Form Il444 2378B – Fill Out and Use This PDF

The IL444-2378B form is a vital document for residents of Illinois who are seeking cash assistance, medical assistance, and Supplemental Nutrition Assistance Program (SNAP) benefits through the State of Illinois Department of Human Services. It is designed to gather necessary information, including personal details, household composition, and citizenship/immigration status, to determine eligibility for these programs. For those in need of support, completing and submitting this form is the first step towards accessing valuable resources. Fill out the IL444-2378B form by clicking the button below and start the process towards receiving the assistance you need.

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Form Il444 2378B PDF Details

Understanding the IL444 2378B form is essential for anyone seeking cash assistance, medical assistance, or SNAP benefits in Illinois. As part of the State of Illinois Department of Human Services, this form acts as a primary gateway for individuals and families in need to access vital support services. From the outset, the form requires basic yet crucial information such as personal identification details, address, and contact numbers, ensuring that applicants can be accurately identified and communicated with throughout the process. It also addresses critical matters like citizenship or immigration status, household composition, and specific needs related to disabilities, living arrangements, and educational pursuits, underscoring the state's commitment to inclusivity and comprehensive support. Key to its design is the emphasis on immediate application processing, highlighted by the provision that allows for initial filing with minimal information and the detailed instructions guiding applicants through their rights and responsibilities, ensuring clarity and transparency. Additionally, the form facilitates the nomination of an approved representative, enabling those who may need assistance during the application process to have a trusted individual act on their behalf. With sections dedicated to providing explicit consent for representation and detailed instructions for both applicants and those assisting them, the IL444 2378B form stands as a critical document for accessing assistance services in Illinois, demonstrating a structured yet compassionate approach to public assistance.

Question	Answer
Form Name	Form Il444 2378B
Form Length	20 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min
Other names	illinois medicaid form 267, apllication for state medicad illinios, illinois medicaide forms 2378b and 267, application for medicaid in illinois

Form Preview Example

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Last Name:

First Name:

MI:

Maiden Name:

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Present Address:

Apartment Number:

City:

State:

Zip Code:

County:

Birth Date:

Social Security Number:

Are you homeless?

Yes

Mailing Address (if different from above):

City:

State:

Zip Code:

County:

Telephone number(s) Home:

Work:

Other:

Daytime phone:

Best time to call you:

Signing here will start your application. You must sign Page 18 before we approve you for any benefits.

Signature:		Date:

Approved Representative

When you sign to have an approved representative it means you give permission for this person (1) to sign your application for you, (2) to receive official information about this application, and (3) to act for you on all matters with this agency.

Do you want to name an approved representative? Yes No Name of approved representative:

Phone Number:

Organization Name:

Signature of applicant:

If yes, complete the following: Address:

ID # if applicable:

Instructions to person(s) applying for Cash, Medical, and/or SNAP benefits

Cash -

Medical -

SNAP -

1.Please print all of your answers on the application form so that we can read and understand your answers.

2.You have the right to immediately file the application as long as the top of this page (Page 1) is completed with your name, address and signature. The filing of this signed page (Page 1) starts the application processing timetable. Providing your date of birth and Social Security Number on this signed page will help us with the application registration process.

3.Read pages 14 & 15 to know your rights and responsibilities for SNAP benefits.

Read pages 16, 17 and 18 to know your rights and responsibilities for Cash and Medical benefits.

4.Before you can get any benefits, you must sign page 18.

5.If applying for SNAP benefits, a decision on your eligibility will be made within 30 days. If determined eligible, SNAP benefits will be issued from the date the application is filed.

6.You may be entitled to receive SNAP benefits right away if:

*your gross nonexempt income and liquid assets are less than your monthly rent or mortgage payment and the appropriate utility standard: or,

*you have assets of $100 or less and

-your gross monthly income for the month of application is less than $150; or

-at least one person applying is a migrant who is "out of funds."

7.This application must be filed with the Illinois Department of Human Services (IDHS). You may complete this form at home and return it to your local Family Community Resource Center (FCRC) in person or by mail. You have the right to choose the office where you apply. Use the IDHS Office Locator to find an FCRC at www.dhs.state.il.us/page.aspx?module=12 or call the IDHS Helpline at 1-800-843-6154. You may also mail this form to the Central Scan Unit (CSU), P.O. Box 19138, Springfield, IL 62763. You can also apply for benefits at ABE.illinois.gov or by calling the IDHS Helpline at 1-800-843-6154. Another member of the household or an adult who knows you may complete and return the form to us also. If someone else completes this form for the household, they are to answer the questions for the person(s) they are applying for, not himself or herself.

8.If you want to register to vote, fill out the enclosed Illinois Voter Registration Application (SBE R-19) and give it to your IDHS Family Community Resource Center (FCRC) or your local election official. For help filling it out or for translation services, contact your IDHS Family Community Resource Center (FCRC). You may also call the Helpline at 1-800-843-6154, or 1-866-324-5553 TTY/Nextalk, 711 TTY Relay. For information online, see www.dhs.state.il.us or www.elections.il.gov/. Filling out the Voter Registration Application as part of this application is optional. Registering to vote is your choice and will not affect the amount of benefits you get from this agency.



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 1 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Citizenship/Immigration Status

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If you or any other persons are not applying because you do not wish to provide information about your immigration status, you do not have to give us that information. The failure to provide immigration information will not affect processing the application for the remaining persons. However, any person who is applying for benefits for himself or herself has to provide information on their immigration status.

