Request Form - SSC - HR - VOE - External, Department of Health and Human Services

Employee Information

Employee First Name:

Employee Last Name:

University of Michigan Employee DOB (MM/DD/YYYY):

If known, please list the employee's eight digit University of Michigan ID number:

UM Employee Full SSN

Case Name:

Case Number:

MDHHS Office (County):

Specialist Name / ID (if known):

Specialist Email (this is our preferred return method once forms are completed):

MDHHS Office Phone:

MDHHS Office Fax:

Gross Earnings

Gross earnings from ________ to _______

Gross Earnings Start Date

Gross Earnings End Date

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