Form IL444-2378B at a glance
What it is: A State of Illinois Department of Human Services request for cash assistance, medical assistance and the Supplemental Nutrition Assistance Program (SNAP).
Where and when to file: You can mail or bring this form to an Illinois Department of Human Services, Family Community Resource Center (FCRC). You can also apply for benefits at ABE.Illinois.gov, or by calling the Helpline at 1-800-843-6154. 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.
What to bring and attach to Form IL444-2378B
A caseworker will explain what you need to provide at your interview and will allow you 10 calendar days to return the information.
If you need help with getting the information, contact the Family Community Resource Center where you had your interview.
Examples of what you can provide as your proof of IDENTITY: Driver's license, Federal or State ID, Any other government issued ID, Work or School ID, military ID or draft card, Voter registration card, Birth certificate, Wage stub.
SOCIAL SECURITY NUMBER Social Security card, or document with the person's name, SSN and signature or photograph.
A filled-in Form IL444-2378B example: a first page for cash, medical and SNAP benefits
How to fill out Form IL444-2378B, box by box
Last Name, First Name and Present Address
Fill in Last Name, First Name, MI and Maiden Name.
Fill in Present Address, Apartment Number, City, State, Zip Code and County.
Birth Date, Social Security Number and Are you homeless?
Fill in Birth Date and Social Security Number, and check Yes or No for Are you homeless?
Mailing Address, Telephone numbers and Signature
If your mailing address is different, fill in Mailing Address, City, State, Zip Code and County. Fill in Telephone number(s) Home, Work, Cell and Alternate, and the Best time to call you. Check Yes or No for Do you wish to receive text alerts and reminders? If yes, list the number that can accept text messages; *** standard fees may apply from your mobile service provider ***. Sign in Signature and enter the Date: signing here will start your application, and you must sign Page 18 to get approved for any benefits.
Approved Representative
Signing to have an approved representative 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.
Check Yes or No for Do you want to name an approved representative? If yes, complete the following: Name of approved representative, Address, Phone Number, Organization Name and ID # if applicable, and Signature of applicant.
If an approved representative completes and signs this application, written authorization from the applicant is required.
If your situation is different
You are signing Page 18
Applicant and Spouse sign and enter the Date, certifying under the penalty of perjury that the information provided on this application form is the truth to the best of their knowledge.
If you have made your mark (X) instead of signing your name, one witness must sign in Signature of Witness and enter the Date.
For Applicant Blind, applications based on blindness must be attested to by two witnesses, who sign in Signature of Witness and enter the Date.
If the application is initiated by someone else for the applicant, they must sign under APPROVED REPRESENTATIVE SIGNATURE and enter Relationship.
You are applying for SNAP benefits
If you are applying for SNAP benefits, complete the Shelter Costs page.
You will be interviewed within 14 days, or right away if you qualify for an expedited SNAP interview.
You are applying for cash or medical benefits
If you are applying for cash or medical benefits, complete the Your Family's Health Coverage page.
Is anyone listed on this application offered health coverage from a job? Check YES even if the coverage is from someone else's job, such as a parent's or spouse's.
If YES, complete Page 11.
A person is blind, has a disability or is age 65 or older
Resource Information: Complete only for persons who are blind, have a disability or are age 65 or older.
If married and living with spouse, also enter any resources the spouse owns.
If yes to any of the following, enter the details. Attach proof.
Check Yes or No for Does anyone own any property (ies) such as a home, vacation home, time share, building or land?
Check Yes or No for Does anyone own a car, truck, motorcycle, boat, trailer or other vehicle?
Check Yes or No for Does anyone own any life insurance?
A person does not wish to provide immigration status
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 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.
Common questions about Form IL444-2378B
Where do I file it?
You can mail or bring this form to an Illinois Department of Human Services, Family Community Resource Center (FCRC).
Is there a penalty?
If you have given false information or intentionally failed to disclose information, you may be subject to prosecution, criminal, civil or both.
Sources
[1] Form IL444-2378B (R-02-26), Request for Cash Assistance, Medical Assistance and Supplemental Nutrition Assistance Program (SNAP), Illinois Department of Human Services (the Official source link on this page).