Are all persons U.S. Citizens?

Yes

Complete the following for any non-citizens who are applying for benefits. If you need more room, attach another sheet of paper.

Name

Age

Arrival Date in the United States

Registration document/number

If there are persons who are not applying for SNAP and/or cash benefits because they do not wish to provide proof of their immigration status, please list them below. We will only ask questions about their income & assets.

Name (Last)	(First)	(MI)	Name (Last)	(First)	(MI)

1.			3.

2.			4.

General Household Questions


1. Are you or is anyone who lives with you blind?	Yes	No Disabled?	Yes	No
2. Does anyone in the household receive Social Security Disability or Railroad Retirement benefits? Yes					No
If yes, who:	What is their SSN or RRB claim number?

3.Does anyone have a physical, mental or emotional health condition that limits common activities (like bathing, dressing, daily chores, etc)? Yes No

If yes, who:

4. Does anyone applying live in a nursing home facility, supportive living facility, or other facility or institution? Yes No

If yes, who:		Name of facility:

5.	Does anyone in your household want help paying for medical bills from the last 3 months?				Yes	No
6.	Has anyone in your household been in foster care at age 18 or older?		Yes	No
If yes, name of person:

7.	Is anyone in your household age 18 or older a full time student? (college, or trade school)				Yes	No
If yes, name of person:

Language Preference

Does the adult member of your household who will discuss your case with IDHS speak English fluently?

Yes

If no, please list your preferred spoken language:

Does the adult member of your household who will usually receive mail or written information from IDHS read English fluently?

Yes

If no, please list your preferred written language:



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 2 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Household Composition

How many people live with you (include yourself)?

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Complete the following for everyone in the household. Include people who live with you who are not requesting assistance. You must give us the Social Security Number for each person for whom you are requesting benefits. You do not have to give us the number for any person for whom you are not requesting benefits, but if you do, it may speed up the application process.

Person 1

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

SELF

Social Security #

Gender Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Do you plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will you file jointly with a spouse?

Yes

If yes, list name(s):

Do you have any dependents?

Yes

If yes, list name(s):

Will you be claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How are you related to the tax filer?

The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount. This information is to assure that program benefits are distributed without regard to race, color or national origin.

1. Is this person Hispanic or Latino?		Yes		No

2. What is your race? (Select one or more)

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Person 2

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

Social Security #

Gender

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Does this person plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will this person file jointly with a spouse?

Yes

If yes, list name(s):

Does this person have any dependents?

Yes

If yes, list name(s):

Is this person claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How is this person related to the tax filer?

Is this person Hispanic or Latino?

Yes

What is his/her race? (Select one or more)

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 3 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Household Composition (Continued)

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Person 3

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

Social Security #

Gender

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Does this person plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will this person file jointly with a spouse?

Yes

If yes, list name(s):

Does this person have any dependents?

Yes

If yes, list name(s):

Is this person claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How is this person related to the tax filer?

1.	Is this person Hispanic or Latino?			Yes	No
1.	Is this person Hispanic or Latino?			Yes	No

2.	What is his/her race? (Select one or more)
	American Indian/Alaskan Native	Asian	Black or African American			Native Hawaiian or Other Pacific Islander	White

Person 4

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

Social Security #

Gender

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Does this person plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will this person file jointly with a spouse?

Yes

If yes, list name(s):

Does this person have any dependents?

Yes

If yes, list name(s):

Is this person claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How is this person related to the tax filer?

1.	Is this person Hispanic or Latino?			Yes	No
1.	Is this person Hispanic or Latino?			Yes	No

2.	What is his/her race? (Select one or more)

	American Indian/Alaskan Native	Asian	Black or African American			Native Hawaiian or Other Pacific Islander	White



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 4 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Household Composition (Continued)

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Person 5

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

Social Security #

Gender

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Does this person plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will this person file jointly with a spouse?

Yes

If yes, list name(s):

Does this person have any dependents?

Yes

If yes, list name(s):

Is this person claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How is this person related to the tax filer?

Is this person Hispanic or Latino?

Yes

What is his/her race? (Select one or more)

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Person 6

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

Social Security #

Gender

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Does this person plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will this person file jointly with a spouse?

Yes

If yes, list name(s):

Does this person have any dependents?

Yes

If yes, list name(s):

Is this person claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How is this person related to the tax filer?

1.	Is this person Hispanic or Latino?			Yes	No
1.	Is this person Hispanic or Latino?			Yes	No

2.	What is his/her race? (Select one or more)

		Asian	Black or African American			Native Hawaiian or Other Pacific Islander	White
	American Indian/Alaskan Native	Asian	Black or African American			Native Hawaiian or Other Pacific Islander	White
	American Indian/Alaskan Native

If needed, please list extra household members on an additional piece of paper.

IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 5 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

If you are applying for SNAP benefits complete this page.

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How much money do you or anyone who lives with you have in cash, checking, and/or savings? $

What is the monthly gross income (income of all sources before any deductions)
for you and everyone who lives with you?	$

How much money have you or anyone who lives with you received or expect to receive from any source in the month of application?

$ When?Who:Source:

Shelter Costs

1. How much are you charged each month for your rent or mortgage? $

(For mortgage include property taxes and insurance.)
Do you share this expense with anyone?	Yes	No

2. Did you receive a payment of $21 or more this month or in any of the last 12 months from the Low Income Home

Energy Assistance Program (LIHEAP), (in Chicago paid through CEDA)?

