Il444 2378 B Form PDF Details

Il444 2378 B form is a tax form that deals with business expenses. This form can be used by taxpayers to report certain types of expenses for their businesses. The instructions for this form can be quite complex, so it is important that taxpayers understand them thoroughly before filing their return. There are many different types of expenses that can be claimed on this form, so taxpayers should carefully review the instructions to make sure they are claiming all the qualified expenses they are entitled to. Filing this form incorrectly can result in penalties and interest charges, so it is important to get it right the first time. Taxpayers who have any questions about how to fill out Il444 2378 B form should consult with a tax professional before submitting their return.

Here is the data about the PDF you were looking for to fill out. It can show you just how long it will require to finish il444 2378 b form, what parts you will have to fill in, and so forth.

QuestionAnswer
Form NameIl444 2378 B Form
Form Length20 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min
Other namesform il444 2378b, illinois medicaid application form pdf, 2378b form fillable, il forms 444 2378b r 07 18

Form Preview Example

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:

 

 

Present Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Apartment Number:

 

 

 

 

 

 

 

 

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

County:

 

 

Are you homeless?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

Name of approved representative:

 

 

 

 

Phone Number:

 

 

Organization Name:

 

Signature of applicant:

 

 

 

 

If yes, complete the following:

Address:

ID # if applicable:

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.

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.You may complete this form at home and mail or bring it to a Department of Human Services (DHS) office. 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. You have the right to choose the office where you apply. Once you submit your application to an office it will be processed by that office.

8.If you want to register to vote, fill out the enclosed Illinois Voter Registration Application (SBE R-19) and give it to your DHS office or your local election official. For help filling it out or for translation services, contact your DHS Family Community Resource Center. You may also call the Helpline at 1-800-843-6154, or 1-800-447-6404 (for TTY).

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-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 1 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Citizenship/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 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

1.

2.

3.

4.

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:

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

No

 

 

If yes, who:

 

Name of facility:

 

 

 

 

 

 

5.

Does anyone in your household want help paying for medical bills from the last 3 months?

Yes

No

 

 

6.

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

Yes

No

 

 

 

 

 

If yes, name of person:

 

 

 

 

 

 

 

 

7.

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

Yes

No

 

 

 

If yes, name of person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Language Preference

Does the adult member of your household who will discuss your case with DHS speak English fluently?

Yes

No

If no, please list your preferred spoken language:

Does the adult member of your household who will usually receive mail or written information from DHS read English fluently? Yes No

If no, please list your preferred written language:

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 2 of 18

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)?

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 #

 

Sex

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies

 

 

 

M

expected?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are applying for Medical assistance answer question 1.

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

 

 

 

Yes

 

No If yes, answer 2-4 below

 

 

 

 

 

 

 

 

 

 

 

2.

Will you file jointly with a spouse?

 

Yes

 

No

 

If yes, name of spouse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Do you have any dependents?

 

Yes

 

No

 

If yes, list name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

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

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, list the name of the tax filer:

 

 

 

 

 

 

 

How are you related to the tax filer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The following questions are for informational purposes only: (optional)

Are you Hispanic or Latino?

 

Yes

 

No

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 #

 

Sex

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies

 

 

 

M

expected?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

No If yes, answer 2-4 below

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Will this person file jointly with a spouse?

 

Yes

 

No

 

 

 

 

If yes, name of spouse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Does this person have any dependents?

 

Yes

 

No

 

 

 

 

If yes, list name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

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

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, list the name of the tax filer:

 

 

 

 

 

 

 

 

How is this person related to the tax filer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The following questions are for informational purposes only: (optional)

Is this person Hispanic or Latino?

 

Yes

 

No

What is this person's race? (Select one or more)

 

American Indian/Alaskan Native

 

Asian

 

Black or African American

 

Native Hawaiian or Other Pacific Islander

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 3 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Household Composition (Continued)

 

Person 3

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 #

 

Sex

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies

 

 

expected?

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

No If yes, answer 2-4 below

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Will this person file jointly with a spouse?

 

Yes

 

No

 

 

 

If yes, name of spouse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Does this person have any dependents?

 

Yes

 

No

 

 

 

If yes, list name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

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

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, list the name of the tax filer:

 

 

 

 

 

 

 

How is this person related to the tax filer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The following questions are for informational purposes only: (optional)

Is this person Hispanic or Latino?

 

Yes

 

No

What is this person's race? (Select one or more)

American Indian/Alaskan Native

 

Asian

 

Black or African American

 

Native Hawaiian or Other Pacific Islander

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person 4

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 #

 

Sex

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies

 

 

 

M

expected?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

No If yes, answer 2-4 below

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Will this person file jointly with a spouse?

 

Yes

 

No

 

 

 

If yes, name of spouse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Does this person have any dependents?

 

Yes

 

No

 

 

 

If yes, list name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

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

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, list the name of the tax filer:

 

 

 

 

 

 

 

How is this person related to the tax filer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The following questions are for informational purposes only: (optional)

Is this person Hispanic or Latino?

