Form Mo 886 3846 PDF Details

If you are like most people, you probably don't think too often about the Internal Revenue Service (IRS). However, if you are self-employed or own your own business, it's important to be aware of a few things that the IRS requires of small businesses. One of these is Form Mo 886 3846, which is used by businesses to calculate their quarterly estimated tax payments. Let's take a closer look at this form and what it means for your business.

Below is the data relating to the form you were in search of to fill out. It will tell you the time you will require to complete form mo 886 3846, exactly what parts you need to fill in, etc.

QuestionAnswer
Form NameForm Mo 886 3846
Form Length7 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 45 sec
Other namesmo healthnet application, missouri medicaid application print out, medicaid application form missouri, mo medicaid form im1

Form Preview Example

MissOuri departMent Of sOcial services faMily suppOrt divisiOn

appLICaTIoN foR mo hEaLThNET (mEdICaId)

Need help with your application?

Call us at 1-855-373-4636. If you need help in a language other than English, tell the customer service representative the language you need. TTY users can call: 1-800-735-2966. If you are blind or visually impaired and would like information regarding Rehabilitation Services for the Blind, please call 1- 800-592-6004.

¿Necesita ayuda con su aplicación?

Llámenos al 1-855-373-4636. Si necesita ayuda en una lengua que no sea el inglés, dígale al representante de servicio al cliente la lengua que usted necesite. Los usuarios de teléfonos de texto pueden llamar al: 1-800-735-2966. Si usted es ciego o tiene una discapacidad visual y desearía informacion sobre los Servicios de Rehabilitación para Invidentes, por favor llame al 1-800-592-6004.

MO 886-3846 (7-15)

page 1 Of 7

pERmaNENT      iM-1Ma (07/15)

 

 

 

 

foR offICE uSE oNLY

 

MissOuri departMent Of sOcial services

date applied

 

 

faMily suppOrt divisiOn

 

 

 

appLICaTIoN foR mo hEaLThNET (mEdICaId)

 

SECTIoN 1: Your Basic Information

 

dcn #1

dcn #2

 

 

 

applicant full legal naMe (first, Middle, last)

 

Maiden naMe (if any)

 

HOMe address (HOuse nuMber, street Or rural rOute, pO bOx, HOMeless)

city, state, zip cOde

 

Mailing address (if different frOM HOMe address)

city, state, zip cOde

 

priMary pHOne nuMber

 

cell    Home    Work

alternate pHOne nuMber

cell    Home    Work

 

 

 

Other: ________________

 

Other: ________________

e-Mail address

 

 

 

 

 

preferred MetHOd Of cOntact

 

 

 

 

call

*text 

e-mail 

Mail      *Texting is not available in all locations.

 

sOcial security nuMber

date Of birtH

place Of birtH

 

 

 

race* (OptiOnal)

sex

 

M 

f

Hispanic (OptiOnal)

yes 

nO

* 1. caucasian 

2. black/african aMerican 

3. aMerican indian/alaska native 

4. asian 

5. native HaWaiian/pacific islander

i, the above named applicant, apply for MO Healthnet under the laws of the state of Missouri. check any of these that apply to you or your spouse if your spouse wants coverage.

i/We are over age 65.

i/We are disabled and get social security disability or ssi.

i/We are disabled and do not get social security disability or ssi.

If you check this box, also fill out appendix a to help determine if you meet the disability requirements.

i/We are blind or visually impaired.

If you check this box, also fill out section 8 of this application to see if you qualify for Blind programs.

i/We live in a nursing home or similar facility.

If you check this box, please list:

facility naMe

facility address

i/We are age 63 and over and need in-home nursing care.

If you check this box, also fill out appendix B if you’re married, and one of you either lives in a nursing home or needs skilled nursing care at your home.

i/We need help paying for Medicare premiums and co-insurance costs.

i/We work and pay income taxes, and want coverage under the ticket to Work program.

If you check this box, this may let you qualify for mo healthNet by paying a premium.

i/We need help with medical bills from the last 3 months.

i/We have a conservator, guardian, attorney-in-fact, or another person to represent us.

If you check this box, fill out appendix C to name an authorized representative, or provide conservator, guardian, or power of attorney documents. Then fill out the representative’s contact information on page 7.

all applicants must fill out sections 2 through 7

MO 886-3846 (7-15)

page 2 Of 7

pERmaNENT      iM-1Ma (07/15)

SECTIoN 2: Your household

below, list your spouse first, then anyone who lives with you, or would be if you weren’t in a nursing home.

naMe

 

(first, Middle, last)

(Maiden)

Hispanic

race*

sex

y/n

(optional)

(optional)

 

 

 

 

relatiOnsHip

TO yOu

(spouse, son, sister, friend)

date Of birtH

cHeck ()

sOcial

if tHey’re security nuMber

applying

(if applying)

place Of birtH

(if applying)

* 1. caucasian 

2. black/african aMerican 

3. aMerican indian/alaska native

4. asian

5. native HaWaiian/pacific islander

 

 

are yOu Married and live WitH yOur spOuse, Or lived WitH yOur spOuse WHen yOu entered a nursing HOMe? 