Yes

3. If No, are you billed separately from rent or mortgage for:

NOTE: Air conditioning is a window air or central air conditioning unit.

A. Heat or air conditioning? Yes No

B. Excess cost for heat or air conditioning? Yes	No
C. Does anyone outside of your SNAP household pay or help pay for your housing costs?			Yes	No
D. Does anyone outside of your SNAP household pay your utility expenses?		Yes	No
		Yes	No

If yes, please list the bills and the amounts paid:

Please complete the following information if you answered No, to question 2 or 3 and are not billed for heat or air conditioning separately

Expenses

Amount

How Often Due

Amount You Pay

Paid By Others

Electricity

Water and/or Sewerage

Garbage

Cooking Fuel

Basic Phone Service (including cell phone)

Septic Tank Installation Maintenance

Well Installation /Maintenance

A Fee for Starting Utility Service

A Flat Amount for Utilities

Explain:



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 6 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Migrant or Seasonal Farmworker Questions

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Is this a SNAP household of migrant or seasonal farm workers?			Yes	No
Did the household have income prior to the date of application?			Yes	No
If yes, did the income recently stop?	Yes	No If yes, date the income stopped?

Are liquid assets of household $100 or less AND does the household have a destitute migrant or seasonal farmworker?

Yes No

Are you or is anyone who lives with you expecting to receive more than $25 in income from a new source within the next 10

days? Yes No

Benefit Information

Has the primary applicant received SNAP benefits in any state in the month of application? Yes No Is the applicant a resident of a domestic violence shelter? Yes No

Medical Deduction for Persons Disabled or Age 60 or Older

If a SNAP household member is disabled or age 60 or older your SNAP household may be entitled to a Standard Medical Deduction. To get the Standard Medical Deduction, you have to prove you pay out of pocket monthly medical expenses of $36 or more.

*If you do not live in a group home the Standard Medical Deduction is $200. *If you live in a group home the Standard Medical Deduction is $485.

Can you prove that you pay $36 or more monthly in medical expenses?

Yes

If yes and you give us proof, we will allow the Standard Medical Deduction that applies to your household. If your monthly medical expenses that you pay are more than $200/$485 and you give us proof, we will allow your actual medical expenses.

Application Interview - Cash and SNAP

Please complete the following:

We will interview you within 14 days, or right away if you qualify for an expedited SNAP interview.

I am able to come to an office interview.

I must be interviewed by phone because:

I am applying for SNAP

And someone in my household is employed.

Problems with health, transportation, caring for a child or disabled adult, ongoing severe weather or educational activities conflict with work hours.

I am applying for cash assistance

Hours of work or educational activities conflict with office hours.

Problems with health, transportation, caring for a child or disabled adult, ongoing severe weather or educational activities conflict with work hours.

I can be reached by phone Monday - Friday between 8:30 and 5:00 at:



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 7 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Income - Benefits - Expenses

Is anyone in your household currently employed?

Yes

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If yes, complete the following:

Name of Person:

Employer:

Employer Address:

Employer Phone:

Number of hours worked weekly:

Amount Paid (including tips) before taxes $

How often paid:

Weekly

Every two weeks

Twice a month

Monthly

Name of Person:

Employer:

Employer Address:

Employer Phone:

Number of hours worked weekly:

Amount Paid (including tips) before taxes $

How often paid:

Weekly

Every two weeks

Twice a month

Monthly

Is anyone in your household self-employed?

Yes

If yes, name of person:

What kind of work do they do?

How much will they make this month, once they pay business expenses? $

Complete only if your income changes from month to month. If you don't expect changes, skip this section. What is the total income for each person for this year? If you anticipate a change, what will it be next year?

Person:	Total income this year:	$	Total income next year:	$

Person:	Total income this year:	$	Total income next year:	$

Person:	Total income this year:	$	Total income next year:	$

Does anyone named on this form RECEIVE money from any source other than employment (such as Social Security, educational

benefits, child support, spousal support, rental property, unemployment benefits, pensions, retirement, trusts)?			Yes	No
			Yes	No
If yes, complete the following:
Name of Person:	Source:	Monthly Amount $

Name of Person:	Source:	Monthly Amount $

Name of Person:	Source:	Monthly Amount $

(Include additional pages, if needed.)

If this income is from rental property, is this person receiving the income also the property manager?

Yes

In the past year, has anyone in your household changed jobs, stopped working or started working fewer hours?

Yes

If yes, name of Person:

Does anyone in your household pay any of the following expenses?

Alimony paid: $

How often?

Weekly

Every two weeks

Twice a month

Monthly

How often?

Student loan interest: $

Weekly

Every two weeks

Twice a month

Monthly

How often?

Day-care: $

Weekly

Every two weeks

Twice a month

Monthly

How often?

Child Support paid : $

Weekly

Every two weeks

Twice a month

Monthly

Other deductions (Do not include any expenses you have already reported)

Type of expense:

How often?

Weekly

Every two weeks

Twice a month

Monthly



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 8 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

American Indian or Alaska Native Family Member (AI/AN)

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Are you or anyone in your family American Indian or Alaska Native (AI/AN)?	Yes	No
Are you or anyone in your household a member of a federally-recognized tribe?	Yes	No
If yes, tribe name:

If No, skip to next section.

Indian Health Services

List any family members who received services from the Indian Health Service, a tribal health program, or urban Indian health program. If nobody received these services, is anyone qualified to receive them?