 

Yes

 

No

What is this person's race? (Select one or more)

 

American Indian/Alaskan Native

 

Asian

 

Black or African American

 

Native Hawaiian or Other Pacific Islander

 

White

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 4 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Household Composition (Continued)

 

Person 5

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 #

 

Sex

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies

 

 

 

M

expected?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

No If yes, answer 2-4 below

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Will this person file jointly with a spouse?

 

Yes

 

No

 

 

 

If yes, name of spouse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Does this person have any dependents?

 

Yes

 

No

 

 

 

If yes, list name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

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

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, list the name of the tax filer:

 

 

 

 

 

 

 

How is this person related to the tax filer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The following questions are for informational purposes only: (optional)

Is this person Hispanic or Latino?

 

Yes

 

No

What is this person's race? (Select one or more)

American Indian/Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White

 

Person 6

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 #

 

Sex

Birth Date

Marital Status

Pregnant? If yes, due date

How many babies

 

 

expected?

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

No If yes, answer 2-4 below

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Will this person file jointly with a spouse?

 

Yes

 

No

 

 

 

If yes, name of spouse:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Does this person have any dependents?

 

Yes

 

No

 

 

 

If yes, list name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

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

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If yes, list the name of the tax filer:

 

 

 

 

 

 

 

How is this person related to the tax filer?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The following questions are for informational purposes only: (optional)

Is this person Hispanic or Latino?

 

Yes

 

No

What is this person's race? (Select one or more)

 

American Indian/Alaskan Native

 

Asian

 

Black or African American

 

Native Hawaiian or Other Pacific Islander

 

White

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If needed, please list extra household members on an additional piece of paper.

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 5 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

If you are applying for SNAP benefits complete this page.

How much money do you or anyone who lives with you have in cash, checking, and/or savings? $

What is the monthly gross income (income of all sources before any deductions)

 

for you and everyone who lives with you?

$

How much money have you or anyone who lives with you received or expect to receive from any source in the month of application?

$ When?Who:Source:

Shelter Costs

1. How much are you charged each month for your rent or mortgage? $

(For mortgage include property taxes and insurance.)

 

Do you share this expense with anyone?

Yes

No

2. Did you receive a payment of $21 or more this month or in any of the last 12 months from the Low Income Home

Energy Assistance Program (LIHEAP), (in Chicago paid through CEDA)?

Yes

No

3.If No, are you billed separately from rent or mortgage for:

NOTE: Air conditioning is a window air or central air conditioning unit.

A. Heat or air conditioning? Yes No

B. Excess cost for heat or air conditioning?

Yes

No

 

 

 

C. Does anyone outside of your SNAP household pay or help pay for your housing costs?

Yes

No

D. Does anyone outside of your SNAP household pay your utility expenses?

Yes

No

 

 

 

 

 

If yes, please list the bills and the amounts paid:

Please complete the following information if you answered No, to question 2 or 3 and are not billed for heat or air conditioning separately

Expenses

Amount

How Often Due

Amount You Pay

Paid By Others

Electricity

Water and/or Sewerage

Garbage

Cooking Fuel

Basic Phone Service (including cell phone)

Septic Tank Installation Maintenance

Well Installation /Maintenance

A Fee for Starting Utility Service

A Flat Amount for Utilities

Explain:

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 6 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Migrant or Seasonal Farmworker Questions

Is this a SNAP household of migrant or seasonal farm workers?

Yes

No

If yes, did the income recently stop?

Yes

No If yes, date the income stopped?

Are liquid assets of household $100 or less AND does the household have a destitute migrant or seasonal farmworker?

Yes No

Are you or is anyone who lives with you expecting to receive more than $26 in income from a new source within the next

10 days? Yes

No

Benefit Information

Has the primary applicant received SNAP benefits in any state in the month of application? Yes No Is the applicant a resident of a domestic violence shelter? Yes No

Medical Deduction for Persons Disabled or Age 60 or Older

If a SNAP household member is disabled or age 60 or older your SNAP household may be entitled to a Standard Medical Deduction. To get the Standard Medical Deduction, you have to prove you pay out of pocket monthly medical expenses of $36 or more.

*If you do not live in a group home the Standard Medical Deduction is $245. *If you live in a group home the Standard Medical Deduction is $485.

Can you prove that you pay $36 or more monthly in medical expenses? Yes No

If yes and you give us proof, we will allow the Standard Medical Deduction that applies to your household. If your monthly medical expenses that you pay are more than $245/$485 and you give us proof, we will allow your actual medical expenses.

Application Interview - Cash and SNAP

Please complete the following:

We will interview you within 14 days, or right away if you qualify for an expedited SNAP interview.

I am able to come to an office interview.

I must be interviewed by phone because:

I am applying for SNAP

And someone in my household is employed.

Problems with health, transportation, caring for a child or disabled adult, ongoing severe weather or educational activities conflict with work hours.

I am applying for cash assistance

Hours of work or educational activities conflict with office hours.

Problems with health, transportation, caring for a child or disabled adult, ongoing severe weather or educational activities conflict with work hours.

I can be reached by phone Monday - Friday between 8:30 and 5:00 at:

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 7 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Income - Benefits - Expenses

Is anyone in your household currently employed?

