Date

RE:

Provider ID:

PIN:

RESPONSE REQUIRED WITHIN TWO WEEKS OF THIS NOTICE

Dear

Your child is currently receiving guardianship assistance. The guardianship assistance can be in the form of a monthly support check, Medicaid, and/or payment for services covered by the medical subsidy program. State law (MCL 722.875(7)) requires a guardian to file a report with the department at least once each year relating to their child’s continued eligibility for guardianship assistance.

Failure to complete the Annual Report/Status Change within two weeks of this notice will result in further action.

If you have more than one child receiving guardianship assistance you will receive separate mailings for each child due in the month of the child’s birthdate.

You have four options for completing the attached form.

1.	Online: Go to the Adoption and Guardianship Assistance Annual Reporting System website (https://mdhhs.michigan.gov/AGAARS). Enter your Provider ID and PIN information that is listed above. Answer the questions and submit the information. If you need to submit additional documentation you may fax, scan, or email the additional information to the Adoption and Guardianship Assistance Office (AGAO).

2.	Mail: Complete the Annual Report/Status Change attached to this notice. Return the form to the AGAO using the prepaid self-addressed envelope included with this notice.

3.	Fax: Complete the Annual Report/Status Change attached to this notice. Fax the completed form to 517-241-7042.

4.	Email: Complete the Annual Report/Status Change attached to this notice. Scan and email the form to the guardianship assistance caseload analyst assigned to your case.

It may be necessary to contact you concerning the completed Annual Report/Status Change. Please include your contact information when completing the report.

If you have any questions about completing this form, please contact your assigned adoption assistance caseload analyst. For the name and contact information of your assigned adoption assistance caseload analyst, please see the AGAO contact list online (https://www.michigan.gov/documents/dhs/DHS-AdoptionSubsidy-Contacts_253834_7.pdf) or call 517-335-7801.

Sincerely,

Patricia Neitman, Manager

Adoption and Guardianship Assistance Office

dhs-2047, annual report/status change

Guardianship Assistance Program

(Revised 2-22)

Section 1 – child/family identification

Child’s Name	Child’s Date of Birth

Last 4 digits of Child’s Social Security Number	Home Phone Number	Cell Phone Number

section 2 – status of child (Check only the boxes which currently apply)

Child is currently living with us/me and is our/my legal responsibility
Child is married Date:
Child has entered military service Date:
Child is no longer our responsibility (Explain on additional sheet of paper) Date:
Child is no longer living with me (Explain on additional sheet of paper) Date:
Child is age 6 or older
Enrolled in school (Including home school programs) Date:
School name
School address
Not in school Reason: Date:
Child is currently a temporary court ward Date:
Name of court (Provide copy of court order)
Date of Wardship (Note: This is not the adoptive placement date)
Guardianship has been terminated Date:
Child died Date:
Other (Explain on additional sheet of paper)

section 3 – benefits/money child is receiving (Other than guardianship assistance)

Current Amount	Date Current Benefits Began
No other benefits being received for child.
Social Security (Attach copy of claim letter obtained from SSA)	$
Veteran’s Benefits	$
Family Support Subsidy (FSS) from MDHHS	$

section 4 – medical coverage for child (Other than Medical Subsidy)

Medicaid Name of Medicaid Health Plan
Children’s Special Health Care Services
Private Insurance Name of Private Insurance
Private Insurance Coverage Major Medical Dental Vision Catastrophic Only
No Private Insurance for Child

SECTION 5

We are requesting guardianship assistance for above named child to be Continued Discontinued

Be sure all items are completed before signing. At least one box must be checked in each section. Under the penalty of perjury, I state that I have reviewed the information in the annual report, and to the best of my knowledge and belief, the answers I have provided are true and accurate.

Guardian Signature (If there are two guardians, the payee must sign)	Date

DHS-2047 ANNUAL REPORT INSTRUCTIONS

PLEASE READ BEFORE FILLING OUT THE FORM.

Dear Guardian:

Complete the enclosed Annual Report and return it to the MDHHS Adoption and Guardianship Assistance Office at the address below within two weeks. Completion of this report is required by law (MCL 400.115i). IF YOU DO NOT RETURN THE FORM, THE DEPARTMENT WILL INITIATE FURTHER INVESTIGATION.

Michigan Department of Health and Human Services

Adoption and Guardianship Assistance Office – Suite 612

PO Box 30037

Lansing, MI 48909

Other options for submitting the Annual Report include:

Submit online at https://mdhhs.michigan.gov/AGAARS/

Submit over the phone by calling the analyst assigned to your case (see enclosed contact list)

Each Section on the form must be completed.