List the names of anyone who received services:

List the names of anyone who qualifies for services:

Tribal Related Income

Does the income you listed on Page 7 include money from any of the following:	Yes	No
Payments from a tribe that come from natural resources, usage rights, leases or royalties?	Yes	No

If yes, amount: $

Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the

Department of the Interior (including reservations and former reservations)?				Yes	No
If yes, amount:	$

Money from selling things that have cultural significance?		Yes	No
If yes, amount:	$

SNAP and Cash Applicants:

Have you or any other person applying for Cash been convicted of a felony involving drugs on or after 08/22/96? Yes No

If yes, Name of Person:

If the drug-related felony conviction was NOT Class X or Class I, did the felony take place more than 2 years ago, or has the

person completed a drug treatment program, or is the person in a drug treatment program now?

Yes

Has any person been convicted in state or federal court of misrepresenting an address to receive assistance in two or more states at the same time? Yes No

If yes, who

Is any person in violation of their parole or probation?

Yes

If yes, who

Is anyone fleeing from felony prosecution, an outstanding felony warrant or jail? Yes No

If yes, who



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 9 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Your Family's Health Coverage

Complete this page if you are applying for cash or medical benefits.

Is anyone enrolled in health coverage now from any of the following? If write their names next to the coverage they have.

Medicaid

CHIP

Medicare

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YES, check the type of coverage and

Tricare (Don't check if you have

Direct Care or a Line of Duty)

Veteran's Health Insurance Program

Peace Corps Health Insurance

Employer Insurance

Name of Insurance

Policy Number

Is this a retiree health plan?

Yes

Is this COBRA coverage?

Yes

Other

Is this a limited-benefit plan (such as a school accident policy)?

Yes

Is anyone listed on this application offered health coverage from a job?

Yes

Check YES even if the coverage is from someone else's job, such as a parent's or spouse's.

If YES, complete Page 11.

Tell us about the job that offers coverage:

Employer Name:

Employer Address:

Employer Phone Number:

Employer Identification Number (EIN):

Who can we contact about employee health coverage at this job?

Phone Number:

E-Mail address:

Can you get coverage now or sometime in the next 3 months?

Yes

If yes, when?:

List the name of anyone who can get coverage from this job:



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 10 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Your Family's Health Coverage

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Complete this page if you are applying for cash or medical benefits and anyone listed on this application is offered health coverage from a job.

Does the employer offer a health plan that pays at least 60% of the total costs of benefits? (The minimum value standard for health plans) Yes No

For the lowest-cost minimum value plan offered to the employee ONLY (don't include family plans):

Does the employer offer wellness programs? Yes	No
If yes, what premium would the employee pay if he or she got
the maximum discount for a tobacco cessation program?	$

a.How much would the employee have to pay in premiums for this plan? $

How often?

Weekly

Every two weeks

Twice a month

Quarterly

Yearly

What changes will the employer make for the new plan year, if you know?

Employer won't offer health coverage.

Employer will start offering health coverage to employees.

Employer will change the premium for the lowest-cost plan minimum value plan available to the employee only.

a.How much would the employee have to pay in premiums for this plan? $

How often?

Weekly

Every two weeks

Twice a month

Quarterly

Yearly

You must answer for all household members age 19 or younger:

Did anyone lose health insurance from a job within the past three months? Yes No

If yes, answer the questions below:

a.Name of household member:

b.When did the insurance end?

c.Reason insurance ended:

General Medical Questions

Does anyone applying receive services through Department on Aging's Community Care Program or has anyone applied

for these services?	Yes	or	No
	Yes	or	No
If yes, enter the person's name:
Is anyone applying a Veteran or the spouse, child, widow(er) or parent of a Veteran?				Yes or	No
If yes, enter the person's name and relationship to the Veteran:



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 11 of 18
Printed by Authority of the State of Illinois	-0- Copies
Printed by Authority of the State of Illinois	-0- Copies

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

RESOURCE INFORMATION

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Complete only for persons who are blind, have a disability or are age 65 or older. If married and living with spouse, also

enter any resources the spouse owns. If yes to any of the following, enter the details below. Attach proof. Attach additional sheet(s) if needed.

Does anyone own any property (ies) such as a home, vacation home, time share, building or land?

Yes

Owner

Address

Type

Value

Amount Owed

Does anyone own a car, truck, motorcycle, boat, trailer or other vehicle?

Yes

Owner

Type

Make/Model/Year

Value

Amount Owed

Does anyone own any life insurance?

Yes

Owner

Insurance Company

Policy Number

Face Value

Cash Value

Does anyone have an insurance policy that pays when he or she is in a nursing home?

Yes

If yes, list the following:

Policy Number:

Name of Company:

Does anyone own any of the following resources? Check all that apply:

Business	Savings	Checking Account	Stocks, Bonds	Government Bonds
Life Estate	Funeral/Burial Plans	Money Market Account	Deferred Comp	Mutual Funds
Annuity	Nursing Home Account	Trust Funds	Inheritance	Promissory Note/Loan
Burial Plots	IRA/401 K	Certificates of Deposit	Reverse Mortgage	Mineral/Oil Rights

Other List, If other:

Owner(s)	Type of Resource	Account/Policy No.	Value	Name of Bank, Company, etc.

			$

			$

Do you have resources that are held jointly with another person? Yes			No

(Jointly held resources are those held in two or more names; for example, in your name and in the name of another person(s). This includes resources that may be held by you and your spouse, son or daughter, brother or sister, grandchild, friend, companion, etc.)

