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.

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

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:

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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

State of Illinois

Department of Human Services

Request for Cash Assistance - Medical Assistance -

Supplemental Nutrition Assistance Program (SNAP)

Household Composition (Continued)

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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 #

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.

1.	Is this person Hispanic or Latino?		Yes	No
2.	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

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 #

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.


1.	Is this person Hispanic or Latino?			Yes	No
1.	Is this person Hispanic or Latino?			Yes	No

2.	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 4 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 (Continued)

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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 #

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?

1.	Is this person Hispanic or Latino?	Yes	No
2.	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

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 #

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?

1.	Is this person Hispanic or Latino?	Yes	No
2.	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

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

IL444-2378B (R-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 5 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)

If you are applying for SNAP benefits complete this page.

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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-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 6 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)

Migrant or Seasonal Farmworker Questions

					2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Is this a SNAP household of migrant or seasonal farm workers?			Yes	No
Did the household have income prior to the date of application?			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 $25 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 $200. *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

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 $200/$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-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 7 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)

Income - Benefits - Expenses

Is anyone in your household currently employed?

Yes

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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

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

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

Yes

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

Day-care: $

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-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 8 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)

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

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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?	Yes	No

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:

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-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 9 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)

Your Family's Health Coverage

Complete this page if you are applying for cash or medical benefits.	2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c

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

Is this COBRA coverage?

Yes

Other

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

Yes

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

Yes

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

If yes, when?:

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

IL444-2378B (R-09-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program		Page 10 of 18
Printed by Authority of the State of Illinois	-0- Copies

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

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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.

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