using a Transfer on Death Deed. Please seek professional legal advice if you are not sure this is the correct form for your situation.
DHS 6165A Application for Certificate of Clearance for Medical Assistance Claims - Decree of Descent (PDF) - This form is used to request a Certificate of Clearance when the property was transferred by a Decree of Descent. Please seek professional legal advice if you are not sure this is the correct form for your situation.
Medical Transportation Forms:
View Trip Log on MTM Website - Record your trips used for Medical Appointments
Request for Waiver, Assisted Living, or Nursing Home Services (current MA recipients):
DHS 3543 Request for Payment of Long Term Care Services - This form is for people currently open on Medical Assistance (MA) that need waiver services, assisted living services, or nursing home services paid.
Other State Forms:
DHS-6054 Personal Statement about Assets for Cash Programs - This form can be used by cash program applicants or recipients to attest to the value or availability of certain assets. This is the DocuSign version of this form. You will have the option to save a copy of the form for yourself. We recommend that you do that.
DHS 1795 SSI Interim Assistance Agreement - This is an agreement the client signs promising to repay funds received from state or county funded programs while their SSI application is being processed
DHS 1795A Interim Assistance Agreement (Non-SSI) - This is an agreement the client signs promising to repay funds received from state- or county-funded programs while their application for other non-SSI benefits is being processed.
DHS 8334 Cancel Appeal Form - This is an online form to cancel/withdraw the appeal you requested.
DHS 2402 Change Report Form - This form is used to report income, asset, and circumstance changes.
DHS 8107 Household Update Form - This form is for people currently open on Cash or SNAP programs that need to complete a review following the COVID emergency
DHS 2120 Household Report Form - This form is for people currently open on Cash or SNAP programs that need to complete a monthly household report form.
DHS 5576 Combined Six Month Report - This form is for people currently open on Cash, SNAP, or Healthcare that are required to complete a six month review.
Additional State forms can be found at: Minnesota Department of Human Services Website
Document Upload Portal
Documents can be submitted to the Economic Assistance Document Upload Portal Here
Instructions for using the portal can be found Here
Document Drop Off Locations
Anoka County is now accepting a variety of paperwork at two county locations and only vehicle tab renewals at two others. The locations accepting paperwork including vehicle tab renewals, property tax documents, child support and economic assistance applications, and reporting forms are:
- Anoka County Government Center, 2100 3rd Ave., Anoka
- Blaine Human Service Center, 89th Ave. NE
Paperwork that CANNOT be accepted at drop boxes are documents related to legal service, litigation, or court matters. If your child support, economic assistance (EA), or property tax paperwork involves a petition or claim to the Anoka County Attorney, those documents MUST be served on the County Attorney. Please see your child support/EA paperwork for service by mail directions regarding legal proceedings. Questions about legal documents can be directed to the County Attorney’s Office: 763-324-5550.
Paperwork can also be submitted by email to EADocs@co.anoka.mn.us. You may also mail any paperwork to our mailing address listed on this page.