Form Cf Es 2282 – Fill Out and Use This PDF

Form Cf Es 2282 is a document that can be downloaded from the IRS website. It contains information about your income and expenses.

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Form Cf Es 2282 PDF Details

Form Cf Es 2282 is a government form used to request information from the IRS about a specific taxpayer. The form can be used to request information such as the taxpayer's name, address, social security number, and other details. It's important to note that the form cannot be used to obtain tax return information. If you need information about a specific tax return, you should use Form 4506-T.

You will discover more details about the form cf es 2282 by looking through the table we prepared.

Question	Answer
Form Name	Form Cf Es 2282
Form Length	3 pages
Fillable?	Yes
Fillable fields	62
Avg. time to fill out	13 min 13 sec
Other names	how to file for medicaid in florida, how to apply for florida medicaid, medicaid application, florida medicaid application online

12

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MEDICAID/MEDICARE BUY-IN APPLICATION			Page 1

Demographic Information:
Please complete all information for you and your spouse. If no spouse, indicate “None”.

Your Name (Applicant):

First

MI

Last

Your Social Security Number:		Sex:
Name of Spouse:

Male

Female

First

MI

Last

Spouse’s Social Security Number (if applying):

Sex:

Male

Female

Do you and your spouse live together?

Yes

No

Your Medicare claim number:

Spouse’s Medicare # (if applying):

Living Address: ______________________________________________________________________________________________

Number

Street

Apt #

City

Zip Code

Mailing Address: ______________________________________________________________________________________________

NumberStreetApt #CityZip Code

Telephone Number:

Telephone #

Contact Person:	__________________________________________________________________________
(Other than Yourself)	First	Last		MI
	______________________________________________________________________________________________
	Number	Street	Apt #	City	Zip Code

___________________________________

Telephone #

Relationship of Contact Person to you:___________________________________________

Do you want eligibility determined for the
three months before the month of application?	Yes	No

Technical Information:

Please complete all information for you and your spouse.

Date of Birth:	________________	________________
	You	Spouse
Are you a U.S. Citizen? You:		Spouse:
	Yes	No	Yes	No

Date Stamp: (Official DCF use only)

If not a citizen, provide alien number and status: __________________________________ ; __________________________________

You	Spouse (if applying)

Do you intend to remain in the State of Florida? You:

Yes

Do you and/or spouse have any other insurance other than Medicare? If Yes, Complete the following information:

Spouse:

NoYes No

You:		Spouse:
Yes	No	Yes	No

______________________________________________________________________________________________________________

Name of Other Insurance CompanyOther Insurance Policy Number

______________________________________________________________________________________________________________

Address of Other Insurance Company	Who is Covered by This Insurance
CF-ES 2282, PDF 07/2006

BUY-IN APPLICATION

					Page 2
Asset Information: Please list all assets owned by you and/or spouse (even if your spouse is not applying).
TYPE	NAME OF BANK/	ADDRESS	ACCOUNT NUMBER	VALUE OF	IN WHOSE NAME
	FINANCIAL INSTITUTION			ASSET	IS IT HELD
CASH

SAVINGS ACCOUNT

CHECKING ACCOUNT

CAR
Make/Model/Year:

HOMESTEAD

OTHER PROPERTY

TRUST FUND

STOCKS/BONDS

TAX SHELTERED
ACCOUNTS
LIFE INSURANCE

KEOGH PLAN

Other: Please Specify

Income Information: Please complete all information for you and your spouse (even if spouse is not applying).

Are you or your spouse self-employed?

Applicant

Yes	No	Gross Amount
		Earned Monthly

Spouse

Yes	No	Gross Amount
		Earned Monthly

Do you or your spouse work for someone else?

Applicant

Yes	No	Gross Amount
		Earned Monthly

Spouse

Yes	No	Gross Amount
		Earned Monthly

Do you or your spouse receive income from any of the following?
		Gross Amount Received Each Month
		(Before Any Deductions)
Type	Benefit No.	Applicant	Spouse
Veterans Benefits
Pension
Interest/Dividends
Civil Service Annuity
Income from another person
Black Lung
Social Security
Other (e.g. SSI, Annuities): (specify)

CF-ES 2282, PDF 07/2006

BUY-IN APPLICATION

Page 3

YOUR RIGHTS AND RESPONSIBILITIES: Read this sheet before you sign your name.

