Il444 2378 B Form – Fill Out and Use This PDF

The IL444 2378 B form, generated by the State of Illinois Department of Human Services, serves as a comprehensive application for individuals seeking Cash Assistance, Medical Assistance, and the Supplemental Nutrition Assistance Program (SNAP). It meticulously gathers applicant information to ensure precise and equitable distribution of aid. For ease and assurance in securing the necessary support, click the button below to initiate your application.

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Il444 2378 B Form PDF Details

In the State of Illinois, individuals or families seeking aid have access to crucial support through the IL444 2378 B form, a comprehensive application for cash assistance, medical assistance, and the Supplemental Nutrition Assistance Program (SNAP). This form gathers applicant information including name, address, social security number, citizenship/immigration status, household composition, and more. It facilitates the filing for three major types of benefits under a single application, streamlining the process for applicants. With sections dedicated to household composition, the application ensures all members, whether applying for benefits or not, are considered. Applicants are also required to provide detailed information regarding their financial situation, health conditions, living arrangements, and potential representation by an approved representative. The form is designed to make the application process accessible and inclusive, offering sections for preferred language and documents for individuals with disabilities. Moreover, the IL444 2378 B form underscores the importance of rights and responsibilities, guiding applicants through the necessary steps to complete and submit their application successfully, either online, by mail, or in person. Additionally, it includes provisions for immediate SNAP benefits under specific emergency conditions and offers the optional step of voter registration, emphasizing the state's commitment to engaging its citizens in the democratic process while seeking to meet their immediate needs.

Question	Answer
Form Name	Il444 2378 B Form
Form Length	20 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	5 min
Other names	illinois medicaid application form printable, il 444 2378b, il444 2378b form, il444 23788

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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

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.

Do you want to name an approved representative? Yes No If yes, complete the following:

Name of approved representative:					Address:
Phone Number:			Organization Name:				ID # if applicable:

Signature of applicant:

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-09-21) 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

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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.

Name

Age

Arrival Date in the United States

Registration document/number

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:

Does anyone applying live in a nursing home facility, supportive living facility, or other facility or institution?

Yes

If yes, who:

Name of facility:

bills from the last

Does anyone in your household want help paying for medical

3 months?

Yes

Has anyone in your household been in foster care at age 18 or older?

Yes

If yes, name of person:

Is anyone in your household age 18 or older a full time student? (college, or trade school)

Yes

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

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

If no, please list your preferred written language:

IL444-2378B (R-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 2 of 18
Printed by Authority of the State of Illinois	-0- Copies

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Household Composition

How many people live with you (include yourself)?

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Complete the following for everyone in the household. Include people who live with you who are not requesting assistance. You must give us the Social Security Number for each person for whom you are requesting benefits. You do not have to give us the number for any person for whom you are not requesting benefits, but if you do, it may speed up the application process.

Person 1

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

SELF

Social Security #

Gender

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Do you plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will you file jointly with a spouse?

Yes

If yes, list name(s):

Do you have any dependents?

Yes

If yes, list name(s):

Will you be claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How are you related to the tax filer?

The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount. This information is to assure that program benefits are distributed without regard to race, color or national origin.

1.	Is this person Hispanic or Latino?	Yes	No
2.	What is your race? (Select one or more)

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Person 2

Mark the box for the program this person is applying for:

SNAP

Medical

Cash

First

M.I.

Last

Suffix

Former Name, if any

Relationship to you

Social Security #

Gender

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies expected?

If this person is applying for Medical assistance answer question 1.

1. Does this person plan to file a Federal Tax Return next year?

Yes

If yes, answer 2-4 below

Will this person file jointly with a spouse?

Yes

If yes, list name(s):

Does this person have any dependents?

Yes

If yes, list name(s):

Is this person claimed as a dependent on someone else's tax return?

Yes

If yes, list the name of the tax filer:

How is this person related to the tax filer?

The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.

This information is to assure that program benefits are distributed without regard to race, color or national origin.

Is this person Hispanic or Latino?

Yes

What is his/her race? (Select one or more)

American Indian/Alaskan Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

IL444-2378B (R-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 3 of 18
Printed by Authority of the State of Illinois	-0- Copies

How to Edit Il444 2378 B Form Online for Free

This PDF editor was made to be as easy as it can be. As you comply with the following actions, the procedure for managing the illinois medicaid application form printable file is going to be effortless.

Step 1: Initially, click the orange button "Get Form Now".

Step 2: You can now manage your illinois medicaid application form printable. Our multifunctional toolbar permits you to include, erase, adapt, and highlight content or perhaps perform several other commands.

These particular sections will constitute the PDF template that you'll be filling out:

Make sure you enter your details within the segment Approved Representative When you, No If yes complete the following, Yes, Name of approved representative, Signature of applicant, Organization Name, ID if applicable, Address, Instructions to persons applying, Cash, Medical, SNAP, Please print all of your answers, your gross nonexempt income and, and your gross monthly income for the.

Write the main particulars in This application must be filed, ILB R Request for Cash Assistance, Copies, and Page of field.

form il444 23788 This application must be filed, ILB R Request for Cash Assistance, Copies, and Page of fields to insert

Take the time to specify the rights and responsibilities of the parties within the State of Illinois Department of, Request for Cash Assistance, CitizenshipImmigration Status, aabfaadedabbcfbdc, If you or any other persons are, Yes, Name, Age, Arrival Date in the United States, and Registration documentnumber paragraph.

Check the fields Name Last First MI, Name Last First MI, General Household Questions, Are you or is anyone who lives, No Disabled, Yes, Yes, Yes, If yes who, What is their SSN or RRB claim, Does anyone have a physical, Yes, If yes who, Does anyone applying live in a, and Yes and then fill them in.

Step 3: Choose the "Done" button. Next, you may export the PDF file - download it to your electronic device or send it through electronic mail.

Step 4: To avoid possible future troubles, you need to get a minimum of a few copies of every document.

Il444 2378 B Form – Fill Out and Use This PDF

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