Form W 119D – Fill Out and Use This PDF

To prove this factor, provide:

Eligibility Factor

ONE of the following OR

TWO* of the following:

Identity

•

Photo I.D.

• Statement from another person

•

•

You must establish identity for each person

Driver’s license

Birth/baptismal certificate

listed.

•

U.S. passport

• Validated Social Security Number

•

Naturalization certificate

(SSN)

•

Hospital/Doctor’s records

•

Adoption papers

Marital Status

•

Marriage/Death certificates

•

Statement from clergy

•

Separation agreement

•

You must prove if you are married, divorced,

Census records

•

•

separated or widowed (not required for the

Divorce decree

Newspaper notice

Supplemental Nutrition Assistance Program

•

Social Security records

• Statement from another person

[SNAP]).

•

Veterans Administration (VA) records

Relationship

•

Birth certificate (long form)

•

Applicant’s statement

•

Adoption papers/records

•

Newspaper notice

If you are related to a child in the household,

•

Court records

•

Statement from clergy

you must prove the relationship.

•

Medical records

• Statement from another person

Residence

•

Statement from landlord/primary

• Statement from another person

tenant

•

You must verify your place of residence

Current mail

•

(if applicable).

Current rent receipt or lease

•

School records

•

Mortgage records

Household Composition/Size

•

Statement from nonrelative landlord

• Statements from other persons

•

School records

You must prove who is living with you.

Age

•

Birth certificate

•

Insurance policy

•

Baptismal records/certificate

•

Census records

You must prove the age of each person

•

•

School records

applying for assistance, where appropriate.

Hospital records

•

Adoption papers/records

• Statement from another person

•

Naturalization certificate

•

Physician statement

•

Driver’s license

• Official correspondence from Social

Security Administration (SSA)

Absence/Death of Parent(s)

•

Death certificate

•

Newspaper notice

•

Survivor’s benefit records

•

Insurance company records

If the parent(s) of any child in your home is not

•

Hospital records

•

Institutional records

living with you, you must prove this (not

required for SNAP).

•

VA or military records

• Agency case records and burial

•

Divorce papers

payment files

•

Proof of remarriage

• Statement from another person

Absent Parent Information

•

Pay stubs

NA

•

Tax returns

If the parent(s) of any child in your home is not

•

Social Security or VA records

living with you, you must provide information

you have about the individual’s: name, address,

•

Monetary determination letters

SSN, birth date, and employment (not required

•

ID cards (health insurance)

for SNAP).

•

Driver’s license or registration

Social Security Number

•

Social Security card

NA

For Temporary Assistance, SNAP Benefits and

• Official correspondence from SSA

Medical Assistance only, you do not have to

A Social Security number is not required

provide proof of your SSN unless the SSN you

for aliens who are seeking Medical

give does not match the SSA’s records or

cannot be verified by the Agency.

Assistance for emergency treatment only

or are Medical Assistance – only

applicants who are pregnant.

Form W-119D (page 2) LLF

Human Resources Administration

Rev. 8/22/12

Family Independence Administration

Eligibility Factor

To prove this factor, provide ONE of the following:

Citizenship or Current Alien Status

•

Birth certificate

•

Baptismal certificate/records

Status – U.S. citizens are eligible for Temporary Assistance, the

•

Hospital records

Supplemental Nutrition Assistance Program and medical

•

U.S. passport

assistance. Aliens must be in satisfactory immigration status in

•

Military service records

order to be eligible for Temporary Assistance, the Supplemental

Nutrition Assistance Program and medical assistance. Immigration

•

Naturalization certificate

status is not an eligibility factor for pregnant women or immigrant

•

USCIS documentation

children applying for Child Health Plus B. Undocumented

•

Evidence of continuous U.S. residence since prior to 1/1/72

immigrants and temporary nonimmigrants are eligible only for the

treatment of an emergency medical condition.

Earned Income

• Current wage stubs and statements of tips

•

Pay envelopes

From employer

•

Contact with employer

• On letterhead, rate of pay per hour, hours worked per week,

first pay date, if new and employer’s phone number

•

Business records

•

Tax records

From self-employment

•

Records and related materials concerning self-employment

earnings and expenses

• Current income tax return

•

Current contribution check

Income from rent or room/board

•

Statement from roomer, boarder, tenant

•

Income tax record

Unearned Income

• Statement from Family Court

• Statement from person paying support

Child Support

•

Check stubs

• Official correspondence from the Child Support Enforcement

Unit

•

Current award certificate

Unemployment Insurance Benefits (UIB)

•

Official correspondence with New York State Department of

Labor

•

Current award certificate/letter

Social Security benefits (including SSI)

•

Current benefit check

• Official correspondence from SSA

• Veterans Administration official correspondence

Veteran’s benefits

•

Current award certificate/letter

•

Current benefit check

Worker’s Compensation

•

Award certificate/letter

•

Check stub

•

Statement from school

Education grants and loans

•

Statement from bank

• Statement from agency administering grant/award letter

Interest/dividends/royalties

• Statement from bank or credit union

• Statement from broker/financial institution/agent

•

Current award letter

•

Current benefit check

Private pension/annuity

•

Official correspondence from source of income

• Contact with source of income

•

Current contribution check

Assistance (CA) and Medical Assistance (MA), original

documents are needed to verify identity

and citizenship/alien status. Copies of documents for all

Eligibility Factors other than identity and

citizenship/alien status are acceptable.