Yes

No

 

 

 

 

 

 

 

If yes, complete the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person:

 

 

 

 

 

Employer:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Address:

 

 

 

 

 

Employer Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number of hours worked weekly:

 

 

Amount Paid (including tips) before taxes $

 

How often paid:

 

 

 

 

 

 

 

 

 

 

 

Weekly

Every two weeks

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

Name of Person:

 

 

 

 

 

 

Employer:

 

Employer Address:

 

 

 

 

 

Employer Phone:

 

 

 

 

 

 

 

 

 

 

 

 

Number of hours worked weekly:

 

 

 

Amount Paid (including tips) before taxes $

 

How often paid:

 

 

 

 

 

 

 

 

 

 

Weekly

Every two weeks

Twice a month

Monthly

 

 

 

 

 

Is anyone in your household self-employed? Yes

No

If yes, name of person:

 

What kind of work do they do?

 

 

 

 

 

 

 

 

 

 

 

How much will they make this month, once they pay business expenses? $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Complete only if your income changes from month to month. If you don't expect changes, skip this section. What is the total income for each person for this year? If you anticipate a change, what will it be next year?

Person:

 

Total income this year:

$

 

Total income next year:

$

 

 

Person:

 

Total income this year:

$

 

Total income next year:

$

 

 

Person:

 

Total income this year:

$

 

Total income next year:

$

 

 

 

 

 

 

 

 

 

 

 

Does anyone named on this form RECEIVE money from any source other than employment (such as Social Security, educational

benefits, child support, spousal support, rental property, unemployment benefits, pensions, retirement, trusts)? Yes

No

If yes, complete the following:

 

 

 

 

 

Name of Person:

 

Source:

 

Monthly Amount $

 

 

Name of Person:

 

Source:

 

Monthly Amount $

 

 

Name of Person:

 

Source:

 

Monthly Amount $

 

 

 

 

 

 

 

 

 

(Include additional pages, if needed.)

 

 

 

 

 

If this income is from rental property, is this person receiving the income also the property manager?

 

Yes

No

 

In the past year, has anyone in your household changed jobs, stopped working or started working fewer hours?

Yes

No

If yes, name of Person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone in your household pay any of the following expenses?

 

 

 

 

 

 

Alimony paid: $

 

How often?

Weekly

Every two weeks

Twice a month

Monthly

 

Student loan interest: $

 

How often?

Weekly

Every two weeks

Twice a month

Monthly

 

Daycare: $

 

How often?

Weekly

Every two weeks

Twice a month

Monthly

 

Child Support paid : $

 

How often?

Weekly

Every two weeks

Twice a month

Monthly

 

Other deductions (Do not include any expenses you have already reported)

 

 

 

 

 

 

Type of expense:

 

$

 

How often?

 

Weekly

Every two weeks

Twice a month

Monthly

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 8 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

American Indian or Alaska Native Family Member (AI/AN)

Are you or anyone in your family American Indian or Alaska Native (AI/AN)?

Yes

No

Are you or anyone in your household a member of a federally-recognized tribe?

Yes

No

If yes, tribe name:

 

 

 

 

If No, skip to next section.

Indian Health Services

List any family members who received services from the Indian Health Service, a tribal health program, or urban Indian health program. If nobody received these services, is anyone qualified to receive them?

List the names of anyone who received services:

List the names of anyone who qualifies for services:

Tribal Related Income

Does the income you listed on Page 7 include money from any of the following?

Yes

No

Payments from a tribe that come from natural resources, usage rights, leases or royalties?

If yes, amount: $

 

 

 

Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the

Department of the Interior (including reservations and former reservations)?

Yes

No

 

If yes, amount:

$

 

 

 

 

 

 

Money from selling things that have cultural significance?

Yes

No

 

 

 

If yes, amount:

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SNAP and Cash Applicants:

Have you or any other person applying for Cash been convicted of a felony involving drugs on or after 08/22/96?

Yes

No

If yes, Name of Person:

 

 

 

 

 

 

 

 

 

 

 

If the drug-related felony conviction was NOT Class X or Class I, did the felony take place more than 2 years ago, or has the

 

person completed a drug treatment program, or is the person in a drug treatment program now? Yes

No

 

 

Has any person been convicted in state or federal court of misrepresenting an address to receive assistance in two or more

 

states at the same time?

Yes

No

 

 

 

 

 

 

 

 

If yes, who

 

 

 

 

 

 

 

 

 

 

 

Is any person in violation of their parole or probation?

Yes

No

 

 

 

 

 

 

If yes, who

 

 

 

 

 

 

 

 

 

 

 

Is anyone fleeing from felony prosecution, an outstanding felony warrant or jail?

Yes

No

 

 

 

 

If yes, who

 

 

 

 

 

 

 

 

 

 

 

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 9 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Your Family's Health Coverage

Complete this page if you are applying for cash or medical benefits.

Is anyone enrolled in health coverage now from any of the following? If YES, check the type of coverage and write their names next to the coverage they have.

Medicaid

CHIP

Medicare

Tricare (Don't check if you have

Direct Care or a Line of Duty)

Veteran's Health Insurance Program

Peace Corps Health Insurance

Employer Insurance

Name of Insurance

Policy Number

Is this a retiree health plan?

