Michigan Form DHS-330, the Authorized Representative Request, is the official MDHHS form that a client signs to give another person legal authority to apply, recertify, report changes, or pick up benefits on their behalf for programs run by the Michigan Department of Health and Human Services. The current revision date is printed in the bottom-left corner of the form, and readers should always confirm they are using the latest version posted on the MDHHS forms library before signing.
A missing, blank, or wrongly completed DHS-330 is one of the most common reasons MDHHS rejects an Authorized Representative (AR) and forces the client to start the process over, which can interrupt food, cash, child care, or medical benefits. According to MDHHS caseload data published in the Bridges Eligibility Manual, more than 1.3 million Michigan households receive Food Assistance Program (FAP) benefits each month, and a meaningful share rely on an AR because the head of household is elderly, disabled, working multiple jobs, or homebound.
Here is what this guide covers:
- 📝 Exactly what each line, box, and signature on DHS-330 means
- 👨👩👧 Three full named-person scenarios showing what real filers write
- 📬 Every way to submit the form (MI Bridges, mail, fax, in person, caseworker)
- ⚠️ The 10 most common DHS-330 mistakes and what each one costs you
- ❓ Twelve plain-English FAQs that answer the questions caseworkers hear most
What the Form Is and Who Must File It
Form DHS-330 is the single statewide document MDHHS uses to record an Authorized Representative designation across the Food Assistance Program (FAP), the Family Independence Program (FIP), the State Disability Assistance (SDA) program, Medicaid (MA), the Child Development and Care (CDC) program, and State Emergency Relief (SER). The form is governed by Bridges Administrative Manual (BAM) 110, which sets the rules MDHHS workers must follow when accepting an AR.
For FAP, federal law at 7 CFR 273.1(f) requires the head of household to designate the AR in writing. For Medicaid, 42 CFR 435.923 sets the parallel federal rule. DHS-330 satisfies both. The form is filed by the client (the person whose case it is), not by the AR; the AR only co-signs to accept the role.
Common filers include elderly FAP recipients who need an adult child to handle recertification, disabled Medicaid applicants whose nursing-home staff submit paperwork, working parents on CDC who let a trusted neighbor pick up notices, and SER applicants who are hospitalized when a shutoff notice arrives. If a client cannot sign, a witness must sign and the client marks an X; the rules for this are also in BAM 110.
A DHS-330 is not a power of attorney. It does not let the AR control bank accounts, sign tax returns, or make medical decisions outside MDHHS programs. It only gives access to the MDHHS case it names.
Before You Start: Documents and Information You Need
Gathering the right documents before opening DHS-330 prevents the most common rejection reason, which is mismatched identifying information between the form and the MDHHS case file. The MI Bridges help center recommends having every item below in front of you before you sign.
- Client’s full legal name as it appears on the MDHHS case. A nickname or married-name mismatch will cause the worker to reject the form.
- Client’s MDHHS case number or recipient ID. Without this, MDHHS cannot attach the form to the right case, and benefits can lapse during the search.
- Client’s date of birth and last four of SSN. These are cross-checked against Bridges; a typo triggers a manual hold.
- Client’s current address and phone number. If the address differs from the case file, the worker must verify before adding the AR.
- Authorized Representative’s full legal name, address, phone, and relationship to client. MDHHS mails notices to the AR at this address.
- Scope of authority you want to grant. Decide before signing whether the AR can apply, recertify, report changes, receive notices, or access the EBT card.
- Start and end dates for the designation. Leaving the end date blank makes the AR permanent until revoked in writing.
- Photo ID for both client and AR. The local office will ask for ID when the form is dropped off, and an ID mismatch voids the form.
- A witness, if the client signs with an X. The witness must sign the same day and print their name and address.
- A copy of any existing AR form on file. Submitting a new DHS-330 replaces the old one only if the new form is complete; otherwise both are voided.
Where to Get the Form and How to Access It
The current DHS-330 lives on the MDHHS forms page as a fillable PDF that can be typed into on a computer, printed, and signed. Clients can also pick up a paper copy at any local MDHHS office, request one by phone, or download it from the MI Bridges portal after logging in.