YOU HAVE THE RIGHT TO:

•Apply for assistance and have a determination of your eligibility made without regard to race, color, sex, age, handicap, religion, national origin, marital status or political belief.

•Have a representative help you fill out the eligibility forms.

•Have action taken on your application promptly and be notified of such action.

•Be informed of other available services of the Department of Children and Families.

•Request a fair hearing when you disagree with a decision of the Department of Children and Families.

•Have the information about you and/or your spouse that is collected by the department treated confidentially in accordance with federal and state laws.

YOU HAVE THE RESPONSIBILITY TO (things you must do):

•Assist in determining your eligibility by giving complete and correct information and provide written proof of information, as requested, within the time limits given.

•Declare the citizenship or alien status for you and your spouse by signing the Medicaid/Medicare Buy-In Application.

•File for any payments or benefits from other sources if this application, or other information, indicates that you or your spouse may be eligible for such payments or benefits.

•Assign your rights to third party benefits and cooperate in reporting any insurance or other health plan that covers medical costs for you (and/or your spouse, if applying) unless good cause can be shown not to do so.

•Report changes in your situation (e.g., income, assets) within 10 days of the change.

•Report your (and your spouse’s, if applying) Social Security numbers. Without accurate numbers, we will be unable to provide Medicaid/Medicare buy-in benefits if you are determined eligible for any benefits.

IMPORTANT INFORMATION ABOUT MEDICAID:

Any person (including the designated representative) who knowingly withholds information or knowingly misrepresents the truth may be punished under federal or state law or both. If you get medical assistance for which you do not qualify, you may have to repay the cash value of that assistance.

Certification of Citizenship/Alien Status: I certify, under the penalty of perjury, by signing my name on this application, that I and my spouse (if applicable) are U.S. citizens or nationals of the United States or qualified aliens.

Certification: In signing this application, I swear and affirm, under penalty of perjury, that the information I have given on this application is correct and complete to the best of my knowledge. I have read and understand the above rights and responsibilities and important information about Medicaid.

Applicant				Go Back To Page 1
Applicant
Signature:					Date:
Spouse
Signature:					Date:

Designated
Representative Signature:					Date:


HELPING PERSON: (Official use only)
					Date:

Signature of Individual Who Assisted Applicant in Completing Buy-In Application Form

In accordance with Federal law and our policy, the Department of Children and Families is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, religion, political belief, or marital status.

CF-ES 2282, PDF 07/2006

How to Edit Form Cf Es 2282 Online for Free

This PDF editor allows you to complete forms. There's no need to do much to update medicaid application documents. Only consider the next actions.

Step 1: Click the button "Get Form Here".

Step 2: So, you're on the file editing page. You can add content, edit current details, highlight particular words or phrases, place crosses or checks, insert images, sign the template, erase unwanted fields, etc.

These particular sections will help make up the PDF document:

medicaid application florida blanks to fill in

Write down the necessary details in Apt, City, Zip, Code Number, Telephone Street, Telephone, Number Contact, Person, Other, than, Yourself, First Last, Number, Street, Apt, City, Zip, Code Telephone, and Yes section.

Entering details in medicaid application florida stage 2

You'll be required to write down the information to let the platform fill out the section Spouse, if, applying You, You, Yes, Spouse, Yes, Spouse, You, Yes, and Yes.

Spouseifapplying, You, You, Yes, Spouse, Yes, Spouse, You, Yes, and Yes in medicaid application florida

The space NAME, OF, BANK ADDRESS, VALUE, OF ASSET, IN, WHOSE, NAME IS, IT, HELD FINANCIAL, INSTITUTION ACCOUNT, NUMBER CASH, SAVINGS, ACCOUNT CHECKING, ACCOUNT CAR, Make, Model, Year HOMESTEAD, and OTHER, PROPERTY is going to be where to include each side's rights and responsibilities.

part 4 to filling out medicaid application florida

Prepare the form by checking the next areas: Are, you, or, your, spouse, self, employed Applicant, Yes, Gross, Amount, Earned, Monthly Do, you, or, your, spouse, work, for, someone, else Applicant, Yes, Gross, Amount, Earned, Monthly Type, Veterans, Benefits Pension, Interest, Dividends Civil, Service, Annuity Income, from, another, person and Black, Lung

stage 5 to entering details in medicaid application florida

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