Okdhs Form PDF Details

Are you looking for information about the Oklahoma Department of Human Services (OkDHS) Form? If so, then you've come to the right place. Here we'll provide a comprehensive overview of this important document, including what it is and how to fill it out accurately. We'll also answer some common questions about the form and go over why having this knowledge can be helpful. With this insight, completing or understanding the OkDHS Form should no longer present an obstacle; make sure to read on in order to learn all you need!

QuestionAnswer
Form NameOkdhs Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other namesdhs forms oklahoma, okdhs forms oklahoma, okdhs forms okdhs, oklahoma department of human services forms

Form Preview Example

*PS1 *

Date:

 

__ _____

 

 

 

 

 

 

 

 

 

Case name:

 

______________________

Case number:

 

 

____________________

County number.

 

 

_____________________

Supervisor/worker number: /

Request for Benefits

For use with Forms 08MP002E and 08MP003E _______

What you need to do to get started:

Read the following descriptions and check all of the programs for which you would like to apply. Fill out this form or have someone else fill it out for you.

Program

Description

Apply?

 

 

 

Supplemental Nutrition

Helps buy food. Formerly known as the Food

 

Assistance Program (SNAP)

Stamp Program.

 

 

 

 

Child Care Subsidy

Helps pay for care for your child so you can

 

 

work, go to school, or attend training.

 

 

 

 

Health care coverage -

Helps pay for medical costs for pregnant

 

SoonerCare (Medicaid)

women and families with children.

 

 

 

 

 

Helps pay for medical costs for people who

 

 

are elderly or disabled.

 

 

 

 

 

Helps pay for nursing care in your home or in

 

 

a nursing home.

 

 

 

 

 

Helps pay Medicare Part A and B premiums.

 

 

 

 

 

State Supplemental Payment (SSP) - gives a

 

 

small cash payment to low-income people

 

 

who are blind, 65 years of age or older, or

 

 

receive Supplemental Security Income (SSI)

 

 

or Social Security disability.

 

 

 

 

 

Family Planning Services - helps pay for birth

 

 

control and family planning services.

 

 

 

 

Temporary Assistance for

Helps low income families with minor children

 

Needy Families (TANF)

by providing temporary cash and services.

 

 

 

 

Form 08MP001E (PS-1) revised 01-1-2012 may continue on next page, page 1 of 6

When you ask for help from OKDHS, you have a right to:

receive equal treatment regardless of race, color, age, sex, disability, religion, political belief, or national origin; and

ask for a fair hearing, either orally or in writing, if you disagree with any action taken on your case. Any person you choose may represent you at the hearing.

What to do when you complete the form:

Sign this form and take, mail, or fax it to the local OKDHS office.

After you give us this form, we will set up your interview. During your interview, we will help you complete the rest of the application. We will also tell you which benefits you can receive.

Schedule my interview.

Please put an X in the table for the days and times you are available for your interview:

Morning Afternoon

Monday

Tuesday

Wednesday

Thursday

Friday

What you will need to bring to your interview:

proof of identity, such as driver license or school identification;

Social Security number or card for everyone who wants benefits;

proof of citizenship for everyone who wants benefits;

proof of legal status for anyone who is not a U.S. citizen and wants benefits;

proof of income for everyone living with you, such as pay stubs or award letters;

proof of all resources, such as bank accounts, car titles, or land; and

proof of your need for child care, such as your work or school schedule, and the name of the place you want to use to care for your child.

You may be asked to give more information after your interview. You have the right to refuse to give any or all information. However, if you don't give us the information we need, we may not be able to help you.

How can we contact you?

Name

Mailing address, street or P.O. Box

City

State

Zip

Street address or directions to your home, if different than mailing address

Phone number where you can be reached

Email address

Form 08MP001E (PS-1) revised 1-1-2012 may continue on next page, page 2 of 6

Tell us about everyone who lives in the home starting with the adult head of household.

This person will be the payee. You must check yes or no in the U.S. citizen block and fill in the Social Security number for each person who wants benefits. If there are more than six persons in your household, attach another sheet of paper showing their information.

Person 1. Name of adult head of household

Name at birth, if different from above

Sex

M F

State of birth

Date of birth

County of birth

Mother's maiden name as listed on this person's birth certificate - First, M.I., Last

U.S. citizen

Alien registration number

Social Security number

Yes

No

 

 

 

 

 

 

Marital status

Hispanic or Latino

Relationship to payee

 

 

Yes

No

self

Race - check all that apply

 

White

Asian

Black or African American

Native Hawaiian or other Pacific Islander

American Indian or Alaskan native

 

 

 

 

 

 

 

 

Person 2. Name

Name at birth, if different from above

Sex

M F

State of birth

Date of birth

County of birth

Mother's maiden name as listed on this person's birth certificate - First, M.I., Last

U.S. citizen

Yes No

Hispanic or Latino

Yes No

Alien registration number

Social Security number Marital status

Relationship to spouse of payee

Race - check all that apply

 