Resource:	Value:	Name and relationship of Other Person(s) Holding the Resource:

Property in Illinois:	$

Property in another state:	$

Checking/Savings account:	$

Certificate of Deposit:	$

Stocks/Mutual Funds:	$

Other:	$

IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 12 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Employment and Employment Related Expenses

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Complete only for employed persons who are blind, have a disability or are age 65 or older. Also enter the employment expenses for an employed spouse or parent of a child under age 18 if they live together.

Employed person's name: (1)

Amount received before deductions (gross amount): $

How often paid:

Weekly

Every two weeks

Bi-Monthly

Monthly

Federal, State and City taxes withheld: $

Social Security tax withheld: $

Does this person buy or bring lunch to work?

Buy Lunch

Bring Lunch

Does this person buy uniforms or special tools?

Yes

If yes, enter the items bought, how often, and cost. Attach proof.

How does this person get to and from work?

Own car

Bus

Other Please list. if other:

If this person uses his/her own car, how many miles to and from work?

If this person person takes the bus, what is the fare to and from work? $

If other transportation is used, enter type and cost. Attach proof.

Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan

withholding as a condition of employment?	Yes	No Monthly amount: $

Employed person's name: (2)

Amount received before deductions (gross amount): $

How often paid:

Weekly

Every two weeks

Bi-Monthly

Monthly

Federal, State and City taxes withheld: $

Social Security tax withheld: $

Does this person buy or bring lunch to work?

Buy Lunch

Bring Lunch

Does this person buy uniforms or special tools?

Yes

If yes, enter the items bought, how often, and cost. Attach proof.

How does this person get to and from work?

Own car

Bus

Other Please list. if other:

If this person uses his/her own car, how many miles to and from work?

If this person person takes the bus, what is the fare to and from work? $

If other transportation is used, enter type and cost. Attach proof.

Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan

withholding as a condition of employment?

Yes

No Monthly amount: $



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 13 of 18
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Printed by Authority of the State of Illinois	-0- Copies

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

SNAP - CLIENT RIGHTS AND RESPONSIBILITIES

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Read carefully before signing this application on page 18. Ask your caseworker to explain anything you do not understand.

Because the SNAP program requires a Social Security Number (SSN) for every member of your household who is applying for SNAP benefits, we are explaining how your SSN is used by IDHS.

What does IDHS do with your Social Security Number?

The SSN will be used in the administration of the SNAP program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes. If you or any member of your household wants to apply for SNAP benefits, but does not have a SSN, we can help you apply for one. The SSN (or any other information in this application) may be used in computer matching and program reviews or audits and to make sure the household is eligible for SNAP benefits, other Federal assistance programs, and Federally assisted state programs, such as school lunch, TANF, and Medicaid. This may result in criminal or civil action or administrative claims against persons fraudulently participating in the SNAP program. We do not require a Social Security Number for any member of your household who is not eligible for the SNAP program or who does not wish to apply.

Why does IDHS collect your Social Security Number?

IDHS secures and uses information about all clients through the income and eligibility verification system. This includes such information as receipt of social security benefits, unemployment insurance, unearned income and wages from employment. When information does not match, we may contact a third party, such as employers, claims representatives, or financial institutions to verify the information. This information may affect your eligibility for assistance and the amount of assistance provided.

Right to appeal.

A fair hearing may be requested either orally, in writing, by using the ABE Appeals Portal, facsimile (fax), mail or in person at the Bureau of Hearings or at any FCRC if there is a disagreement with any action taken on this case. The SNAP unit's case may be presented at the hearing by any person chosen by the SNAP unit.

Non-Discrimination.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State of Illinois Department of Human Services) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http:// www.ascr.usda.gov/complaint_filing_cust.html , and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

(2)Fax: (202) 690-7442; or

(3)Email: program.intake@usda.gov.

This institution is an equal opportunity provider.

Additional Illinois Nondiscrimination Information

You may also write the Illinois Department of Human Services (IDHS) at Illinois Department of Human Services, Bureau of Civil Affairs, 401

South Clinton St., 6th Floor, Chicago, Illinois, 60607 or call the IDHS Helpline Number at 1-800-843-6154 or 866-324-5553 TTY/Nextalk or 711 TTY Relay.

IDHS, HHS, and USDA are equal opportunity providers and employers.

The State of Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 14 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

SNAP - CLIENT RIGHTS AND RESPONSIBILITIES continued

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Declaration Regarding Citizenship/Alien Status

I declare, under penalty of perjury, that the statements I have made regarding the citizenship or alien status of each person requesting assistance are true and correct. I understand that the alien status of each person requesting assistance who is not a citizen of the United States will be verified with the United States Citizenship and Immigration Services (USCIS). This will require the disclosure to USCIS of certain identifying information which I have provided. The information received from USCIS may affect eligibility for assistance and the benefit level.

I understand that documents may have to be provided to prove what I have said. I agree to do this. If documents are not available, I agree to give the name of the person or organization the IDHS Family Community Resource Center (FCRC) may contact to obtain the necessary proof. The information on this form is subject to verification by Federal, State, and Local Officials. If any information is found to be inaccurate, I may be denied SNAP benefits, and/or be subject to criminal prosecution for knowingly providing false information.

I understand that a change that happens after the eligibility interview and before the notice of decision must be reported within 10 calendar days unless otherwise notified. If I have any doubt about whether to report a change, I will ask my Human Services caseworker.