 

yes   

nO

 

 

 

 

if yes, we need your spouse’s income and resource information, but your spouse doesn’t have to apply for coverage.

 

 

 

 

enter tHe date yOu gOt Married

 

 

 

 

 

 

 

SECTIoN 3: money available To You

 

 

 

 

 

 

 

are yOu Or yOur spOuse a party tO a trust? 

 

 

 

yes   

nO

 

 

 

 

if yes, we must review the entire trust. you must provide it and fill out below:

naMe and date Of trust

WHat is yOur Or yOur spOuse’s rOle in tHe trust?

i/We have the following resources (include trust assets you can access): check () all that apply.

CaSh aNd SECuRITIES

 

owNER

aCCouNT #(S)

BaNk/LoCaTIoN

 

vaLuE

 

checking accounts/Joint checking accounts

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

savings accounts/Joint savings accounts,

 

 

 

 

 

 

 

 

$

 

 

christmas club savings, certificates of deposit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

credit union accounts

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pre-paid card (other than ebt)

 

 

 

 

 

 

 

 

 

$

 

 

Example: card of Social Security income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

patient accounts at a nursing home or other

 

 

 

 

 

 

 

 

$

 

 

institution

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

cash on hand

 

 

 

 

N/a

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

stocks, bonds, iras, retirement plans, other

 

 

 

 

 

 

 

 

$

 

 

investments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

annuities (We will need the whole contract)

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

notes or mortgages owed to you

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pRE-paId BuRIaL pLaN

 

 

 

 

 

 

 

 

 

 

 

 

i/We OWn 1 Or MOre pre-paid burial plans

 

 

 

 

 

 

 

 

 

 

 

 

yes    nO

 

 

 

 

 

 

 

 

 

 

 

 

if yes, fill out below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NamE of INSuREd

 

fuNERaL homE

 

poLICY/CoNTRaCT #

 

CaSh SuRRENdER

REvoCaBLE oR

 

 

 

 

 

 

 

 

vaLuE

 

REfuNdaBLE?

 

 

 

 

 

 

 

 

 

 

 

 

yes 

nO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes 

nO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

yes     

nO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MO 886-3846 (7-15)

page 3 Of 7

pERmaNENT      iM-1Ma (07/15)

SECTIoN 4: Your Income and Expenses

i/We receive income from the following. check () all that apply.

uNEaRNEd INComE

who gETS IT?

whERE IS IT fRom?

amouNT pER moNTh

social security

 

n/a

$

claim number:

 

 

 

 

 

 

 

 

supplemental security income (ssi)

 

n/a

$

 

 

 

 

 

 

trusts and annuities

 

 

$

 

 

 

 

 

 

 

non-va pensions, retirement, and disability

 

 

$

 

 

 

 

 

 

 

interest or dividends

 

 

$

 

 

 

 

 

 

 

unemployment compensation

 

 

$

 

 

 

 

 

 

 

Worker’s compensation

 

 

$

 

 

 

 

 

 

 

Military branch retirement pension

 

 

$

 

 

 

 

 

 

 

Worker’s compensation

 

 

$

 

 

 

 

 

 

 

Money from friends or family

 

 

$

 

 

 

 

 

 

 

va payments (check all that apply)

 

n/a

$

va pension

 

 

$

disability compensation

 

 

$

dic compensation

 

 

$

aid & attendance

 

 

$

Homebound allowance

 

 

$

Medical reimbursement

 

 

$

 

 

 

 

Other (explain where the money comes from and the amount)

 

 

EaRNEd INComE

EmpLoYER

INComE BEfoRE TaxES

how ofTEN aRE You paId

ThISamouNT?(ChECk oNE)

i am employed

 

 

 

Weekly

every 2 Weeks

 

 

 

tWice a MOntH

MOntHly

 

 

 

 

 

 

 

 

 

 

My spouse is employed

 

 

 

Weekly

every 2 Weeks

 

 

 

tWice a MOntH

MOntHly

 

 

 

 

 

 

 

 

 

 

____________________ is employed

 

 

 

Weekly

every 2 Weeks

 

 

 

tWice a MOntH

MOntHly

 

 

 

 

 

 

 

 

 

SELf-EmpLoYmENT

who IS

TYpE of BuSINESS

moNThLY INComE afTER

SELf-EmpLoYEd?