White

Asian

Black or African American

Native Hawaiian or other Pacific Islander

American Indian or Alaskan native

 

 

 

 

 

 

 

 

Form 08MP001E (PS-1) revised 1-1-2012 may continue on next page, page 3 of 6

Person 3. Name

Sex

 

M F

Name at birth, if different from above

State of birth

 

 

Date of birth

County of birth

Mother's maiden name as listed on this person's birth certificate - First, M.I., Last

U.S. citizen

Alien registration number

Social Security number

Marital status

Yes

No

 

 

 

Hispanic or Latino

Relationship to payee

Relationship to spouse of payee

Yes

No

 

 

 

Race - check all that apply

 

 

White

Asian

Black or African American

 

Native Hawaiian or other Pacific Islander

American Indian or Alaskan native

Person 4. Name

Name at birth, if different from above

Sex

M F State of birth

Date of birth

County of birth

Mother's maiden name as listed on this person's birth certificate - First, M.I., Last

U.S. citizen

Alien registration number

Social Security number

Marital status

Yes

No

 

 

 

Hispanic or Latino

Relationship to payee

Relationship to spouse of payee

Yes

No

 

 

 

Race - check all that apply

 

 

White

Asian

Black or African American

 

Native Hawaiian or other Pacific Islander

American Indian or Alaskan native

Person 5. Name

Name at birth, if different from above

Sex

M F State of birth

Date of birth

County of birth

Mother's maiden name as listed on this person's birth certificate - First, M.I., Last

U.S. citizen

Alien registration number

Social Security number

Marital status

Yes

No

 

 

 

Hispanic or Latino

Relationship to payee

Relationship to spouse of payee

Yes

No

 

 

 

Race - check all that apply

 

 

White

Asian

Black or African American

 

Native Hawaiian or other Pacific Islander

American Indian or Alaskan native

Form 08MP001E (PS-1) revised 1-1-2012 may continue on next page, page 4 of 6

Person 6. Name

Name at birth, if different from above

Sex

M F

State of birth

Date of birth

County of birth

Mother's maiden name as listed on this person's birth certificate - First, M.I., Last

U.S. citizen

Yes No

Hispanic or Latino

Yes No

Alien registration number

Relationship to payee

Social Security number Marital status

Relationship to spouse of payee

Race - check all that apply

 

White

Asian

Black or African American

Native Hawaiian or other Pacific Islander

American Indian or Alaskan native

 

 

 

 

If you are applying for health benefits, does anyone need medical care today?

Yes

No

 

If yes, please check the reason(s) below:

just got out of the hospital;

need a prescription;

pregnant;

need to see a doctor;

other

If you need child care:

Are you in danger of losing a job due to a lack of child care?

Yes

No

Have you made payment arrangements with the child care provider until a decision can

be made on your child care application?

 

Yes

No

Are you starting a new job? Yes

No

If yes, starting date:

 

 

Once you have completed the application and interview, the earliest date you can get help with child care is the date you bring all needed information to your local OKDHS office.

Please answer these questions to see if you can get food benefits within seven calendar days.

1.How much money did you get or will you get

this month from working (total amount before taxes)? $

2.How much other money did you get or will you get

 

from all other sources this month (total amount)?

$

 

 

3.

How much cash do you have?

$

 

 

4.

How much money do you have in bank accounts?

$

 

 

5.

How much do you pay for your rent or mortgage?

$

 

 

6.

Do you pay the heating or cooling bill where you live?

Yes

No

7.

Are you a seasonal or migrant farm worker?

Yes

No

8.

Does anyone in your household receive tribal food

 

 

 

 

commodities?

Yes

No

Form 08MP001E (PS-1) revised 1-1-2012 may continue on next page, page 5 of 6

Households entitled to a decision within seven calendar days regarding their food benefit application are:

households with less than $150 gross monthly income and liquid resources less than $100;

households with monthly rent or mortgage and/or utilities which cost more than the combined monthly gross income and liquid resources; and

destitute migrant or seasonal farm worker households with liquid resources less than $100.

If this describes your household, please stay for an interview or to get an appointment date and time.

Read this information and then you must sign below:

I give OKDHS permission to check the information I gave on this form to make sure it is true.

I understand that the names and Social Security numbers I gave will be used to obtain information from other state and federal agencies.

I give OKDHS permission to share information with other agencies.

Your signature

Today's date

Please give this form to the receptionist or fax or mail it to your local OKDHS office.

OKDHS use only:

Date form was received:

Date screened:

Screened by:

 

Is the household eligible for expedited food benefits? Yes

No

Interview date:

Interviewed by:

OKDHS routing information: The original is imaged or filed in the case record. Upon request, a copy is given to the client.

Form 08MP001E (PS-1) revised 1-1-2012 may continue on next page, page 6 of 6

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okdhslive org forms conclusion process described (stage 1)

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Morning Afternoon, You may be asked to give more, and Name Mailing address street or PO inside okdhslive org forms

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