Public Assistance Forms
SNAP Application Packet:
SNAP Application Packet - This packet provides SNAP program information to people applying for SNAP benefits.
AREP Authorization form for SNAP, CASH, Medical (DOC) Opens a New Window. - This form is used to designate an authorized representative of your choosing who can communicate with Economic Assistance.
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.
GEN 205 Emergency Programs Release Form - This form is used to allow Economic Assistance to contact landlords and utility companies in order to complete our Emergency Assistance or Emergency General Assistance application.
GEN 260 Sponsor Release of Information - This form is used to allow Economic Assistance to communicate with the client's sponsor.
Voicemail Release (Public Assistance Programs)- This DocuSign form is used to allow Economic Assistance to leave a detailed message on a voicemail system for a specific phone number or to contact you by text. For the Child Support Communications Consent that allows Child Support staff to leave detailed voicemails on a voicemail system, please click here.
*Please note that when completing the DocuSign forms for voicemail, text, and email release, you will have the option to download a copy for yourself. We recommend you download a copy. This makes it easier for you to send us the completed form if the form does not reach us due to technical issues.
DHS-2146 Authorization for Release of Employment Information - This form is completed by an employer to verify employment start, stop, or wage change.
GEN 262 Special Diets - This form is used to provide information regarding diets prescribed by a doctor.
GEN 335 General Assistance Advanced Age Form - This form is used to verify a person meets the advanced age guidelines for General Assistance.
DHS 5893 Application for Certificate of Clearance for Medical Assistance Claim - Transfer on Death Deed (PDF) Opens a New Window. - 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) Opens a New Window. - 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:
MCC Recipient Notice - Instructions for getting reimbursed for Medical Transportation
MCC Trip Log 2020-2021 - Record your trips used for Medical Appointments
MNsure Application Help:
Applying for MNsure Helpful Information - This document gives you step by step instructions for completing an online MNsure application.
MNsure Change in Circumstance Forms:
GEN 344 - MNsure Add a Newborn Form - MNsure recipients use this form to report the birth of a baby.
MNS 33 - MNsure Address Change Form - MNsure recipients use this form to report changes in address.
GEN 351 - MNsure Income Change Form - MNsure recipients use this form to report changes in income.
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 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:
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.
Call this number for Adult and Family intake information.
Anoka County Government Center
2100 3rd Ave.
Anoka, MN 55303
Adult IntakePh: 763-422-7200
Child SupportPh: 763-324-2420
Blaine Human Services Center
1201 NE 89th Ave.
Blaine, MN 55434
MN Dept. of Human Services Website