The fillable PDF is the version most filers use because it auto-aligns the text inside each box, which reduces the chance a caseworker cannot read the entry. Adobe Acrobat Reader, the free version, opens the file without trouble. Tablets and phones can also open the PDF using the Adobe Reader mobile app, although signatures still need to be in ink or a saved digital signature image.
Spanish and Arabic translations of major MDHHS notices are available, but DHS-330 itself is published in English; a translator must sit with the client if needed, and the translator’s name should be written next to the signature line. The form revision date is printed on the lower-left of page 2, and readers should make sure they have not downloaded an outdated copy from a third-party site, since legacy versions are no longer accepted by Bridges.
Step-by-Step: How to Fill Out Michigan Form DHS-330 Line by Line
The line-by-line walkthrough below uses the exact field names printed on the current DHS-330. Each field has its own short subsection so a filer can scroll to just the box they are stuck on. Sample entries are italicized so they stand out from the instructions.
Field 1: Client Name
This field asks for the full legal name of the person whose MDHHS case the AR will access. Write the first name, middle initial, and last name exactly as they appear on the Bridges case, using the format printed on the most recent MDHHS notice. Maria E. Lopez writes her name as it shows on her FAP redetermination letter, not as it shows on her driver’s license if the two differ.
An edge case comes up for clients who recently married or divorced and have not yet updated MDHHS. In that situation, use the name currently on the case file and submit a separate name-change request after the AR is added. A common mistake is writing a nickname like Mari or a hyphenated married name MDHHS has not yet recorded; the worker will reject the form because Bridges cannot find a match. A misconception filers hold is that the name on the AR form must match a photo ID, but the controlling source is the MDHHS case record, not the ID.
Field 2: Case Number / Recipient ID
This field asks for the 10-digit MDHHS case number, sometimes labeled the recipient ID, printed at the top of every MDHHS notice. Enter the number exactly as printed, with no spaces or dashes, even if the printed version uses dashes for readability. James Carter copies 1234567890 from his last FAP determination notice.
If a client has separate cases (for example, FAP under one number and Medicaid under another), list the primary case number in this box and add the second case number in the Comments area on page 2. A common mistake is leaving this box blank because the client cannot find a notice; the consequence is automatic rejection because Bridges has no way to attach the AR. A misconception is that the Social Security Number can substitute for the case number, but BAM 110 requires the MDHHS case number specifically.
Field 3: Client Date of Birth
This field asks for the client’s date of birth in MM/DD/YYYY format. Write each part with leading zeros where needed, like 03/07/1948, so the entry matches the Bridges field layout. Dorothy Williams writes 03/07/1948 even though she usually writes 3/7/48.
An edge case is when the client’s date of birth on file is wrong; in that case, use the wrong date that MDHHS has on file so the worker can find the case, and submit a DHS-1010 correction request after the AR is added. A common mistake is writing the date in DD/MM/YYYY format, which makes a March 7 birthday look like a July 3 birthday and triggers a verification hold. A misconception is that the year can be written with two digits; Bridges requires four.
Field 4: Client Address
This field asks for the client’s current residential address, including street, city, state, and ZIP code. Use the address MDHHS has on file, and if the client recently moved, file a change-of-address through MI Bridges the same day the DHS-330 is signed. Robert Singh writes 4421 Maple Ave, Apt 2B, Detroit, MI 48201.
An edge case is a homeless client with no fixed address; in that case, write General Delivery followed by the city and ZIP of the post office where mail will be held, which is allowed under BAM 115. A common mistake is using a P.O. Box when a street address is required for benefit delivery, especially for EBT card mailings; the consequence is a delayed card. A misconception is that the AR’s address can be substituted here, but this box is always the client’s address.
Field 5: Client Phone Number
This field asks for a current phone number where MDHHS can reach the client. Write a 10-digit number including area code, formatted as (313) 555-0142, so the worker can call to verify the AR designation if needed. Aisha Brown writes (313) 555-0142.
An edge case is a client with no phone of their own; in that case, write the phone number of the AR and add the word via AR in parentheses so the worker knows the line is shared. A common mistake is leaving the box blank because the client only uses a cell phone occasionally; MDHHS treats a blank phone field as a refusal to cooperate with verification. A misconception is that the phone number is optional; under BAM 105, MDHHS must have a working contact method.
