A18 DHS-Family Systems Variance Request Form - dhs state mn 2025

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The document is a request form for variances related to family care services, including child foster care, adult foster care, and community residential settings. It outlines the types of variances that can be requested, the criteria for serving individuals over 18 in child foster care, and the necessary information required for processing the request. The form includes sections for compliance issues, reasons for the variance request, alternative measures for safety, and recommendations from county licensors.

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Click ‘Get Form’ to open it in the editor.
Begin by filling in the Agency/County Name and Licensor details at the top of the form. This information is crucial for identifying your request.
Next, provide your Provider Name and complete the Address, City, and Zip fields accurately to ensure proper communication.
Select the Type of Care you are requesting a variance for by checking the appropriate box (Child Foster Care, Family Child Care, etc.).
Indicate the specific type of variance requested by checking one or more boxes related to age limits or supervision requirements.
Answer whether crisis services are being provided in your home by selecting 'YES' or 'NO'.
Provide detailed responses to questions regarding compliance issues and reasons for requesting a variance in the designated fields.
If applicable, include information about any specific individuals involved, including their names and dates of birth.
Complete the start and end dates for your variance request and indicate if this is a new request.
Finally, ensure all signatures are obtained where required before submitting your form.

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