Yes

No

 

 

 

Is this COBRA coverage?

Yes

No

 

 

 

Other

 

 

 

 

 

 

Is this a limited-benefit plan (such as a school accident policy)? Yes

No

 

 

Is anyone listed on this application offered health coverage from a job?

Yes

No

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.

Tell us about the job that offers coverage:

Employer Name:

Employer Address:

Employer Phone Number:

Employer Identification Number (EIN):

Who can we contact about employee health coverage at this job?

Phone Number:

 

 

E-Mail address:

 

 

Can you get coverage now or sometime in the next 3 months?

Yes

No

If yes, when?:

 

 

 

 

 

 

List the name of anyone who can get coverage from this job:

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 10 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Your Family's Health Coverage

Complete this page if you are applying for cash or medical benefits and anyone listed on this application is offered health coverage from a job.

Does the employer offer a health plan that pays at least 60% of the total costs of benefits? (The minimum value standard for

health plans)

Yes

No

 

For the lowest-cost minimum value plan offered to the employee ONLY (don't include family plans):

Does the employer offer wellness programs? Yes

No

If yes, what premium would the employee pay if he or she got

the maximum discount for a tobacco cessation program?

$

a.How much would the employee have to pay in premiums for this plan? $

b.

How often?

Weekly

Every two weeks

Twice a month

Quarterly

Yearly

What changes will the employer make for the new plan year, if you know?

Employer won't offer health coverage.

Employer will start offering health coverage to employees.

Employer will change the premium for the lowest-cost plan minimum value plan available to the employee only.

a.How much would the employee have to pay in premiums for this plan? $

b.

How often?

Weekly

Every two weeks

Twice a month

Quarterly

Yearly

You must answer for all household members age 19 or younger:

 

 

Did anyone lose health insurance from a job within the past three months?

Yes

No

If yes, answer the questions below:

a.Name of household member:

b.When did the insurance end?

c.Reason insurance ended:

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 11 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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 below. Attach proof. Attach additional sheet(s) if needed.

 

Does anyone own any property (ies) such as a home, vacation home, time share, building or land?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner

 

 

 

 

Address

 

 

 

 

Type

 

 

 

 

Value

 

 

Amount Owed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone own a car, truck, motorcycle, boat, trailer or other vehicle?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner

 

 

 

Type

 

 

Make/Model/Year

 

 

 

Value

 

 

Amount Owed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone own any life insurance?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner

 

 

 

Insurance Company

 

 

 

Policy Number

 

 

 

Face Value

 

 

Cash Value

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone have an insurance policy that pays when he or she is in a nursing home?

 

Yes

No

 

 

 

 

 

If yes, list the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Policy Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Company:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone own any of the following resources? Check all that apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

Business

 

 

Savings

 

 

Checking Account

 

Stocks, Bonds

 

Government Bonds

 

Life Estate

 

 

Funeral/Burial Plans

Money Market Account

Deferred Comp

 

Mutual Funds

 

Annuity

 

 

Nursing Home Account

Trust Funds

 

Inheritance

 

Promissory Note/Loan

 

Burial Plots

 

 

IRA/401 K

 

 

Certificates of Deposit

 

Reverse Mortgage

 

Mineral/Oil Rights

 

Other List, If other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Owner(s)

 

 

 

Type of Resource

 

Account/Policy #

 

 

Value

 

 

Name of Bank, Company, etc.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have resources that are held jointly with another person?

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

(Jointly held resources are those held in two or more names; for example, in your name and in the name of another person(s). This includes resources that may be held by you and your spouse, son or daughter, brother or sister, grandchild, friend, companion, etc.)

 

Resource:

Value:

Name and relationship of Other Person(s) Holding the Resource:

 

 

 

 

 

 

 

Property in Illinois:

$

 

 

 

 

 

 

 

 

Property in another state:

$

 

 

 

 

 

 

 

 

Checking/Savings account:

$

 

 

 

 

 

 

 

 

Certificate of Deposit:

$

 

 

 

 

 

 

 

 

Stocks/Mutual Funds:

$

 

 

 

 

 

 

 

 

Other:

$

 

 

 

 

 

 

 

 

 

 

 

 

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 12 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Employment and Employment Related Expenses

Complete only for employed persons who are blind, have a disability or are age 65 or older. Also enter the employment expenses for an employed spouse or parent of a child under age 18 if they live together.

Employed person's name: (1)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount received before deductions (gross amount): $

 

 

 

 

 

 

 

 

 

 

 

 

How often paid:

Weekly

Every two weeks

 

Bi-Monthly

 

Monthly

 

 

Federal, State and City taxes withheld: $

 

 

 

 

 

Social Security tax withheld: $

 

 

 

 

Does this person buy or bring lunch to work?

Buy Lunch

 

 

Bring Lunch

 

 

Does this person buy uniforms or special tools?

 

Yes

No

 

 

 

 

 

 

 

 

 

If yes, enter the items bought, how often, and cost. Attach proof.