Field 6: Authorized Representative Name
This field asks for the full legal name of the person being given AR authority. Write the AR’s first name, middle initial, and last name as they appear on the AR’s government ID, because the worker will compare the name to the AR’s photo ID at drop-off. Carlos M. Rivera writes his name exactly as it appears on his Michigan driver’s license.
An edge case is naming an organization (for example, a nursing home or a community-action agency) instead of an individual; in that case, write the organization name on this line and add a specific staff member’s name in the Comments section so MDHHS knows who to call. A common mistake is writing the AR’s nickname or omitting a middle initial that appears on the ID; the worker will refuse the drop-off. A misconception is that an AR must be a family member; BAM 110 allows any adult the client chooses, as long as the AR is not a disqualified person such as a retailer banned from SNAP.
Field 7: Authorized Representative Address and Phone
This field asks for the AR’s mailing address and phone number, because MDHHS will copy notices to this address once the AR is active. Write the AR’s street, city, state, ZIP, and 10-digit phone the same way the client’s address was written. Carlos M. Rivera writes 882 Greenleaf Dr, Lansing, MI 48910 and (517) 555-0177.
An edge case is an AR who travels for work or lives in two states; in that case, use the address where the AR receives mail most reliably and add a note in Comments. A common mistake is using the client’s address for the AR; this defeats the purpose of having an AR and causes notices to be sent to the wrong person. A misconception is that an out-of-state AR is not allowed, but Michigan accepts out-of-state ARs as long as the AR can perform the duties listed.
Field 8: Relationship to Client
This field asks how the AR knows the client (for example, adult child, spouse, neighbor, nursing home social worker, attorney, case manager). Write a short, specific relationship label rather than a vague one like friend. Janet Park writes adult daughter rather than family.
An edge case is a paid caregiver from a home-care agency; in that case, write paid caregiver, [agency name] so MDHHS can identify the employer in case of fraud review. A common mistake is writing power of attorney in this box when the AR does not actually hold a POA; the worker will then ask for POA paperwork that does not exist. A misconception is that the relationship determines the AR’s authority, but the scope of authority checkboxes in Field 9 are what actually control access.
Field 9: Scope of Authority Checkboxes
This field asks the client to check the specific powers being granted to the AR. The boxes typically include apply for benefits, complete recertification/redetermination, report changes, receive copies of notices, access the EBT card and PIN, and attend interviews. Check each box the client wants to grant, and leave the rest blank; do not check all if the client only wants partial authority. Dorothy Williams checks complete recertification and receive copies of notices but leaves access EBT card unchecked because she wants to keep her card.
An edge case is when the client wants the AR to handle only one program (for example, FAP but not Medicaid); in that case, write the program name next to the checked boxes and note the limit in Comments. A common mistake is checking every box without thinking, which gives a casual helper full control over the EBT card and opens the door to misuse. A misconception is that unchecked powers can be added later by phone; under BAM 110, any expansion of authority requires a new DHS-330.
Field 10: Start Date and End Date
This field asks when the AR designation begins and when it ends. Write a start date no earlier than the signature date, and write an end date that matches a natural milestone like the next FAP recertification or the end of a hospital stay. Robert Singh writes a start date of 05/21/2026 and an end date of 11/21/2026 to match his six-month FAP cycle.
An edge case is a client who wants an indefinite designation; in that case, write Until revoked in writing in the end-date box rather than leaving it blank, because a blank end date is sometimes read as a one-day designation by inexperienced workers. A common mistake is writing an end date in the past, which makes the form void on arrival. A misconception is that the AR designation auto-renews; it does not, and a new DHS-330 is required after the end date.
Field 11: Client Signature
This field asks for the client’s ink or digital signature, plus the date signed. Sign in blue or black ink on a paper form, or paste a saved signature image on a digital fillable PDF. Maria E. Lopez signs her name and writes 05/21/2026 next to it.
An edge case is a client who cannot physically sign; in that case, the client marks an X and a witness signs Field 13 the same day. A common mistake is signing without dating; the worker will treat the form as undated and reject it. A misconception is that a typed name in a signature font counts as a signature; MDHHS requires either an actual handwritten signature, a digital signature with an audit trail, or an X with a witness.