I understand that if I am approved for SNAP benefits and I receive more benefits than I am entitled to, whether an error on my part or an agency error, the amount of overpaid benefits may be subtracted from my monthly benefit amount.

	AT THE APPLICATION

You Must Report		You must report and verify:

Child care expenses		Medical expenses

Rent or mortgage payment, property taxes and insurance and		Child support paid to a non-SNAP Unit member
utility expenses.		Child support paid to a non-SNAP Unit member
utility expenses.

Failure to report or verify above expenses will be seen as a statement by your SNAP Unit that you do not want to receive a deduction for the unreported expenses.

Child support payments are subject to verification by computer matching with the records of the Division of Child Support Enforcement.

Penalty Warning - What are the SNAP Program Penalties?

	If you	Then you will lose SNAP benefits

	* Hide or give wrong information on purpose to get SNAP benefits
	* Trade, steal or sell SNAP benefits, or resell food bought with SNAP
	benefits	* 12 months first time
	* Use SNAP benefits to buy non-food items like alcohol or tobacco.	* 24 months the second time
	* Use someone else's SNAP benefits for yourself or someone else.	* Permanently the third time
	* Throw away beverages purchased with SNAP benefits just to get
	money back from a container deposit.

	Trade SNAP benefits for controlled substance, such as drugs.	* 24 months first time
		* Permanently the second time
		* Permanently the second time

	Trade SNAP benefits for firearms, ammunition or explosives.	* Permanently

	Buy, sell, steal or trade SNAP benefits of more than $500.00	* Permanently

	* Give false information about who you are and where you live so you can	* 10 years
	get extra SNAP benefits.	* 10 years
	get extra SNAP benefits.

You can also be fined up to $250,000 and put in prison up to 20 years or both. In addition, you may be barred from SNAP for an additional 18 months if court ordered. You can also be charged under other Federal Laws. Persons who are fleeing felons or probation/parole violators are ineligible for SNAP benefits.



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 15 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Read carefully before signing this application on page 18. Ask your caseworker to explain anything that you do not understand.

To receive benefits, a person must have a valid Social Security Number (SSN) or proof that he or she has applied for one, unless exempt. If you or any member of your household wants to apply for assistance, but do not have a SSN, we can help you to apply for one. State law requires us to explain how your SSN is used by the State of Illinois.

üYour Social Security Number (SSN) will be used in the administration of the cash and/or medical program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes to the cash and/or medical program.

•The SSN (or any other information in this application) may be used in computer matching and program reviews or audits and to make sure the household is eligible for assistance, other federal assistance programs, and federally assisted state programs, such as school lunch, TANF, and Medicaid.

•IDHS secures and uses information about all clients through the income and eligibility verification system. This includes such information as receipt of social security benefits, unemployment insurance, unearned income and wages from employment.

•Any information obtained will be used in determining eligibility for assistance and the amount of assistance provided for all programs.

•When discrepancies are found, verification of this information may be obtained through contacts with a third party, such as employers, claims representatives, or financial institutions. This information may affect your eligibility for assistance and the amount of assistance provided.

•IDHS will only use your SSN for the purpose for which it was collected.

•IDHS will not: sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly display your SSN; print your SSN on any card required for you to access our services; require you to transmit your SSN over the Internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any materials that are mailed to you, unless State or Federal law requires that number be on documents mailed to you, or unless we are confirming the accuracy of your SSN.

üWhen an application for cash or medical assistance is filed, a determination of eligibility under all of the programs administered by IDHS will be made unless I do not want to be considered for a particular program(s). If I do not want to be considered for a particular program, IDHS will not consider my eligibility for that program(s).

üThe information provided on this form will be subject to verification by Federal, State, and Local officials. If any information is found to be inaccurate, I may be denied cash benefits and/or medical assistance. I understand that anyone who knowingly misuses the medical card issued by the State of Illinois may be committing a crime.

üAll information related to the establishment of paternity and child support enforcement has been provided to the best of my knowledge.

üIf my application is approved, I give the State of Illinois the right to recover under the terms of any private or public health care coverage any amount for which I or a member of my family may be eligible.

üI also authorize staff of the IDHS to obtain information from my records or copy my records from the Social Security Administration (SSA). I authorize release of my records from SSA to the staff of IDHS with respect to any claims for disability benefits and all related appeals. I certify that I understand that the materials requested may be protected under the Privacy Act. I authorize release of any material protected under the Privacy Act to the staff of IDHS.



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 16 of 18
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Printed by Authority of the State of Illinois	-0- Copies

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued

üI understand that the State of Illinois will release information concerning medical services that I have received for any reason authorized by law.

üI understand that if the children I am applying for are approved for "All Kids Share or All Kids Premium", then I am responsible for paying the premiums and copayment amounts.

üIf I am approved for TANF Cash and/or medical benefits for myself and my children, and the State of Illinois pays medical bills for me, I give my right to collect medical support payments to the State of Illinois. I understand I must help to obtain medical support payments for members of my family unless I have a good reason not to. My children can get health insurance even if I do not help when the Department asks me to.

üAs a condition of eligibility, if I am approved for TANF Cash and/or medical assistance for myself and my children, I understand that I may be required to cooperate with child support enforcement.

•Cooperation includes establishment of paternity and/or support enforcement and modification of child support orders.

•I assign and give all my rights, title and interest of child support and medical support to Healthcare and Family Services (HFS) as long as I receive TANF Cash/or medical assistance.

