Snap Form W 113K PDF Details

In an ever-evolving landscape of public assistance and food stamp programs, thorough and updated documentation remains a cornerstone of ensuring that assistance reaches those who need it most. With the latest revisions to the Documentation Requirements and/or Assessment Follow-Up form (W-113K) and the Eligibility Factors and Suggested Documentation Guide (W-119D), announced by the Family Independence Administration on March 22, 2007, a comprehensive effort has been made to streamline the process for applicants. These changes not only reflect a shift towards more accessible and understandable documentation requirements but also aim to enhance the efficiency of the eligibility determination process. Notably, the W-113K form now extends to two pages, incorporating several critical additions such as a "Forms Reminder" and "PA Appointment Reminder" sections, designed to keep applicants informed and engaged in fulfilling their documentation requirements. Furthermore, the form aligns with Local Law 73 by adopting the "LLF" designation, ensuring it meets the necessary translation requirements to aid non-English speakers. The modifications to the W-119D guide further complement these efforts by offering a detailed breakdown of documents acceptable for verifying eligibility, thereby easing the application process for public assistance and food stamps. These revisions promise not only to facilitate a better understanding among applicants but also to promote a more efficient administrative process for staff members at Job Center and Paperless Office System (POS) sites dealing with Non-Public Assistance (NPA) Food Stamp (FS) applications.

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Form NameSnap Form W 113K
Form Length15 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 45 sec
Other namesusted, Declaracin, Expedientes, los

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FAMILY INDEPENDENCE ADMINISTRATION

Seth W. Diamond, Executive Deputy Commissioner

James K. Whelan, Deputy Commissioner

Lisa C. Fitzpatrick, Assistant Deputy Commissioner

Policy, Procedures and Training

Office of Procedures

POLICY BULLETIN #07-36-OPE

(This Policy Bulletin Replaces PB #03-194-OPE)

REVISIONS TO FORMS W-113K AND W-119D

 

Date:

 

Subtopic(s):

 

 

March 22, 2007

 

Forms

 

 

 

 

 

 

This procedure can

This policy bulletin is to inform all Job Center and Paperless Office

 

 

now be accessed on

System (POS) Non-Public Assistance (NPA) Food Stamp (FS) staff

 

 

the FIAweb.

that the Documentation Requirements and/or Assessment Follow-Up

 

 

 

 

 

 

form (W-113K) and the Eligibility Factors and Suggested

 

 

 

Documentation Guide (W-119D) have been revised.

 

 

 

Please note: the W-113K will only be used at Job Center and POS

 

 

 

NPA FS sites. The Notice of Outstanding Required Documentation

 

 

 

(W-120D) will continue to be used at all non-POS NPA FS sites until

 

 

 

further notice.

 

 

 

The W-113K now includes reminders for forms and appointments that

 

 

 

may be needed to complete eligibility requirements. The revised W-

 

 

 

119D will be attached to the W-113K to allow applicants/participants

 

 

 

to see the list of all possible documents that are acceptable to verify

 

 

 

eligibility factors. The W-119D is the local equivalent of the New York

 

 

 

State Office of Temporary and Disability Assistance Documentation

 

 

 

Requirements form (LDSS-2642).

 

 

 

The following revisions apply to the new W-113K:

 

 

 

•

The form is now two pages instead of one.

 

 

 

•

The “LLF” designation has been added to the header, indicating

 

 

 

 

that the form meets Local Law 73 requirements and therefore

 

 

 

 

must be translated into the required languages.

 

 

 

•

The title of the form has been changed from “Documentation

 

 

 

 

Requirements” to “Documentation Requirements and/or

 

 

 

 

Assessment Follow-Up.”

 

 

 

 

 

 

 

 

 

 

 

HAVE QUESTIONS ABOUT THIS PROCEDURE?

Call 718-557-1313 then press 2 at the prompt followed by 765 or

send an e-mail to FIA Call Center

Distribution: X

PB #07-36-OPE

•The first paragraph under the title has been changed to:

“In order to make a determination of or maintain your current eligibility for public assistance (PA) and/or food stamps (FS), you must provide the documents and/or information indicated below, together with this form, by the due date. If you cannot get the required documents/information by the due date, contact your Worker and ask for an extension. If you cannot get the required documents/information at all, contact your Worker immediately, as s/he may assist you in obtaining the required documents/information. The W-119D, which lists the common documents that may be used to verify the eligibility factors, is attached.”