Field 12: Authorized Representative Signature
This field asks the AR to sign and date, confirming they accept the role and understand the duties listed in BAM 110. The AR signs in ink or pastes a digital signature, then writes the date. Carlos M. Rivera signs and writes 05/21/2026.
An edge case is when the AR is a staff member of an organization; in that case, the staff member signs their own name and writes their title under the signature (for example, Social Worker, Sunrise Manor). A common mistake is the AR forgetting to sign because the client filled out the rest of the form alone; without the AR’s signature, the designation is void. A misconception is that the AR can sign later; both signatures should be dated the same day or within a short window.
Field 13: Witness Signature (if client signs with an X)
This field is only used when the client cannot sign their own name and instead marks an X in Field 11. The witness, who must be an adult not named as the AR, prints their name, signs, and adds their address and phone. Mrs. Helen Park, a neighbor, prints her name, signs, and writes 880 Greenleaf Dr, Lansing, MI 48910, (517) 555-0190.
An edge case is a witness who is also a household member; that is allowed under BAM 110 as long as the witness is not the AR. A common mistake is using the AR as the witness, which voids the form because the same person cannot both accept the role and witness the granting of it. A misconception is that a notary is required; MDHHS does not require notarization for DHS-330.
Field 14: Comments / Special Instructions
This field asks for any limits, second case numbers, organization details, or language notes that did not fit elsewhere. Write short, specific notes; do not use this box to repeat information already on the form. Janet Park writes AR authority limited to FAP only; do not share Medicaid information.
An edge case is a client who wants different ARs for different programs; in that case, file a separate DHS-330 for each program and note the split in Comments on both forms. A common mistake is leaving long handwritten notes that the worker cannot read; the consequence is the worker ignoring the note. A misconception is that anything written in Comments is binding even if it conflicts with the checkboxes in Field 9; the checkboxes control, and Comments only clarifies.
Three Filled-Out Examples Using Real Scenarios
The three scenarios below show how named filers complete DHS-330 from top to bottom. Each table has exactly two columns and at least eight rows. Sample entries are italicized.
Scenario 1: Dorothy Williams (elderly FAP recipient names her adult daughter)
| Form Section | What Dorothy Enters |
|---|---|
| Client Name | Dorothy J. Williams |
| Case Number | 2233445566 |
| Client Date of Birth | 03/07/1948 |
| Client Address | 512 Oak St, Flint, MI 48503 |
| AR Name | Janet R. Park |
| AR Address | 514 Oak St, Flint, MI 48503 |
| Relationship | adult daughter |
| Scope of Authority | complete recertification; receive copies of notices |
| Start / End Date | 05/21/2026 / 11/21/2026 |
| Signatures | Dorothy signs; Janet signs; both date 05/21/2026 |
Scenario 2: Robert Singh (disabled Medicaid applicant names a nursing-home social worker)
| Form Section | What Robert Enters |
|---|---|
| Client Name | Robert A. Singh |
| Case Number | 4455667788 |
| Client Date of Birth | 11/19/1962 |
| Client Address | Sunrise Manor, 17 Pine Rd, Ann Arbor, MI 48103 |
| AR Name | Sunrise Manor, c/o Linda Chen, LMSW |
| AR Address | 17 Pine Rd, Ann Arbor, MI 48103 |
| Relationship | nursing home social worker |
| Scope of Authority | apply for benefits; report changes; receive copies of notices |
| Start / End Date | 05/21/2026 / Until revoked in writing |
| Signatures | Robert marks X; Linda signs as AR; neighbor witnesses |
Scenario 3: Aisha Brown (working parent on CDC names a trusted neighbor)
| Form Section | What Aisha Enters |
|---|---|
| Client Name | Aisha M. Brown |
| Case Number | 6677889900 |
| Client Date of Birth | 08/14/1991 |
| Client Address | 2210 Cherry Ln, Grand Rapids, MI 49503 |
| AR Name | Marcus T. Bell |
| AR Address | 2212 Cherry Ln, Grand Rapids, MI 49503 |
| Relationship | neighbor |
| Scope of Authority | report changes; receive copies of notices |
| Start / End Date | 05/21/2026 / 05/21/2027 |
| Signatures | Aisha signs; Marcus signs; both date 05/21/2026 |
How to File the Completed Form
DHS-330 can be filed through five channels, and MDHHS treats all five as equally valid as long as the form arrives complete. Pick the channel that gives the client the best proof of filing.