TaxES &ExpENSES

 

 

 

someone in my house or i am self-

 

 

 

$

 

employed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

fILL ouT ThIS SECTIoN oNLY If You’RE maRRIEd aNd LIvINg IN a NuRSINg homE

 

 

My spouse and i pay these costs

 

 

 

 

 

TYpE of CoST

amouNT

 

how ofTEN do You paY foR IT?

utilities (not including phone)

$

 

 

 

 

 

 

 

 

 

 

Mortgage

$

 

 

 

 

 

 

 

 

 

 

rent

$

 

 

 

 

 

 

 

 

 

 

real estate taxes

$

 

 

 

 

 

 

 

 

 

 

Homeowner’s insurance

$

 

 

 

 

 

 

 

 

 

 

condo fees

$

 

 

 

 

 

 

 

 

 

 

phone

$

 

 

 

 

MO 886-3846 (7-15)

page 4 Of 7

pERmaNENT      iM-1Ma (07/15)

fILL ouT ThIS SECTIoN If You paY aNY ChILd SuppoRT oR aLImoNY paYmENTS

CaSE NumBER

amouNT pER moNTh

whaT STaTE doES ThE oRdER ComE fRom?

$

$

$

SECTIoN 5: Your Citizenship and Residency

1.i/We are residents Of MissOuri and plan tO stay in MissOuri

yes  nO

2.all applicants are u.s. citizens

yes 

nO      if no, fill out the following:

NamE of NoN-CITIzEN appLICaNT

ImmIgRaTIoN STaTuS

REgISTRaTIoN NumBER

daTE of ENTRY

3. i/We agree tO apply fOr OtHer benefits i/We May be able tO get (rsdi, ssi, va, etc)

yes 

nO      if no, you may not be able to get MO Healthnet.

SECTIoN 6: Your personal property

TRaNSfER of pRopERTY oR moNEY

Has anyOne in yOur HOMe sOld Or given aWay MOney, veHicles, Or prOperty WitHin tHe last five years?

yes    nO      if yes, fill out below:

MOney/veHicle/prOperty sOld Or given

dates sOld Or given

 

 

persOn it Was sOld Or given tO

reasOn

 

 

value Of MOney/veHicle/prOperty

aMOunt received

$

$

 

 

vEhICLES

list cars, trucks, vans, motorcycles, recreational vehicles, and others. 

i/We don’t own a vehicle.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

makE/modEL

YEaR

 

owNER

 

vaLuE

amouNT owEd

 

how IS IT uSEd?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REaL ESTaTE pRopERTY

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We OWn Or are buying real estate.

 

 

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, provide a copy of the deed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ENTER ThE addRESS oR LoCaTIoN

 

 

owNER

 

 

vaLuE

 

amouNT

 

how IS IT uSEd?

 

 

 

 

 

(home, rental,

(for mobile homes, see personal property below)

 

 

 

 

 

owEd

 

 

 

 

 

 

 

 

 

acreage, other)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pERSoNaL pRopERTY

i/We own the following types of personal property (include trust assets that you have access to). check () all that apply.

TYpE of pRopERTY

how maNY?

dESCRIpTIoN

 

vaLuE

amouNT You owE

Mobile Home

 

 

$

 

$

check here if this is your home

 

 

 

 

 

 

 

 

 

 

 

 

 

 

farm machinery (include tractors)

 

 

$

 

$

 

 

 

 

 

 

farm livestock

 

 

$

 

$

 

 

 

 

 

 

farm grain or produce in storage

 

 

$

 

$

 

 

 

 

 

 

business equipment

 

 

$

 

$

 

 

 

 

 

 

trailer (utility, boat, etc.)

 

 

$

 

$

 

 

 

 

 

 

boat

 

 

$

 

$

 

 

 

 

 

 

MO 886-3846 (7-15)

page 5 Of 7

pERmaNENT      iM-1Ma (07/15)

aircraft

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

property claims in probate court

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (explain)

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTIoN 7: Your Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have life insurance

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, fill out below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

pERSoN INSuREd

 

INSuRaNCE CompaNY

 

poLICY NumBER

 

CaSh vaLuE

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have Medicare

 

 

 

 

 

 

 

 

 

 

 

yes   

nO     

 

 

 

 

 

 

 

 

 

 

 

if yes, list the names of the people who have Medicare:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have lOng-terM care insurance

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, fill out below:

 

 

 

 

 

 

 

 

 

 

 

 

NamE of pERSoN wITh LoNg-TERm CaRE INSuRaNCE

 

INSuRaNCE CompaNY

poLICY NumBER

pREmIum (per month)

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

i/We Have OtHer HealtH insurance

 

 

 

 

 

 

 

 

 

 

 

yes 

nO      if yes, fill out below:

 

 

 

 

 

 

 

 

 

 

 

 

pERSoN INSuREd

 

INSuRaNCE CompaNY

 

TYpE of CovERagE

poLICY NumBER

pREmIum (per month)

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

if yOu can get casH payMents and Have an accOunt, dO yOu Want tHe casH tO gO directly intO yOur accOunt?