•A “due date” line and checkbox indicating “Must see Worker upon return” have been added.

•A “Forms Reminder” section has been added, a series of Agency forms with checkboxes, which will be completed by the Worker to remind the applicant/participant of documentation needed to complete the eligibility process.

•A “PA Appointment Reminder” section has been added, which consists of appointments that the applicant/participant may be required to participate in to complete the eligibility/recertification process.

•At the top of page 2, checkboxes have been added to identify whether any household members are required to come in to the Office/Center to be finger-imaged, assessed for employment or to sign the public assistance application.

•The Eligibility Factors Chart has been moved to page 2 and the two right-hand columns have been removed.

•The text “Outstanding documentation – see the W-119D for a list of documents that can be used to verify the outstanding eligibility factors” has been added above the chart on page 2.

•The text below the chart was changed to read:

“If this notice does not indicate that you (casehead) must see the Worker upon return, you may submit any required documents/information by mail. However, it remains your responsibility to ensure that the required information reaches the Agency by the prescribed deadline.”

FIA Policy, Procedures and Training

2

Office of Procedures

PB #07-36-OPE

•The bold text was changed to read:

“Failure to submit verification/documentation or contact us on or before the due date may make you ineligible for public assistance and/or food stamps, or may cause a reduction in your public assistance and/or NPA Food Stamp benefits for a specific period of time.”

The following revisions apply to the new W-119D:

•The form has been changed to reflect the flow of categories and subcategories on the LDSS-2642 and has increased from two to three pages.

•On page 1, the “Obtain One” column has been replaced with two columns; the applicant/participant needs one item from the first column or two items from the second column to prove the checked eligibility factor(s). On pages 2 and 3 there is only one column and the applicant/participant will be required to provide one item from the column for each checked factor to prove eligibility.

•On page 1, the statement “(not required for Food Stamps)” was added to the “Marital Status,” “Absence/Death of Parent(s)” and “Absent Parent Information” sections.

•On page 1, for section “Relationship,” the proof “Marriage Certificate was removed and the proofs “Medical Records,” “Applicant’s statement,” “Newspaper Notice,” “Statement from Clergy,” and “Statement form another person” were added.

•On page 2, the subheading, “Private Pension/Annuity” has been added to the “Unearned Income” section.

•On page 2, the subheading “Cash on hand” has been removed from the “Resources” section.

•On page 2, the proof, “Current benefit check” for the subheading “Unemployment Insurance Benefits (UIB) in the section “Unearned Income” has been removed because applicants/participants no longer receive a check (payment is through a direct payment card).

•On page 3, the statement “You must prove rent and other household expenses” has been removed from the “Shelter Expenses” section and replaced with the statement “You must prove how much it costs you to live where you do (you may need to provide separate documentation for each item of shelter expense).

•On page 3, the statement “For FS, for aged/disabled individuals only” was added to the “Medical Expenses” section.

•On page 3, the bulleted item “Medicare prescription drug card” was added as an additional proof for medical expenses.

FIA Policy, Procedures and Training

3

Office of Procedures

PB #07-36-OPE

•On page 3, the statements “If you or anyone living with you is sick or pregnant, you must provide proof” and “(For MA only, resource information is not requested from pregnant women, children and persons eligible for Family Health Plus)” have been added to the “Disabled/Incapacitated/Pregnant” section.

•On page 3, the item “Medical” was removed from the “Unpaid Bills” section.

•On page 3, the statement “(for Safety Net Assistance)” was added under the section head “Past Management” because the program requirements only apply to Safety Net Assistance, not Family Assistance.

•On page 3, four new eligibility factors, “Referral” (with subheading “Employment Service),” “Past Management” (with subheadings “Earned Income” and “Other”), “Potential Benefits” and “Other,” have been added.

Center Directors and NPA FS Office Site Managers must ensure that all previous versions of this form and the multilingual equivalents are removed from circulation and recycled.

Effective Immediately

References:

00-INF-6

05-INF-16

Temporary Assistance Source Book (Chapter 5, page 45) Food Stamp Source Book (Section 17, page 375)

Related Items:

PB #04-10-OPE

PB #04-179-OPE

FIA Policy, Procedures and Training

4

Office of Procedures

Please use Print on Demand to obtain copies of forms.