MI Bridges upload. Log in at the MI Bridges portal, open the case, choose Report Changes or Upload Documents, and attach the signed PDF. There is no fee, processing typically takes 5 to 10 business days, and the portal generates a confirmation number that serves as proof of filing.
Mail. Send the signed original to the local MDHHS office for the county where the client lives. There is no fee, mail processing takes 10 to 15 business days, and the filer should use USPS Certified Mail with return receipt to prove delivery.
Fax. Each county office has its own fax number, listed on the county office directory. There is no fee, fax processing takes 5 to 10 business days, and the filer should keep the fax confirmation sheet as proof.
In person. Drop the signed form at the local MDHHS office front desk during business hours. There is no fee, processing takes 5 to 10 business days, and the filer should ask the clerk for a date-stamped copy as proof.
Through a caseworker. If the client already works with an MDHHS specialist, the form can be handed or emailed directly to that worker, who logs it into Bridges. There is no fee, processing is often same-day, and the worker should send a confirmation email or letter.
What Happens After You File
Once MDHHS receives the form, a specialist reviews it within the processing window for the channel used, confirms that the client name and case number match Bridges, and verifies that both signatures and dates are present. If everything matches, the worker adds the AR to the Bridges case and mails a confirmation notice to both the client and the AR.
If the form is incomplete or mismatched, the worker sends a DHS-3503 Verification Checklist to the client listing what needs to be fixed, with a 10-day deadline. Missing the deadline means the AR is not added and the client must start over. While the AR is pending, the client remains the only person MDHHS will talk to.
After approval, the AR has the powers checked in Field 9 until the end date in Field 10, or until the client revokes the designation in writing. Revocation requires either a new DHS-330 with the powers unchecked or a signed letter sent through any of the five filing channels. MDHHS does not accept verbal revocations under BAM 110.
Mistakes to Avoid When Filling Out the Form
- Leaving the case number blank. The form cannot be attached to any case and is rejected on arrival.
- Using a nickname in Field 1. Bridges cannot match the name, and the worker sends back the form.
- Writing the date in DD/MM/YYYY. MDHHS reads the entry as the wrong month and triggers a verification hold.
- Checking every scope-of-authority box without thinking. The AR ends up with EBT card access the client did not intend to grant.
- Leaving the end date blank. Some workers read this as a one-day designation, which voids the AR almost immediately.
- Using the AR as the witness. The form is void because the same person cannot grant and witness the grant.
- Forgetting the AR’s signature. Without Field 12, MDHHS cannot confirm the AR accepted the role and refuses the designation.
- Submitting an outdated form. Old DHS-330 versions are no longer accepted; Bridges rejects them automatically.
- Listing the AR’s address in Field 4. Notices intended for the client go to the AR’s house instead, breaking the audit trail.
- Writing power of attorney in Field 8 when no POA exists. The worker requests POA paperwork that cannot be produced, and the form sits in limbo.
- Using a P.O. Box when a street address is required. EBT card and ID-card mailings stall.
- Skipping the Comments note when limiting authority to one program. Bridges treats the AR as authorized across all programs on the case.
Do’s and Don’ts
Do’s
- Do download the form fresh from the MDHHS forms library each time, because revisions roll out without warning.
- Do match the client name exactly to the most recent MDHHS notice, since Bridges keys off that record.
- Do keep a photocopy of the signed form before submitting, because lost forms are common at busy county offices.
- Do use Certified Mail when sending by mail, because the return receipt is the only ironclad proof of delivery.
- Do write Until revoked in writing in the end-date box if a permanent AR is intended, since blanks invite confusion.
- Do file a fresh DHS-330 any time the scope of authority changes, because additions cannot be made by phone.
Don’ts
- Don’t let the AR fill in the client’s signature line, because that is forgery under MCL 750.248.
- Don’t check access EBT card unless the client truly wants the AR to shop with the card.
- Don’t use whiteout or cross-outs on key fields, because workers must reject altered forms.