•I understand and agree that any child support payments paid through the clerk of the circuit court and through the State Disbursement Unit (SDU) may be forwarded to the HFS as long as I receive TANF Cash.

•I understand that if I apply for TANF Cash and/or medical assistance for my children only, I am not required to cooperate with child support enforcement, but I may request services.

üI declare under penalty of perjury, that the statements I have made regarding the citizenship or immigration status of each person requesting assistance are true and correct.

üI understand the Department will not share any information about immigration or any persons who do not have an Alien Registration Number.

üThe Department will verify the immigration status of any person for whom I give an Alien Registration Number. To do that, the Department will check the number with the U.S. Citizenship and Immigration Service (USCIS). The Department may send other information to USCIS, such as copies of proof that I give of an Alien Registration Number and the person's Social Security Number, if they have one.

üIf I am approved for Aid to the Aged, Blind, or Disabled (AABD) for cash and/or medical assistance, I understand that IDHS may have the right to place a lien on my home or other real property I own. The amount of the lien is the amount of assistance IDHS has provided to me.

üI agree to inform the agency within 10 days of any change in my household's size, income, property, living arrangements, school attendance, or address.

üI understand that if approved for cash benefits, and I receive more benefits than I am entitled to, whether it be an error on my part or an agency error, the amount of overpaid benefits are subject to recoupment/recovery.

üI understand that a person convicted of a Class X or Class I felony or a comparable federal law, for acts that occurred on or after 08/22/96 involving possession, use, or distribution of a controlled substance is ineligible to receive Cash assistance. I understand that a person convicted of drug-related felony, other than a Class X or Class I, under Illinois or any comparable federal law an act that occurred on or after 08/22/96, is ineligible for Cash assistance for 2 years following the date of the conviction, unless they are in drug treatment or aftercare, or successfully participated in and completed drug treatment and/or aftercare subsequent to their conviction.



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 17 of 18
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State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued

üRight to Appeal I understand that if I am not satisfied with the action taken on my application that I have the right to a fair hearing. I understand that I can ask for a fair hearing by getting in touch with the office where I applied or by writing to: Illinois Department of Human Services, Bureau of Assistance Hearings, 401 South Clinton Street, 6th Floor, Chicago, Illinois 60607, or by calling 1-800-435-0774.

üI understand that if I am mentally and physically unable to apply and I want someone else to apply for cash and/or medical benefits for me, I must attach a written statement that gives the person permission. The statement must include the person's name, address, and phone number. The statement must say that I am still responsible for the information provided by the person

üI understand that if I or anyone I have applied for is not eligible for Medicaid or All Kids, the state will send the information from the application to the Health Insurance Marketplace. The Health Insurance Marketplace needs detailed information about health coverage that my employer may offer even if I do not take it. The information requested on Pages 10 and 11 may be required if the state sends my application to the Health Insurance Marketplace.

üI understand that by signing this application form, I consent to any investigation made by the Department to verify or confirm the information I have given or any other investigation made by them in connection with my request for public assistance. I understand that I must cooperate in these efforts to verify information.

Applicant Signature

I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil or both. I certify under the penalty of perjury that the information I have provided on this application form is the truth to the best of my knowledge.

I declare under penalties of perjury that I have examined this form and all accompanying statements or documents pertaining to the income and resources of myself (the applicant) or any member of my family (the applicant's family) included in this application for aid, or pertaining to any other matter having bearing upon my (the applicant's) eligibility for aid, and to the best of my knowledge and belief the information supplied is true, correct, and complete.

Applicant:				Date
Spouse:				Date
Spouse:				Date

Signature: Applicant Makes a Mark (X)

If you have made your mark (X) instead of signing your name, one witness must sign here:

Signature of Witness:			Date

Signature: Applicant Blind
Applications based on blindness must be attested to by two witnesses.
Signature of Witness:			Date

Signature of Witness:			Date

APPROVED REPRESENTATIVE SIGNATURE

If the application is initiated by someone else for the applicant, they must sign below. If an approved representative completes and signs this application, written authorization from the applicant is required.

Signature of Approved Representative:			Relationship:

Home Address:			Apt. Number:

Phone Number:

You can mail or bring this form to an Illinois Department of Human Services, Family Community Resource Center (FCRC). Use the IDHS Office Locator to find an FCRC at www.dhs.state.il.us/page.aspx?module=12 or call the IDHS Helpline at 1-800-843-6154. You can also apply for benefits at ABE.Illinois.gov or by calling the Helpline at 1-800-843-6154.



IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 18 of 18
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Last 4 digits of Social Security Number

I have none of the above identification numbers

9. Home telephone number, including 10. ID Number - check the applicable box and provide the appropriate number

area code (optional)IL Driver's License or, if none, Sec. of State ID, ot

ILLINOIS VOTER REGISTRATION APPLICATION

FOR ILLINOIS RESIDENTS ONLY	(September 2017)
TO VOTE YOU MUST:	TO COMPLETE THIS FORM:

-Be a United States citizen

-Be at least 18 years old (some 17 year olds may vote in the General Primary Consolidate Primary or Caucus.)

-Live in your election precinct at least 30 days

-Not be convicted and incarcerated.