Form W-119D (page 3) LLF

Human Resources Administration

Rev. 8/22/12

Family Independence Administration

Eligibility Factor

To prove this factor, provide ONE of the following:

Unearned Income continued

Other unearned income

Resources

•

Statement from household

• Statement from nursing home

(For Medical Assistance only, resource information is not

requested from pregnant women, children under the age of 19 and

persons eligible for Family Health Plus.)

Bank Accounts: Checking, savings, retirement (IRA and

•

Current bank records

Keogh), credit union

•

Current credit card records

•

Stocks, bonds, certificates and mutual funds

Stock/bond certificate

• Statement from financial institution

•

Life insurance

Insurance policy

• Statement from insurance company

•

Burial trust or fund, burial plot or funeral agreement

Bank records

•

Burial agreement

•

Burial plot deed

• Statement from funeral director

Income tax refund or Earned Income Tax Credit (EITC)

•

Refund of EITC check

• Statement from tax office

Real estate other than residence

•

Deed

• Statement from real estate broker

• Broker’s appraisal/estimate of current value by broker

Motor vehicle

•

Registration (older models)

•

Title of ownership

• Appraisal of current value by dealer

•

Financing data

Lump sum payment

•

Statement from the source of payment

•

Lump sum check

Other resources

•

Household statement of current value

•

Sales slips

•

Insurance appraisal

Shelter Expenses

• Current rent receipt/lease/mortgage book/records

• Property and school tax records

You must prove how much it costs you to live where you do. (You

•

Landlord statement

may need to provide separate documentation for each item of

•

Sewer and water bills

shelter expense.)

•

Garbage/trash collection bills or receipts

Medical Assistance does not require documentation of shelter

•

Homeowner’s insurance records

expenses.

• Fuel bills/shut-off notice

•

Nonheating utility bills

• Telephone bills (or a statement from the household that the

expense is incurred)

Medical Expenses

• Statement from provider of health insurance premiums

• Copies of medical bills (paid and unpaid)

For SNAP, for aged/disabled individuals only

• Medicare prescription drug card

Form W-119D (page 4) LLF

Human Resources Administration

Rev. 8/22/12

Family Independence Administration

Eligibility Factor

To prove this factor, provide ONE of the following:

•

Insurance policy/card

Health Insurance

•

Statement from provider of coverage

If you or anyone applying has health insurance coverage (even if

•

Medicare card

• Separation or divorce agreement with court-ordered health

paid for by someone else), you must prove this.

coverage

Disabled/Incapacitated/Pregnant

•

Statement from doctor, clinic or hospital verifying pregnancy,

If you or anyone living with you is sick or pregnant, you must

expected date of birth

• Statement from medical professional

provide proof.

•

(For MA only, resource information is not requested from pregnant

Proof of SSA/SSI benefits for disability/blindness

women, children and persons eligible for Family Health Plus).

Unpaid Bills

• Copy of each bill showing amount owed, period of

•

Rent, utility

services and provider

Referral

•

Statement from provider of treatment

Drug/alcohol treatment program

Employment service

• Statement from employment service

Other Expenses/Dependent Care Cost

•

Court order

• Statement from day care center or other child care provider

You must provide proof if you pay court-ordered support, child

•

Statement from aide or attendant

care, recurring loans or for the services of a home health aide or

• Canceled checks or receipts

attendant.

School Attendance

• School records (current report card)

• Statement from school or higher education institution

You must prove who is in school.

Past Management

• Letter from employer giving dates of employment, amount

(For Safety Net Assistance)

earned and reason(s) for leaving

If you were not supporting yourself from employment/earned

Earned Income

income, please bring verification of how you were able to support

yourself in the past such as:

•

Bankbook/bank statement

Other

• Verification of expiration of benefits (workers’ compensation,

disability, Social Security, UIB, etc.)

(For cash assistance only)

•

Statement from person(s) who provided support

Potential Benefits

Statement from person(s) who provided support

• If you or anyone in the household has applied for and been

denied or has been accepted for benefits from any of the

following sources, bring the award letter, check or other

correspondence: Social Security, court payments, SSI,

veteran’s benefits, workers’ compensation, union benefits,

pension, military allotment, railroad retirement, NYS disability or

other source

Other