Il444 2378 B Form – Fill Out and Use This PDF

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.

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.

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.

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:

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

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

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.

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:

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:

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

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

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:

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:

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:	$