Form W 119D PDF Details

Form W-119D is a request for an extension of time to file Form 1040. This form is used by taxpayers who need more time to file their taxes, usually because they have not received all of their tax documents yet. If you are unable to file your taxes by the due date, be sure to use this form to request an extension. Note that this extension only gives you an additional six months to file your taxes; it does not extend the deadline for paying any taxes that you may owe. filing this form also makes you eligible for a penalty waiver if you can show reasonable cause for why you were unable to meet the original deadline. Filing Form W-119D is easy - just complete and submit the form online or by mail. For more information, visit our website. Thank you for choosing our company as your tax preparer!

QuestionAnswer
Form NameForm W 119D
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesKeogh, w119d, w 119d, SSI

Form Preview Example

Form W-119D (page 1) LLF

Rev. 8/22/12

Eligibility Factors and Suggested Documentation Guide

Note: As of August 29, 2012, any reference to the Food Stamp Program shall mean the Supplemental Nutrition Assistance Program (SNAP), and any reference to Food Stamps shall mean SNAP benefits.

 

 

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.

 

 

*If you are applying for the SNAP Benefits or Medical Assistance only, you need to bring one form for each Eligibility Factor checked.

Note: For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash 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 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

Note: For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash

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

 

 

 

 

 

 

 

 

 

 

Note: For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash 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 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

 

 

 

 

 

Note: For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash 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.