Section 1.	This section is to be completely filled out with current information about the child and guardian in each box.
Section 2.	This section is to provide information about the child’s current status and living arrangements. Check the appropriate box or boxes. At least one box must be checked.
Section 3.	This section is to provide current information about money being received for the child from Social Security, (RSDI), Veteran’s benefits (VA), etc. If your child is not receiving benefits other than guardianship assistance, check the first box. Do not include the amount you receive from the guardianship assistance program. If your child receives Social Security (RSDI) benefits, enclose a copy of the most current Notice of Award or claim letter from the Social Security Administration (SSA). To obtain a claim letter, contact your local SSA office either in person or by phone at the number listed in your phone book. If you do not have the above documentation, a printout of benefits can be obtained by calling or visiting your local SSA office. You may send a copy of the benefit letter to us later.
Section 4.	This section is to provide current information about the child’s medical coverage. Check the appropriate box or boxes. If the child has no private medical coverage, check the box, “NO PRIVATE INSURANCE COVERAGE FOR CHILD.” Do not check insurance coverage that you carry only for yourself. If the child is enrolled in a health plan through Medicaid, include the name of the Medicaid health plan.
Section 5.	This section asks if you wish the guardianship assistance to be continued or discontinued. One of the boxes must be checked.
Guardian Signature: This form must be signed by the current payee.

AUTHORITY: MCL 722.875 COMPLETION: Mandatory PENALTY: Failure to comply may result in further investigation.

Michigan Department of Health and Human Services (MDHHS) Please note if needed, free language assistance services are available. Call 517-335-7801 (TTY 711).

Spanish	ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 517-335-7801 (TTY 711).
Arabic	ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 517-335-7801 (رقم هاتف الصم والبكم: 711 ).
Chinese	注意：如果您使用繁體中文，您可以免費獲得語言援助服務。 請致電 517-335-7801 （TTY 711）
Syriac (Assyrian)	ܙܘܼܗܵܪܵܐ: ܐܸܢ ܐܲܚܬܘܿܢ ܟܹܐ ܗܲܡܙܸܡܝܼܬܘܿܢ ܠܸܫܵܢܵܐ ܐܵܬܘܿܪܵܝܵܐ، ܡܵܨܝܼܬܘܿܢ ܕܩܲܒܠܝܼܬܘܿܢ ܚܸܠܡܲܬܹܐ ܕܗܲܝܲܪܬܵܐ ܒܠܸܫܵܢܵܐ ܡܲܓܵܢܵܐܝܼܬ. ܩܪܘܿܢ ܥܲܠ ܡܸܢܝܵܢܵܐ 517-335-7801 (TTY 711)
Vietnamese	CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 517-335-7801 (TTY 711).
Albanian	KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 517-335-7801 (TTY 711).
Korean	주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 517-335-7801 (TTY 711)번으로 전화해 주십시오.
Bengali	লক্ষ্য করুনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায় ভাষা সহায়তা পরিষেবা উপলব্ধ আছে। ফোন করুন ১ 517-335-7801 (TTY ১ 711).
Polish	UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 517-335-7801 (TTY 711).
German	ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer 517-335-7801 (TTY 711).
Italian	ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 517-335-7801 (TTY 711).
Japanese	注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 517-335-7801（TTY 711）まで、お電話にてご連絡ください
Russian	ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 517-335-7801 (телетайп 711).
Serbo-Croatian	OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 517-335-7801 (TTY Telefon za osobe sa oštećenim govorom ili sluhom 711).
Tagalog	PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 517-335-7801 (TTY 711).

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

Further, MDHHS:

Provides free aids and services to people with disabilities to communicate with us, such as:

Qualified sign language interpreters

Written information in other formats (large print, audio, accessible electronic formats, other formats); and

Provides free language services to people whose primary language is not English, such as:

Qualified interpreters

Information written in other languages

If you need these services, contact the Section 1557 Coordinator. The contact information is found below.

If you believe that MDHHS has not provided the above services, or discriminated in another way, you can file a grievance with the Section 1557 Coordinator. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557 Coordinator is available to help you.

MDHHS Section 1557 Coordinator

Compliance Office, 4th Floor

PO Box 30195

Lansing, MI 48909

517-284-1018 (Main), (TTY number—if covered entity has one), 517-335-6146 (Fax),
MDHHS-Section-1557@michigan.gov (Email).

You can also file a civil rights complaint with the responsible federal agency.

If your grievance or complaint is about your Medicaid application, benefits or services you can file a civil rights complaint with the U.S. Department of Health and Human Services at https://bit.ly/2pBS4YG, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD) Complaint forms are available at https://bit.ly/2IKsHMS.	If your grievance or complaint is about your application for or current food assistance benefits, you can file a discrimination complaint with the U.S. Department of Agriculture (USDA) Program by: Completing a Complaint Form, (AD-3027) found online at: https://bit.ly/2g9zzpU or at any USDA office, or write a letter addressed to USDA at the address below. In your letter, provide all the information requested in the form. To request a copy of the complaint form, call 866-632-9992. Send your completed form or letter to USDA by mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 Fax: 202-690-7442; or Email: program.intake@usda.gov

MDHHS is an equal opportunity provider.