-Not claim the right to vote anywhere else

TO VOTE IN THE NEXT ELECTION:

-Mail or deliver this application to your County Clerk or Boardof Election Commissioners no later than 28 days before the next election. (click here for County Clerk/Election Boardlistings) or go to http://www.elections.il.gov

IMPORTANT INFORMATION:

−If you do not have a driver's license, State Identification Card or social security number, and this form is submitted by mail, and you have never registered to vote in the jurisdiction you are now registering in, then you must send, with this application, either (i)a copy of a current and valid photo identification, or (ii) a copy of a current utility bill, bank statement, government check, paycheck,or other government document that shows the name and address of the voter. If you do not provide the information required

above,then you will be required to provide election officials with either (i)or

(ii) described above the first time you vote in person or prior to voting by mail.

-If you change your name you must re-register.

-If you register at a public service agency, any information regarding the agency that assisted you will remain confidential as will any decision not to register.

-If you do not receive a Notice within 2 weeks of mailing or delivering this application, call your County Clerk or Board of Election Commissioners.

Box 1-If you do not have a middle name, leave blank. Box 3-If mailing address is same as Box 2, write "same".

Box 4-By providing an email address you agree to receiveelection related notices via email.

Box 5-If you have never registered before, leave blank. If you do not remember your former address; provide as muchinformation as possible.

Box 6-If you have not changed your name, leave blank.

Box 10-If you have an Illinois Driver's License or Secretary of State ID, check the first box and fill in the number. If you do not have a Driver's License or SOS ID, check the second box and fill in the last four digits of your Social Security Number. If you do not have a SSN, check the third box and send a copy of the appropriate document (as described in the "Important Information" section) along with this form.

Box 11-Read, date and personally sign your name or make your mark in the box.

IF YOU HAVE NO STREET ADDRESS,

below describe your home: list the name of subdivision; cross streets; roads; landmarks; mileage and/or neighbors’ names.

W			E
W			E

If you have questions about completing this form, please call the State Board of Elections at (217) 782-4141 or (312) 814-6440

(or webmaster@elections.il.gov).

TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK

Are you a citizen of the United States of America? (check one)

Yes

Will you be 18 years of age on or before the next election day OR are you currently 17 and

will be 18 by the day of the next General or Consolidated Election? (check one) Yes

If you checked "no" in response to either of these questions, then do not complete this form.

You can use this form to: (Check One)

apply to register to vote in Illinois

change your address

change your name

1. Last Name

First Name

Middle Name or Initial

Suffix (Circle One)

Jr. Sr. II

III IV

Office Use

2. Address where you live (House No., Street Name, Apt. No.)

City/Village/Town

Zip Code

County

Township

3. Mailing address (P.O. Box)

City/Village/Town

Zip Code

4. Email (optional)

5. Former Registration address: (include City and State and Zip Code)

Former County

6. Former Name: (if changed)

7.Date of Birth: MM/DD/YY

8.Sex (circle one)

M F

( ) -

11.Voter Affidavit - Read all statements and sign within the box to the right.

This is my signature or mark in the space below.

I swear or affirm that:

-I am a citizen of the United States;

-I will be at least 18 years old on or before the next election (or the next General or Consolidated Election);

-I will have lived in the State of Illinois and in my election precinct at least 30 days as of the date of the next election;

-The information I have provided is true to the best of my knowledge under penalty of perjury. If I have provided false information, then I may be fined, imprisoned, or if I am not a U.S. citizen, deported from or refused entry into the United States.

Today's date:

12. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.

Name of person assisting.

Full Address

Telephone No.

YOUR ADDRESS	Back of SBE No. R-19

PUT

FIRST

CLASS

STAMP

HERE

MAIL TO:

CHANGE OF ADDRESS

PCT WARD CODE	ADDRESS	CITY ZIP COUNTY DATE	CLERK

SUSPENSION, CANCELLATION AND REINSTATEMENT

DATE	EXPLAIN	CLERK	DATE	EXPLAIN	CLERK

To Election Judges

For Primary, mark D for Democrat R for Republican for all other elections mark V

Voting Record

08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Primary

General

NonPartisan

Special

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1. Complete the medicaid application il printable with a group of necessary fields. Note all of the information you need and be sure there's nothing omitted!

form 267 conclusion process explained (part 1)

2. Soon after completing the last step, head on to the subsequent part and fill in the necessary details in all these fields - If you or any other persons are, Yes, Name, Age, Arrival Date in the United States, Registration documentnumber, If there are persons who are not, Name Last First MI, Name Last First MI, General Household Questions, Are you or is anyone who lives, No Disabled, Yes, Yes, and Yes.

3. Your next part is usually straightforward - fill out every one of the fields in Does anyone applying live in a, Yes, If yes who, Name of facility, Does anyone in your household, Yes, Yes, If yes name of person, Is anyone in your household age, Yes, If yes name of person, Language Preference, Does the adult member of your, Yes, and If no please list your preferred to complete this segment.

4. All set to fill out the next part! In this case you've got all of these Household Composition, How many people live with you, aabfaadedabbcfbdc, Complete the following for, Person, First, Mark the box for the program this, SNAP, Medical, Cash, MI Last, Suffix, Former Name if any, Relationship to you, and SELF fields to do.

form 267 completion process described (part 4)

Be really mindful while completing SNAP and MI Last, because this is where a lot of people make some mistakes.

5. This last point to submit this form is essential. Ensure to fill in the displayed fields, including The following two questions are, Is this person Hispanic or Latino, Yes, What is your race Select one or, American IndianAlaskan Native, Asian, Black or African American, Native Hawaiian or Other Pacific, White, Person, First, Mark the box for the program this, SNAP, Medical, and Cash, before using the pdf. Otherwise, it could result in an incomplete and potentially incorrect document!

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