If you're looking for a reliable way to track your company's expenses, the Mc 371 form is a great option. This form can help you keep track of all your business-related spending, so you can stay within budget and file accurate tax returns. In this blog post, we'll provide an overview of the Mc 371 form and explain how to complete it. We'll also discuss some of the benefits of using this form to manage your company's expenses.
You will see details about the type of form you intend to fill out in the table. It can show you the time you'll need to fill out mc 371 form, exactly what parts you will need to fill in, and so on.
Question | Answer |
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Form Name | Mc 371 Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | dhcs members online, mc 371 medi cal, mc 371, form mc 371 |
State of California - Health and Human Services Agency |
Department of Health Care Services |
Additional Family Members Requesting
u Applicant/Caretaker’s Name (First, Middle, Last) |
Applicant/Caretaker’s Relationship to Child(ren) |
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Name on Birth Certiicate |
Gender |
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Pregnant? q Yes q No |
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q Male q Female |
Due date: _______________ # of babies_____ |
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Social Security No. |
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Date of Birth |
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If Yes, provide Beneits Identiication Card # if you have it: |
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Place of Birth (City/State/Country) |
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U.S. Citizen or National? q Yes q No |
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If No, date arrived in the U.S. |
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Month Day Year |
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Does this person have a physical, mental, emotional or |
Marital Status (check one): |
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developmental disability? |
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q Married q Single q Widowed q Divorced |
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q Yes. Date disability began: |
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q No |
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County Use Only
Case name:
Case #
Worker #
Date:
Linkage
SSN
PREG
ID
Other
v Spouse/Other Parent’s Name (First, Middle, Last) |
Relationship to Applicant/Caretaker |
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Linkage |
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Name on Birth Certiicate |
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Gender |
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Pregnant? q Yes q No |
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SSN |
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q Male q Female |
Due date: |
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# of babies |
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Social Security No. |
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Date of Birth |
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PREG |
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If Yes, provide Beneits Identiication Card # if you have it: |
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Place of Birth (City/State/Country) |
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U.S. Citizen or National? q Yes |
q No |
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ID |
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If No, date arrived in the U.S. |
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Does this person have a physical, mental, emotional |
Marital Status (check one): |
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Other |
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or developmental disability? |
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q Married q Single q Widowed q Divorced |
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q Yes. Date disability began: |
q No |
q Separated |
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w Child’s Name: (First, Middle, Last) or “Unborn” |
Relationship to Applicant/Caretaker |
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Name on Birth Certiicate |
Gender |
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Pregnant? q Yes q No |
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q Male q Female |
Due date: |
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# of babies |
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Social Security No. |
Date of Birth |
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_____ _____ ______ |
If Yes, provide Beneits Identiication Card # if you have it: |
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Month Day |
Year |
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Place of Birth (City/State/Country) |
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U.S. Citizen or National? q Yes |
q No |
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If No, date arrived in the U.S. |
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Month Day Year |
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Child living in home? q Yes q No |
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Child in school? q Yes q No |
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Mother’s Name: |
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Father’s Name: |
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Does this child have a physical, mental, emotional or |
Is either parent: |
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developmental disability? |
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q Deceased q Absent q Incapacitated |
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q Yes. Date disability began: |
q No |
q Unemployed |
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Linkage
SSN
PREG
ID
Medical Support? q Yes q No
q CW 2.1 Q q CW 2.1
qNot in home,
MC 371_07/09 (Replaces MC 321 |
Page 1 of 2 |
x |
Is anyone currently covered by health/dental insurance or Medicare? q Yes q No |
q DHCS 6155 |
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If so, who? |
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OHC Code: |
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y |
Has anyone iled a lawsuit because of an accident or injury? q Yes q No |
q DHCS 6268 |
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z Do you or any family member want |
q MC 210 A |
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and wish to apply for |
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Retroactive Coverage |
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List name(s): |
Month(s) of coverage: |
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Month |
Month |
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Month |
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Have you or any family member ever been in U.S. military service? q Yes q No |
q CW 5 |
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If Yes, who? Name(s): |
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Relationship: |
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The |
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We will share your child’s application with Healthy Families if your child no longer qualiies for free |
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do not want us to share it, check here q |
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We will share your child’s application with Healthy Kids or similar county program if your child does not qualify for |
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Family Income: List the income of every person listed in this application. Include child support and spousal support received. (Use a separate line for each source of income.)
Name of person with Income |
Source of Income |
How often is income |
How much is |
Social Security No. |
(Children who are in school do not have to list |
(Job, social security, |
received? |
the income? |
(Optional) |
their income from a job.) |
pension, etc.) |
(Weekly, biweekly, monthly) |
(Total gross |
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income) |
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$ |
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Expenses: List the monthly expenses for all persons listed above.
Child Day Care or Disabled Dependent Care
For (child or dependent’s name):__________________________________________ Age: ______ Amount Paid: _____________
How Often?______________
For (child or dependent’s name):__________________________________________ Age: _______ Amount Paid: ____________
How Often? _____________
Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________
Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________
Please note that additional information about your property, income and/or resources may be required if applicable.
I certify that I have read and understand the information above. I also certify that the information I have given on this form is true and correct.
Signature_____________________________________________________________________ Date: ________________
MC 371_07/09 (Replaces MC 321 |
Page 2 of 2 |