Pa 1809 Sg Form PDF Details

If you are looking for valuable information about Pennsylvania's state income tax forms, the PA-1809 SG form is an important one to know. This form must be filed by self-employed individuals and business entities that have apportionable income or tangible personal property located in Pennsylvania in order to report their taxable income. By completing this document accurately and submitting it on time, taxpayers can ensure they meet all requirements while avoiding costly fines or penalties from the Department of Revenue (DOR). In this blog post we’ll look at what information should be included when filing a PA-1809 SG Form, as well as how filing online can simplify the process and help avoid mistakes.

QuestionAnswer
Form NamePa 1809 Sg Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameswhat is form pa 1809, 1809 pa form, sg pa citizen, pennsylvania 1809

Form Preview Example

CITIZENSHIP

AND IDENTITY

INFORMATION

The Federal government now requires that EVERY person declaring U.S. citizenship who receives Medical Assistance must provide proof of U.S. citizenship and identity. The most common way to satisfy this requirement is with a birth certificate and a driver’s license. We will help you to meet this new requirement if you need assistance.

If you have a birth certificate and/or driver’s license for some or all of the people who are applying for Medical Assistance, please send these documents with your application for Medical Assistance.

If you do not have a birth certificate and/or a driver’s license for every person who is applying for Medical Assistance that you can send to us, complete this form so that we can help you find other documents that can provide proof of your U.S. citizenship and identity.

PLEASE COMPLETE THE INFORMATION BELOW FOR EVERY U.S. CITIZEN OR U.S. NATIONAL IN YOUR HOUSEHOLD WHO IS APPLYING FOR MEDICAL ASSISTANCE. IF YOU DO NOT HAVE ALL OF THE INFORMATION, PLEASE PROVIDE WHAT YOU KNOW.

1

LAST NAME

FIRST NAME

MIDDLE INITIAL

SEX

DATE OF BIRTH

MOTHER’S MAIDEN NAME

SOCIAL SECURITY NUMBER

DRIVERS

 

 

 

 

M/F

MM/DD/YYYY

FIRSTNAME LASTNAME

 

LICENSE/STATE I.D.

 

 

 

 

 

 

 

 

STATE & NUMBER

 

 

 

 

 

 

 

 

 

NAME ON BIRTH CERTIFICATE LAST,

FIRST, MIDDLE

 

STATE OF BIRTH*

COUNTY OF BIRTH

CITY OF BIRTH

 

2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MIDDLE INITIAL

SEX

DATE OF BIRTH

MOTHER’S MAIDEN NAME

SOCIAL SECURITY NUMBER

DRIVERS

 

 

 

 

M/F

MM/DD/YYYY

FIRSTNAME LASTNAME

 

LICENSE/STATE I.D.

 

 

 

 

 

 

 

 

STATE & NUMBER

 

 

 

 

 

 

 

 

 

NAME ON BIRTH CERTIFICATE LAST,

FIRST, MIDDLE

 

STATE OF BIRTH*

COUNTY OF BIRTH

CITY OF BIRTH

 

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MIDDLE INITIAL

SEX

DATE OF BIRTH

MOTHER’S MAIDEN NAME

SOCIAL SECURITY NUMBER

DRIVERS

 

 

 

 

M/F

MM/DD/YYYY

FIRSTNAME LASTNAME

 

LICENSE/STATE I.D.

 

 

 

 

 

 

 

 

STATE & NUMBER

 

 

 

 

 

 

 

 

 

NAME ON BIRTH CERTIFICATE LAST,

FIRST, MIDDLE

 

STATE OF BIRTH*

COUNTY OF BIRTH

CITY OF BIRTH

 

4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MIDDLE INITIAL

SEX

DATE OF BIRTH

MOTHER’S MAIDEN NAME

SOCIAL SECURITY NUMBER

DRIVERS

 

 

 

 

M/F

MM/DD/YYYY

FIRSTNAME LASTNAME

 

LICENSE/STATE I.D.

 

 

 

 

 

 

 

 

STATE & NUMBER

 

 

 

 

 

 

 

 

 

NAME ON BIRTH CERTIFICATE LAST,

FIRST, MIDDLE

 

STATE OF BIRTH*

COUNTY OF BIRTH

CITY OF BIRTH

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

MIDDLE INITIAL

SEX

DATE OF BIRTH

MOTHER’S MAIDEN NAME

SOCIAL SECURITY NUMBER

DRIVERS

 

 

 

 

M/F

MM/DD/YYYY

FIRSTNAME LASTNAME

 

LICENSE/STATE I.D.

 

 

 

 

 

 

 

 

STATE & NUMBER

 

 

 

 

 

 

 

 

 

NAME ON BIRTH CERTIFICATE LAST,

FIRST, MIDDLE

 

STATE OF BIRTH*

COUNTY OF BIRTH

CITY OF BIRTH

 

 

 

 

 

 

 

 

 

 

COUNTY ASSISTANCE OFFICE USE

COUNTY

DISTRICT

 

 

APPLICATION REG # OR RECORD #

BIRTH CERTIFICATE VERIFICATION

 

CLIENT 1 STATE FILE #

DATE FILED

 

 

 

 

SIGNATURE

 

■NO RECORD FOUND

 

CLIENT 2 STATE FILE #

DATE FILED

 

 

 

SIGNATURE

■NO RECORD FOUND

 

CLIENT 3 STATE FILE #

DATE FILED

 

 

 

SIGNATURE

■NO RECORD FOUND

 

CLIENT 4 STATE FILE #

DATE FILED

 

 

 

SIGNATURE

■NO RECORD FOUND

 

CLIENT 5 STATE FILE #

DATE FILED

 

 

 

SIGNATURE

■NO RECORD FOUND

* If born outside of the United States, list the U.S. territory or country of birth.

We keep information you give us CONFIDENTIAL and only use this information to process your application for Medical Assistance.

PA 1809 SG 12/08

Pa 1809 Sg Form isn’t the one you’re looking for?

Related Documents