 

 

 

 

 

 

 

 

 

 

How does this person get to and from work?

Own car

Bus

Other Please list. if other:

 

 

 

If this person uses his/her own car, how many miles to and from work?

 

 

 

 

If this person person takes the bus, what is the fare to and from work? $

If other transportation is used, enter type and cost. Attach proof.

Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan

withholding as a condition of employment?

Yes

No Monthly amount: $

 

 

 

 

 

Employed person's name: (2)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount received before deductions (gross amount): $

 

 

 

 

 

 

 

 

 

 

 

 

How often paid:

Weekly

Every two weeks

 

Bi-Monthly

 

Monthly

 

 

 

Federal, State and City taxes withheld: $

 

 

 

 

 

Social Security tax withheld: $

 

 

 

 

 

Does this person buy or bring lunch to work?

Buy Lunch

 

 

Bring Lunch

 

 

 

Does this person buy uniforms or special tools?

 

Yes

No

 

 

 

 

 

 

 

 

 

If yes, enter the items bought, how often, and cost. Attach proof.

 

 

 

 

 

 

 

 

 

 

How does this person get to and from work?

Own car

Bus

Other Please list. if other:

 

 

 

 

If this person uses his/her own car, how many miles to and from work?

 

 

 

 

If this person person takes the bus, what is the fare to and from work? $

If other transportation is used, enter type and cost. Attach proof.

Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan

withholding as a condition of employment?

Yes

No Monthly amount: $

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 13 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

SNAP - CLIENT RIGHTS AND RESPONSIBILITIES

Read carefully before signing this application on page 18. Ask your caseworker to explain anything you do not understand.

Because the SNAP program requires a Social Security Number (SSN) for every member of your household who is applying for SNAP benefits, we are explaining how your SSN is used by DHS.

What does DHS do with your Social Security Number?

The SSN will be used in the administration of the SNAP program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes. If you or any member of your household wants to apply for SNAP benefits, but does not have a SSN, we can help you apply for one. The SSN (or any other information in this application) may be used in computer matching and program reviews or audits and to make sure the household is eligible for SNAP benefits, other Federal assistance programs, and Federally assisted state programs, such as school lunch, TANF, and Medicaid. This may result in criminal or civil action or administrative claims against persons fraudulently participating in the SNAP program. We do not require a Social Security Number for any member of your household who is not eligible for the SNAP program or who does not wish to apply.

Why does DHS collect your Social Security Number?

DHS will only use your SSN for the purpose for which it was collected. DHS will not: Sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly display your SSN; print your SSN on any card required for you to access our services; require you to transmit your SSN over the internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any materials that are mailed to you, unless State or Federal law requires that number to be on documents mailed to you, or unless we are confirming the accuracy of your SSN.

Right to appeal.

A fair hearing may be requested either orally or in writing if there is a disagreement with any action taken on this case. The SNAP unit's case may be presented at the hearing by any person chosen by the SNAP unit.

Non-Discrimination.

In accordance with Federal Law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the department. If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call

(866)632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov. You may also contact the Department of Human Services (DHS) at Department of Human Services, Bureau of Civil Affairs, 401 South Clinton St, 2nd Floor, Chicago, Illinois, 60607. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at

(800)221-5689, which is also in Spanish or call the DHS Helpline Number at 1-800-843-6154 or (800)447-6404 (TTY). DHS and USDA are equal opportunity providers and employers.

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 14 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

SNAP - CLIENT RIGHTS AND RESPONSIBILITIES continued

Declaration Regarding Citizenship/Alien Status

I declare, under penalty of perjury, that the statements I have made regarding the citizenship or alien status of each person requesting assistance are true and correct. I understand that the alien status of each person requesting assistance who is not a citizen of the United States will be verified with the United States Citizenship and Immigration Services (USCIS). This will require the disclosure to USCIS of certain identifying information which I have provided. The information received from USCIS may affect eligibility for assistance and the benefit level.

I understand that documents may have to be provided to prove what I have said. I agree to do this. If documents are not available, I agree to give the name of the person or organization the FCRC may contact to obtain the necessary proof. The information on this form is subject to verification by Federal, State, and Local Officials. If any information is found to be inaccurate, I may be denied SNAP benefits, and/or be subject to criminal prosecution for knowingly providing false information.

I understand that a change that happens after the eligibility interview and before the notice of decision must be reported within 10 calendar days unless otherwise notified. If I have any doubt about whether to report a change, I will ask my Human Services caseworker.

I understand that if I am approved for SNAP benefits and I receive more benefits than I am entitled to, whether an error on my part or an agency error, the amount of overpaid benefits may be subtracted from my monthly benefit amount.

 

AT THE APPLICATION

 

 

 

You Must Report

 

You must report and verify:

 

 

 

Child care expenses

 

Medical expenses

 

 

Rent or mortgage payment, property taxes and insurance and

Child support paid to a non-SNAP Unit member

utility expenses.

 

 

 

 

 

 

Failure to report or verify above expenses will be seen as a statement by your SNAP Unit that you do not want to receive a deduction for the unreported expenses.

Child support payments are subject to verification by computer matching with the records of the Division of Child Support Enforcement.

