Iowa Form 470 3361 PDF Details

Tax season is here, and Iowa residents have till April 18th to file their federal and state income taxes. One of the documents needed for filing purposes is Form 470 3361 – Iowa Credit for Taxes Paid to Other States. This form serves as a helpful tax credit if you had already paid any state or local taxes in other states earlier during the year, as it helps offset your current base-state taxes. Read on further to learn how this form works and what information needs to be filed in order to qualify for this particular tax benefit!

QuestionAnswer
Form NameIowa Form 470 3361
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other names470 3361 maximus ssi form

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Iowa Department of Human Services

SSI ADVOCACY PROJECT REFERRAL

The Iowa Department of Human Services has selected MAXIMUS to assist in the identification of children in DHS custody who have severe disabilities and may be eligible for Supplemental Security Income benefits. MAXIMUS will file the application for benefits for children who appear to be eligible. If you have questions about referrals, please contact MAXIMUS at 1-800-778-1406.

Child’s Name

 

Date of Birth

Social Security Number

 

 

 

 

 

Foster Care Parents/Facility

 

 

Telephone

 

 

 

(

)

 

 

 

 

 

 

 

Street

 

City

State

 

Zip Code

 

 

 

 

 

 

Date of Placement

Is there a court order placing the child in DHS or JCS custody?

Does child have a diagnosed mental/physical impairment?

Yes

Yes

No

No

If “no” for either of these questions, do not proceed with referral.

Following are some indicators that a child may qualify for the SSI program (check all that apply):

Child has received (within last six months) or is receiving psychiatric hospital services due to diagnosed mental impairment other than substance abuse

Child was recently discharged from or is currently in a residential facility due to diagnosed mental impairment other than substance abuse

Child receives special education services to address severe learning problems

Child receives intensive outpatient counseling and/or therapy (must check one other indicator in addition to this one)

Child has moderate to severe mental retardation (IQ 70 or less)

Child has severe developmental delays (functioning one-half or less of chronological age)

Child receives intensive medical services and/or treatment for a physical illness

Infant (less than six months old) was born at a very low birth weight (1200 grams or less)

Is the child receiving any benefits based on a deceased, disabled or retired parent’s account?

Yes

No

Referred By

County

Telephone

( )

Date

DHS

JCS

Send referral to: MAXIMUS

Fax: 515-284-8854 E-mail: iowassi@maximus.com

PLEASE REPORT PLACEMENT CHANGES TO MAXIMUS

470-3361 (Rev. 9/05)

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