 

 

 

 

 

yes, i Want direct depOsit    nO, i dO nOt Want direct depOsit.

 

 

 

 

 

only fill out this section (Section 8) if you want Blind pension or Supplemental aid to the Blind.

SECTIoN 8: Blind pension and Supplemental aid to the Blind

1.

do you have a sighted spouse or parent?

yes

nO

2.

do you ask or beg for money?

yes

nO

3.

Have you applied or do you agree to apply for supplemental security income (ssi) as a condition of eligibility?

yes

nO

4.

Have you had eye surgery within the last five years?

yes

nO

5.

if you are younger than 75, are you willing to have medical treatment or an operation to correct your blindness?

yes

nO

6.

Would you be willing to do job training or work at a job for which you are suited?

yes

nO

7.

do you have an eye doctor (either an opthalmologist or an optometrist)?

yes

nO

 

if yes, fill out below:

 

 

facility and dOctOr naMe

address (HOuse nuMber, street Or rural rOute, pO bOx)

city, state, zip cOde

 

 

date Of last eye exaM

date Of next appOintMent

 

 

MO 886-3846 (7-15)

page 6 Of 7

pERmaNENT      iM-1Ma (07/15)

RIghTS aNd RESpoNSIBILITIES: pLEaSE REad CaREfuLLY aNd SIgN BELow

i/We understand that it is against the law to obtain or attempt to obtain benefits to which i/we are not entitled. any false claim, statement or concealment of any material fact whatever, in whole or in part, may subject me to criminal and/or civil prosecution.

i/We authorize the director of family support division or his/her appointee to investigate and verify these circumstances and statements.

i/We understand if i/we disagree with the decision concerning our eligibility, i/we may request a fair hearing by contacting the local family support office. this request must be received within 90 days of the eligibility decision.

i/We understand that i/we must report any changes in circumstances within ten days of when they happen.

i/We understand that i/we must provide social security numbers (ssn) of all persons applying for MO Healthnet. the ssn is used to determine eligibility and verify information (section 1137 of the social security act).

i/We understand that i/we are entitled to fair and equal treatment regardless of race, color, religion, national origin, sex, ancestry, age, sexual orientation, veteran status, or disability.

i/We understand that the state of Missouri may file a claim against my/our estate to recover any assistance received. this does not apply to Qualified Medicare beneficiary and specified low income Medicare beneficiary programs.

i/We understand that i/we must provide complete information regarding any health or accident insurance benefit available to any household member and i/we must report within 30 days any accident for which medical care is received.

i/We hereby authorize all providers of medical benefits who render services or merchandise to me/us under MO Healthnet to release all records regarding such services or merchandise to the department of social services and its representatives.

i/We understand that application for and acceptance of MO Healthnet constitutes an assignment of rights to the department of social services, MO Healthnet division for payment for medical care from a third party.

provided i/we are found to be eligible for assistance, i/we wish payments by the MO Healthnet division and/or the title xviii medical insurance program to be made directly to physicians and medical suppliers on any future covered unpaid bills for medical and other health services furnished me/us while eligible for MO Healthnet.

If signing electronically: by entering my name, i have agreed to submit this application by electronic means. i understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

by signing this application on paper or electronically, you are giving us permission to deliver, or cause to be delivered, phone calls to you regarding your case from an automated dialing system at the primary phone number you provided on page 2. you do not have to consent to this as part of your application. if you want to opt out of getting these calls, check here:

SIgN hERE

my/our signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete.

signature Of applicant

date

signature Of spOuse

date

signature On beHalf Of applicant

date

if yOu are signing On tHe applicant’s beHalf, please identify yOur relatiOnsHip tO tHe applicant:

guardian or conservator

pOa/attorney-in-fact

estate representative

authorized representative (complete form iM-6ar in appendix c)

family member

attorney representing applicant (please provide entry of appearance)

 

 

please print your name and contact information below.

 

representative naMe (first, Middle, last)

 

 

 

 

 

representative Mailing address

 

city, state, zip cOde

 

 

 

MO 886-3846 (7-15)

page 7 Of 7

pERmaNENT      iM-1Ma (07/15)

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