Penalty Warning - What are the SNAP Program Penalties?

If you

Then you will lose SNAP benefits

 

 

* Hide or give wrong information on purpose to get SNAP benefits

 

* Trade, steal or sell SNAP benefits, or resell food bought with SNAP

 

benefits

* 12 months first time

* Use SNAP benefits to buy non-food items like alcohol or tobacco.

* 24 months the second time

* Use someone else's SNAP benefits for yourself or someone else.

* Permanently the third time

* Throw away beverages purchased with SNAP benefits just to get

 

money back from a container deposit.

 

 

 

Trade SNAP benefits for controlled substance, such as drugs.

* 24 months first time

* Permanently the second time

 

 

 

Trade SNAP benefits for firearms, ammunition or explosives.

* Permanently

 

 

Buy, sell, steal or trade SNAP benefits of more than $500.00

* Permanently

 

 

* Give false information about who you are and where you live so you can

* 10 years

get extra SNAP benefits.

 

 

 

You can also be fined up to $250,000 and put in prison up to 20 years or both. You can also be charged under other Federal Laws. Persons who are fleeing felons or probation/parole violators are ineligible for SNAP benefit.

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 15 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES

Read carefully before signing this application on page 18. Ask your caseworker to explain anything that you do not understand.

To receive benefits, a person must have a valid Social Security Number (SSN) or proof that he or she has applied for one, unless exempt. If you or any member of your household wants to apply for assistance, but do not have a SSN, we can help you to apply for one. State law requires us to explain how your SSN is used by the State of Illinois.

üYour Social Security Number (SSN) will be used in the administration of the cash and/or medical program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes to the cash and/or medical program.

The SSN (or any other information in this application) may be used in computer matching and program reviews or audits and to make sure the household is eligible for assistance, other federal assistance programs, and federally assisted state programs, such as school lunch, TANF, and Medicaid.

DHS secures and uses information about all clients through the income and eligibility verification system. This includes such information as receipt of social security benefits, unemployment insurance, unearned income and wages from employment.

Any information obtained will be used in determining eligibility for assistance and the amount of assistance provided for all programs.

When discrepancies are found, verification of this information may be obtained through contacts with a third party, such as employers, claims representatives, or financial institutions. This information may affect your eligibility for assistance and the amount of assistance provided.

DHS will only use your SSN for the purpose for which it was collected.

DHS will not: sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly display your SSN; print your SSN on any card required for you to access our services; require you to transmit your SSN over the Internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any materials that are mailed to you, unless State or Federal law requires that number be on documents mailed to you, or unless we are confirming the accuracy of your SSN.

üWhen an application for cash or medical assistance is filed, a determination of eligibility under all of the programs administered by DHS will be made unless I do not want to be considered for a particular program(s). If I do not want to be considered for a particular program, DHS will not consider my eligibility for that program(s).

üThe information provided on this form will be subject to verification by Federal, State, and Local officials. If any information is found to be inaccurate, I may be denied cash benefits and/or medical assistance. I understand that anyone who knowingly misuses the medical card issued by the State of Illinois may be committing a crime.

üAll information related to the establishment of paternity and child support enforcement has been provided to the best of my knowledge.

üIf my application is approved, I give the State of Illinois the right to recover under the terms of any private or public health care coverage any amount for which I or a member of my family may be eligible.

üI also authorize staff of the DHS to obtain information from my records or copy my records from the Social Security Administration (SSA). I authorize release of my records from SSA to the staff of DHS with respect to any claims for disability benefits and all related appeals. I certify that I understand that the materials requested may be protected under the Privacy Act. I authorize release of any material protected under the Privacy Act to the staff of DHS.

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 16 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued

üI understand that the State of Illinois will release information concerning medical services that I have received for any reason authorized by law.

üI understand that if the children I am applying for are approved for All Kids Share or All Kids Premium, then I am responsible for paying the premiums and copayment amounts.

üI understand that if the children I am applying for are approved for All Kids Rebate, then the State of Illinois is not responsible for additional premiums; deductibles or copayments required by the employer's or private health insurance policy.

üIf I am approved for TANF Cash and/or medical benefits for myself and my children, and the State of Illinois pays medical bills for me, I give my right to collect medical support payments to the State of Illinois. I understand I must help to obtain medical support payments for members of my family unless I have a good reason not to. My children can get health insurance even if I do not help when the Department asks me to.

üAs a condition of eligibility, if I am approved for TANF Cash and/or medical assistance for myself and my children, I understand that I may be required to cooperate with child support enforcement.

Cooperation includes establishment of paternity and/or support enforcement and modification of child support orders.

I assign and give all my rights, title and interest of child support and medical support to Healthcare and Family Services (HFS) as long as I receive TANF Cash/or medical assistance.

I understand and agree that any child support payments paid through the clerk of the circuit court and through the State Disbursement Unit (SDU) may be forwarded to the HFS as long as I receive TANF Cash.

I understand that if I apply for TANF Cash and/or medical assistance for my children only, I am not required to cooperate with child support enforcement, but I may request services.

