Form Il444 2378B – Fill Out and Use This PDF

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:

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

Present Address:

Apartment Number:

City:

State:

Zip Code:

County:

Birth Date:

Social Security Number:

Are you homeless?

Yes

No

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.

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
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)

Citizenship/Immigration Status

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

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

No

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

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

No

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

No

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
Printed by Authority of the State of Illinois		-0- Copies