- Don’t submit a DHS-330 without a case number assuming the worker will look it up.
- Don’t assume an AR from a prior case carries over; each case needs its own form.
- Don’t rely on a verbal revocation; MDHHS requires writing.
Pros and Cons of Filing on Your Own vs. With Help
Pros of filing pro se (without help)
- No fee beyond postage, because DHS-330 itself is free.
- Faster turnaround when the client knows their case number and signs in person.
- Full privacy, since no third party sees the client’s MDHHS information.
- Direct control over which boxes are checked and which are left blank.
- Simpler revocation, because the same person who signed can also revoke.
Cons of filing pro se
- Higher error rate on fields like case number and date format.
- No guidance on which scope-of-authority boxes match the client’s real needs.
- Risk of choosing the wrong AR without legal screening for conflicts of interest.
- Missed deadlines when a DHS-3503 verification checklist arrives in the mail.
- No appeal support if the worker rejects the form.
Pros of filing with help (legal aid, advocate, or Michigan Legal Help)
- Professional review of the scope checkboxes against the client’s situation.
- Help with witness rules when the client cannot sign.
- Proof of filing coordinated by the advocate.
- Appeal preparation in case the form is rejected.
- Coordination with other forms like the DHS-1171 Assistance Application.
Cons of filing with help
- Possible cost if a private attorney is used instead of free legal aid.
- Slower start while the advocate intakes the case.
- Less privacy, because the advocate sees case details.
- Schedule limits during legal-aid intake windows.
- Risk of miscommunication if the advocate is juggling many cases.
How DHS-330 Differs From Related MDHHS Forms
| Form | What It Does |
|---|---|
| DHS-330 Authorized Representative Request | Names an AR across MDHHS programs |
| DHS-1171 Assistance Application | Starts a new application for FAP, FIP, SDA, MA, CDC, or SER |
| DHS-1183 Resident’s Authorized Representative | Specific to nursing-facility Medicaid AR designation |
| MDHHS-5510 Authorized Representative for MA | Medicaid-only AR for application assistance |
| DHS-1010 Change Report | Reports address, income, or household changes |
FAQs
Can I name more than one Authorized Representative on a single DHS-330?
No. Each DHS-330 names one AR. To name a second AR for the same case or a different program, file a second DHS-330 and use the Comments box to explain the split.
Do I have to be related to the person I name as my AR?
No. Bridges Administrative Manual 110 lets a client name any adult who is not a disqualified person, including neighbors, friends, clergy, social workers, and attorneys.
Does DHS-330 give my AR access to my bank account?
No. DHS-330 only grants authority over the MDHHS case checked in Field 9, not bank accounts, tax filings, or medical decisions outside MDHHS programs.
Can I write Mom in Field 1 if MDHHS knows me?
No. Field 1 requires the full legal name on the MDHHS case, because Bridges cannot match a nickname and will reject the form.
Should I leave the end date blank in Field 10 for a permanent AR?
No. Write Until revoked in writing instead, because a blank end date is sometimes treated as a one-day designation and voids the AR almost immediately.
Can my AR pick up my EBT card if I do not check the EBT box in Field 9?
No. EBT card access is granted only when the access EBT card and PIN box is checked; an unchecked box means the AR cannot use the card.
Do I need a notary to sign DHS-330?
No. MDHHS does not require notarization. A witness is required only when the client signs with an X because they cannot write their name.
Can the AR sign Field 12 a week after I sign Field 11?
No. Both signatures should be dated the same day or within a short window. A long gap can cause the worker to question whether the AR truly accepted the role.
Is there a filing fee for DHS-330?
No. Submitting the form is free through MI Bridges, mail, fax, in person, or through a caseworker.
Can I revoke my AR by calling MDHHS?
No. Revocation must be in writing, either through a new DHS-330 with the powers unchecked or a signed letter sent through any of the five filing channels.
Do I write the AR’s address in Field 4 if I live with them?
No. Field 4 always shows the client’s address. If the client and AR share a home, both Field 4 and Field 7 will show the same address, but they are entered separately.
Can I use an old DHS-330 I saved on my computer last year?
No. Bridges accepts only the current revision. Download a fresh copy from the MDHHS forms page before signing.
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