üI declare under penalty of perjury, that the statements I have made regarding the citizenship or immigration status of each person requesting assistance are true and correct.

üI understand the Department will not share any information about immigration or any persons who do not have an Alien Registration Number.

üThe Department will verify the immigration status of any person for whom I give an Alien Registration Number. To do that, the Department will check the number with the U.S. Citizenship and Immigration Service (USCIS). The Department may send other information to USCIS, such as copies of proof that I give of an Alien Registration Number and the person's Social Security Number, if they have one.

üIf I am approved for Aid to the Aged, Blind, or Disabled (AABD) for cash and/or medical assistance, I understand that the DHS may have the right to place a lien on my home or other real property I own. The amount of the lien is the amount of assistance DHS has provided to me.

üI agree to inform the agency within 10 days of any change in my household's size, income, property, living arrangements, school attendance, or address.

üI understand that if approved for cash benefits, and I receive more benefits than I am entitled to, whether it be an error on my part or an agency error, the amount of overpaid benefits are subject to recoupment/recovery.

üI understand that a person convicted of a Class X or Class I felony or a comparable federal law, for acts that occurred on or after 08/22/96 involving possession, use, or distribution of a controlled substance is ineligible to receive Cash assistance. I understand that a person convicted of drug-related felony, other than a Class X or Class I, under Illinois or any comparable federal law an act that occurred on or after 08/22/96, is ineligible for Cash assistance for 2 years following the date of the conviction, unless they are in drug treatment or aftercare, or successfully participated in and completed drug treatment and/or aftercare subsequent to their conviction.

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 17 of 18

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued

üRight to Appeal I understand that if I am not satisfied with the action taken on my application that I have the right to a fair hearing. I understand that I can ask for a fair hearing by getting in touch with the office where I applied or by writing to: Illinois Department of Human Services, Bureau of Assistance Hearings, 401 South Clinton Street,

6th Floor, Chicago, Illinois 60607, or by calling 1-800-435-0774.

üI understand that if I am mentally and physically able to apply and I want someone else to apply for cash and/or medical benefits for me, I must attach a written statement that gives the person permission. The statement must include the person's name, address, and phone number. The statement must say that I am still responsible for the information provided by the person.

üI understand that if I or anyone I have applied for is not eligible for Medicaid or All Kids, the state will send the information from the application to the Health Insurance Marketplace. The Health Insurance Marketplace needs detailed information about health coverage that my employer may offer even if I do not take it. The information requested on Pages 10 and 11 may be required if the state sends my application to the Health Insurance Marketplace.

üI understand that by signing this application form, I consent to any investigation made by the Department to verify or confirm the information I have given or any other investigation made by them in connection with my request for public assistance. I understand that I must cooperate in these efforts to verify information.

Applicant Signature

I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil or both. I certify under the penalty of perjury that the information I have provided on this application form is the truth to the best of my knowledge.

I declare under penalties of perjury that I have examined this form and all accompanying statements or documents pertaining to the income and resources of myself (the applicant) or any member of my family (the applicant's family) included in this application for aid, or pertaining to any other matter having bearing upon my (the applicant's) eligibility for aid, and to the best of my knowledge and belief the information supplied is true, correct, and complete.

Applicant:

 

Date

Spouse:

 

Date

Signature: Applicant Makes a Mark (X)

 

If you have made your mark (X) instead of signing your name, one witness must sign here:

 

Signature of Witness:

 

Date

Signature: Applicant Blind

 

Applications based on blindness must be attested to by two witnesses.

 

Signature of Witness:

 

 

Date

Signature of Witness:

 

 

Date

APPROVED REPRESENTATIVE SIGNATURE

If the application is initiated by someone else for the applicant, they must sign below. If an approved representative completes and signs this application, written authorization from the applicant is required.

I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution, criminal, civil or both. I certify under the penalty of perjury that the information I have provided on this application form is the truth to the best of my knowledge.

Signature of Approved Representative:

 

Relationship:

Home Address:

 

Apt. Number:

Phone Number:

 

 

 

IL444-2378B (R-03-14) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program

Printed by Authority of the State of Illinois

PO# 14-1488 127,000

Page 18 of 18

Today's Date:

ILLINOIS VOTER REGISTRATION APPLICATION

Suggested, August 2008, SBE R-19

FOR ILLINOIS RESIDENTS ONLY

 

 

 

 

 

 

 

 

 

TO COMPLETE THIS FORM:

 

 

 

 

 

 

 

 

TO VOTE YOU MUST:

 

 

 

 

 

·

Box 1-If you do not have a middle name, leave blank.

·

Be a United States citizen

 

 

 

 

 

·

Box 3-If mailing address is same as Box 2, write "same".

·

Be at least 18 years old

 

 

 

 

 

·

Box 4-If you have never registered before, leave blank.

 

 

 

 

 

 

 

 

 

 

 

 

 

·

Live in your election precinct at least 30 days

 

 

 

 

 

 

 

 

 

 

If you do not remember your former address; provide as

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

·

Not be convicted and in jail

 

 

 

 

 

 

 

 

 

 

 

much information as possible.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

·

Not claim the right to vote anywhere else

 

 

 

 

 

·

Box 5-If you have not changed your name, leave blank.

