Form Des 202 PDF Details

Form Des 202 is a document that is submitted to the IRS by certain tax-exempt organizations. This form is used to provide information about the activities of the organization and its directors, officers, and other key employees. Form Des 202 must be filed annually with the IRS by all tax-exempt organizations except churches and small associations of members. In addition, section 6033(a)(2) of the Internal Revenue Code requires all 501(c)(3) organizations to file an annual return on Form 990 or 990-EZ.

To look at a few specific details pertaining to the file you intend to use, here is the facts you might like to look at before filling out the form des 202.

Question	Answer
Form Name	Form Des 202
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	online michigan bdic, revocation, DES-202, pursuant

Form Preview Example

	Clear
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

Last

Your Social Security Number:		Sex:
Name of Spouse:

Male

Female

First

Last

Spouse’s Social Security Number (if applying):

Sex:

Male

Female

Do you and your spouse live together?

Yes

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 Des 202 Online for Free

Very few things are easier than creating files using the PDF editor. There isn't much you have to do to manage the CERTIFICATIONS document - just follow these steps in the next order:

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

Step 2: After you have entered the editing page CERTIFICATIONS, you'll be able to notice all of the actions available for the document within the upper menu.

In order to fill in the document, enter the information the program will request you to for each of the following segments:

Note the necessary data in the box Telephone, Contact Person Last Other than, Number, Street, Apt, City, Zip Code, Telephone, Relationship of Contact Person to, Date Stamp Official DCF use only, Do you want eligibility determined, Yes, Technical Information Please, Date of Birth, and You.

The system will ask you to provide particular significant data to automatically fill in the part Do you andor spouse have any other, Yes, Yes, Name of Other Insurance Company, Address of Other Insurance, and CFES PDF.

It is important to define the rights and responsibilities of both sides in field NAME OF BANK FINANCIAL INSTITUTION, ADDRESS, ACCOUNT NUMBER, VALUE OF ASSET, IN WHOSE NAME IS IT HELD, TYPE, CASH, SAVINGS ACCOUNT, CHECKING ACCOUNT, CAR, MakeModelYear, HOMESTEAD, OTHER PROPERTY, TRUST FUND, and STOCKSBONDS.

stage 4 to entering details in revocation

Prepare the document by checking the next sections: KEOGH PLAN, Other Please Specify, Income Information Please complete, Applicant, Yes, Gross Amount Earned Monthly, Yes, Gross Amount Earned Monthly, Spouse, Do you or your spouse work for, Applicant, Yes, Gross Amount Earned Monthly, Yes, and Gross Amount Earned Monthly.

Step 3: When you hit the Done button, your finalized form can be easily exported to any kind of your gadgets or to electronic mail provided by you.

Step 4: Produce a duplicate of each form. It would save you some time and help you avoid complications down the road. Also, your data will not be distributed or viewed by us.

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