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.

Question	Answer
Form Name	Form Mo 886 3846
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	mo 886, missouri medicaid application, missouri medicaid application print out, medicaid application missouri

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
SECTIoN 1: Your Basic Information
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

* 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*
y/n	race*	sex
(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

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:		n/a	$
claim number:

supplemental security income (ssi)		n/a	$
supplemental security income (ssi)		n/a

trusts and annuities			$
trusts and annuities

non-va pensions, retirement, and disability			$
non-va pensions, retirement, and disability

interest or dividends			$
interest or dividends

unemployment compensation			$
unemployment compensation

Worker’s compensation			$
Worker’s compensation

Military branch retirement pension			$
Military branch retirement pension

Worker’s compensation			$
Worker’s compensation

Money from friends or family			$
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
EaRNEd INComE	EmpLoYER	INComE BEfoRE TaxES		ThISamouNT?(ChECk oNE)
i am employed				Weekly	every 2 Weeks
i am employed				tWice a MOntH	MOntHly
				tWice a MOntH	MOntHly

My spouse is employed				Weekly	every 2 Weeks
My spouse is employed				tWice a MOntH	MOntHly
				tWice a MOntH	MOntHly

____________________ is employed				Weekly	every 2 Weeks
____________________ is employed				tWice a MOntH	MOntHly
				tWice a MOntH	MOntHly

SELf-EmpLoYmENT	who IS	TYpE of BuSINESS		moNThLY INComE afTER
SELf-EmpLoYmENT	SELf-EmpLoYEd?	TYpE of BuSINESS		TaxES &ExpENSES
	SELf-EmpLoYEd?			TaxES &ExpENSES
someone in my house or i am self-				$
employed				$
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			$		$
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

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)

How to Edit Form Mo 886 3846 Online for Free

The PDF editor you are going to apply was made by our top programmers. It is possible to complete the medicaid missouri file shortly and effortlessly applying our app. Just follow this particular instruction to start out.

Step 1: The first thing should be to pick the orange "Get Form Now" button.

Step 2: You will find all the functions that it's possible to take on the file once you have accessed the medicaid missouri editing page.

Fill out the medicaid missouri PDF and provide the information for every single part:

example of empty fields in missouri medicaid application pdf

Remember to note the information within the field iWe are blind or visually impaired, iWe live in a nursing home or, facility naMe, facility address, iWe are age and over and need, iWe need help paying for Medicare, iWe work and pay income taxes and, iWe need help with medical bills, iWe have a conservator guardian, and all applicants must fill out.

Entering details in missouri medicaid application pdf part 2

You need to give some details inside the section naMe first Middle last, Maiden, Hispanic yn optional, race optional, relatiOnsHip TO yOu spouse son, birtH, cHeck if tHeyre security nuMber, if applying, place Of birtH if applying, caucasian, blackafrican aMerican, aMerican indianalaska native, asian, native HaWaiianpacific islander, and are yOu Married and live WitH yOur.

missouri medicaid application pdf naMe first Middle last, Maiden, Hispanic yn optional, race optional, relatiOnsHip TO yOu spouse son, birtH, cHeck if tHeyre security nuMber, if applying, place Of birtH if applying, caucasian, blackafrican aMerican, aMerican indianalaska native, asian, native HaWaiianpacific islander, and are yOu Married and live WitH yOur blanks to fill

Indicate the rights and obligations of the sides in the box checking accountsJoint checking, savings accountsJoint savings, credit union accounts, prepaid card other than ebt, patient accounts at a nursing home, cash on hand, stocks bonds iras retirement plans, annuities We will need the whole, and notes or mortgages owed to you.

missouri medicaid application pdf checking accountsJoint checking, savings accountsJoint savings, credit union accounts, prepaid card other than ebt, patient accounts at a nursing home, cash on hand, stocks bonds iras retirement plans, annuities We will need the whole, and notes or mortgages owed to you fields to fill

Finalize by reading the following sections and filling them out as needed: pREpaId BuRIaL pLaN iWe OWn Or, yes, if yes fill out below, NamE of INSuREd, fuNERaL homE, poLICYCoNTRaCT, CaSh SuRRENdER vaLuE, REvoCaBLE oR REfuNdaBLE, page Of, yes, yes, yes nO, and pERmaNENT iMMa.

Completing missouri medicaid application pdf part 5

Step 3: As soon as you press the Done button, your finalized document can be exported to any kind of your devices or to electronic mail specified by you.

Step 4: Prepare no less than several copies of the document to avoid any sort of possible future concerns.

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