Case Name: MARGARITA SOTELO
Case Number: 131300297
IONIA COUNTY DHS
Date: 11/09/2022
920 E LINCOLN AVE
MDHHS Office: IONIA COUNTY DHS
IONIA MI 48846
Specialist: B. Magda
Phone: (616) 527-5846
Fax: (616) 527-5298
Specialist ID: magdab
MARGARITA YESENIA SOTELO IONIA COUNTY DHS
LOT 157 PO BOX 8123
360 E TUTTLE RD ROYAL OAK MI 48068-9985
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IONIA MI 48846
VERIFICATION CHECKLIST
Please read each page of this notice carefully.
Proofs due by - 11/21/2022 .
We need your help to determine your eligibility for program(s): Food Assistance Program, Medicaid .
Important Information
You must get the proofs to me or call me by the due date above. If you do not, your benefits may be denied,
decreased or cancelled. Call me right away if you have questions or problems getting the proofs. We may be able
to help you get the proofs if you ask for help. If the information must be provided on a Department of Human
Services form, the form is enclosed.
If you have questions regarding this notice, please contact your specialist B. Magda , at (616) 527-5846.
Please return a copy of at least one of the requested proofs for each verification and person listed below.
Original documents which are received as proof may not be returned.
Name Verification Requested Proof (Return one of the following:)
Jason Patricko Wages, Salaries, Tips, and Last 30 days of check stubs or earnings statements
Commissions
For Employer: Employer statement
Reed and Hoppes DHS-38, Verification of Employment
DHS-3569, Agricultural Income Verification
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Please provide additional information about: We need proof of all your earned and unearned income.
Provide proof of the last 30 days for employment,
unemployment, social security benefits, pension, etc.
Also, provide proof of self-employment/expense records
over the last year. Examples of proof include copies of
check stubs, self-employment records or a statement
from your source of income.
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in
some cases religion or political beliefs.
The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious
creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large
print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for
benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the
Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages
other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form,
(AD-3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA
and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call
(866) 632-9992. Submit your completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should
either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State
Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at:
http://www.fns.usda.gov/.
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To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S.
Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200
Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).
This institution is an equal opportunity provider.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or
group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex,
sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing,
hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a MDHHS
office in your area.
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