 

 

 

 

 

 

 

 

 

 

 

 

 

TO VOTE IN THE NEXT ELECTION:

 

 

 

 

 

·

Box 9-If

you have an Illinois Driver's License or Secretary of State

 

 

Mail or deliver this application to your County Clerk or Board

 

 

 

 

 

 

 

ID, check the first box and fill in the number. If you do not have a

 

 

of Election Commissioners no later than 28 days before the

 

 

 

 

 

 

 

Driver's License or SOS ID, check the second box and fill in the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

next election. (click here for County Clerk/Election Board

 

 

 

 

 

 

 

 

 

 

last four digits of your Social Security Number. If you do not have

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

listings) or go to www.elections.il.gov

 

 

 

 

 

 

 

 

 

 

 

a SSN, check the third box and send a copy of the appropriate

IMPORTANT INFORMATION:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

document (as described in the "Important Information" section)

 

 

If you do not have a driver's license, State Identification Card or social security number,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and this form is submitted by mail, and you have never registered to vote in the

 

 

 

 

 

 

 

along with this form.

 

 

 

 

 

 

 

 

 

 

jurisdiction you are now registering in, then you must send, with this application, either (i)

 

·

10-Read, date and personally sign your name or make your

 

 

a copy of a current and valid photo identification, or (ii) a copy of a current utility bill, bank

 

 

 

 

 

 

 

mark in the box.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

statement, government check, pay check, or other government document that shows the

 

 

 

 

 

IF YOU HAVE NO STREET ADDRESS,

 

 

 

 

 

 

 

name and address of the voter. If you do not provide the information required above,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

below describe your home: list the name of subdivision; cross

 

 

then you will be required to provide election officials with either (i) or (ii) described above the

 

 

 

 

 

 

 

 

 

 

streets; roads; landmarks; mileage and/or neighbors names.

 

 

first time you vote at a voting place or by absentee ballot. If you change your name you must

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

re-register. If you register at a public service agency, any information regarding the agency

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

 

that assisted you will remain confidential as will any decision not to register. If you do not

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

receive a Notice within 2 weeks of mailing or delivering this application, call your County Clerk

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or Board of Election Commissioners.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

W

 

 

 

 

 

E

 

 

 

 

 

 

 

If you have questions about completing this form, please call the State

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Board of Elections at (217)782-4141 or (312)814-6440 (or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

webmaster@elections.il.gov).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you a citizen of the United States of America?

(check one)

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Will you be 18 years of age on or before election day?

(check one)

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you checked "No" in response to either of these questions, then do not complete this form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

You can use this form to: (check one)

apply to register to vote in Illinois

Change your address

 

Change your name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Last name

 

 

First Name

 

 

Middle Name or Initial

 

Suffix (Jr. Sr. II III IV)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Address where you live (House No., Street Name, Apt No.)

 

 

 

 

 

City/Village/Town

 

 

Zip Code

County

Township

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Mailing Address (P.O. Box)

 

 

 

 

 

 

 

 

 

City/Village/Town

 

 

Zip Code

County

Township

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Former Registration Address: (include City and State and Zip Code)

 

 

 

 

 

Former County

 

 

 

5. Former Name:

(if changed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. Date of Birth: MM/DD/YYYY

 

8. Home Telephone number

 

 

 

 

9. ID Number-Check the applicable box and provide the appropriate

 

 

 

 

 

 

 

 

including area Code (optional)

 

 

 

 

 

number

 

 

 

IL Driver's License or, if none, Sec. of State ID or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last 4 digits of SSN

 

 

 

 

 

 

 

 

 

7. Sex (check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have none of the above-listed identification numbers

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Voter affidavit - Read all statements and sign within the box to the right.

 

 

 

 

 

 

 

 

 

 

 

 

This is my signature or mark in the space below.

 

 

 

 

 

I swear or affirm that

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

·I am a citizen of the United States;

·I will be at least 18 years old on or before the next election;

·I will have lived in the State of Illinois and in my election precinct at least 30 days as of the date of the next election

·The information I have provided is true to the best of my knowledge under penalty of

perjury. If I have provided false information, then I may be fined, imprisoned, or if I am not a U.S. citizen, deported from or refused entry into the United States.

11. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.

Name of person assisting:

 

Full Address

 

Telephone No.

 

Back of SBE No. R-19

YOUR ADDRESS

______________

PUT

 

 

FIRST

 

CLASS

 

 

STAMP

 

HERE

 

 

_______________

___________________________________________________

MAIL TO:

___________________________________________________

CHANGE OF ADDRESS

PCT WARD CODE

ADDRESS

CITY ZIP COUNTY DATE

CLERK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUSPENSION, CANCELLATION AND REINSTATEMENT

DATE

EXPLAIN

CLERK

DATE

EXPLAIN

CLERK

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To Election Judges

Voting Record

08 09 10 11 12

13 14 15 16 17 18 19 20 21 22 23 24 25

26

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

For Primary, mark

Primary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D for Democrat

General

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R for Republican

NonPartisan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for all other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

elections markV

Special

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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