 

PB #07-36-OPE

Attachments:

 

W-113K

Documentation Requirements and/or

 

Assessment Follow-Up (Rev. 3/22/07)

W-113K (S)

Documentation Requirements and/or

 

Assessment Follow-Up (Spanish) (Rev. 3/22/07)

W-119D

Eligibility Factors and Suggested Documentation

 

Guide (Rev. 3/22/07)

W-119D (S)

Eligibility Factors and Suggested Documentation

 

Guide (Spanish) (Rev. 3/22/07)

FIA Policy, Procedures and Training

5

Office of Procedures

Form W-113K (page 1) LLF

Rev. 3/22/07

Date:

Case Number:

Case Name:

Food Stamp Filing Date:

Subject:

Documentation Requirements and/or Assessment Follow-Up

In order to make a determination of or maintain your current eligibility for public assistance (PA) and/or food stamps (FS), you must provide the documents and/or information indicated below, together with this form, by the due date. If you cannot get the required documents/information by the due date, contact your Worker and ask for an extension. If you cannot get the required documents/information at all, contact your Worker immediately, as s/he may assist you in obtaining the required documents/information. The W-119D, which lists the common documents that may be used to verify the eligibility factors, is attached.

Due Date:

fec Must see Worker upon return.

Forms Reminder (Please return the following Agency form(s), completed and signed where necessary.)

cef M-15 Inquiry Regarding Veteran's Benefits/Allotment

cef W-133D Social Security Number Verification

cef W-146W Verification of Tenant's Rent in Section 8

Housing

cef W-147M Landlord's Statement (Regarding Broker's Fee)

fec W-274U Attestation of Employment as an Informal

Child Care Provider

cef W-451 NYPD – New York Police Department

Report/Referral

PA Appointment Reminder

fec BEV – Bureau of Eligibility Verification Appointment

fec OCSE – Office of Child Support Enforcement Appointment

cef Skills Assessment/Job Placement (Back to Work) Vendor Appointment

cef cef

cef cef

cef

cef

cef

cef

M-30t Verification of Employment

W-146E Request to Pay Rent Arrears in Excess of PA Maximum Shelter Allowance W-147CC Certification of Move Statement

W-147Q Primary Tenant's Statement Regarding Occupancy of Secondary Tenant W-299 Notice to Applicants and Participants Regarding Third Party Health Insurance

SACC – Substance Abuse Case Control

Appointment

WeCARE – Wellness, Comprehensive

Assessment, Rehabilitation and

Employment Medical Provider Appointment

ACS – Agency for Children's Services

Appointment

Form W-113K (page 2) LLF

Human Resources Administration

Rev. 3/22/07

Family Independence Administration

The following household member(s) must return in person for the reason indicated below:

 

fec To be

fec For an

cef To sign the public

 

finger-imaged

employability

 

assistance application

 

 

assessment

 

 

 

 

 

 

 

Name of Household Member

 

 

 

 

 

 

 

 

 

fec To be

fec For an

cef To sign the public

 

finger-imaged

employability

 

assistance application

 

 

assessment

 

 

Name of Household Member

 

 

 

Outstanding documentation – see the W-119D for a list of documents that can be used to verify the outstanding eligibility factors.

ItemsNameEligibility Factor Received

cef

cef

cef

cef

cef

cef

cef

cef

cef

cef

If this notice does not indicate that you (casehead) must see the Worker upon return, you may submit any required documents/information by mail. However, it remains your responsibility to ensure that the required information reaches the Agency by the prescribed deadline.

FAILURE TO SUBMIT VERIFICATION/DOCUMENTATION OR CONTACT US ON OR BEFORE THE DUE DATE MAY MAKE YOU INELIGIBLE FOR PUBLIC ASSISTANCE AND/OR FOOD STAMPS, OR MAY CAUSE A REDUCTION IN YOUR PUBLIC ASSISTANCE AND/OR NPA FOOD STAMP BENEFITS FOR A SPECIFIC PERIOD OF TIME.

Applicant/Participant's Signature

Date

 

 

 

Worker's Signature

Date

Worker's Telephone Number

Form W-113K (S) (page 1) LLF

Rev. 3/22/07

Fecha:

Número del Caso:

Nombre del Caso:

Fecha de Registro de

Cupones para Alimentos:

Tema:

Requisitos Documentales y/o Seguimiento de Evaluación

Para llegar a una determinación de su actual estado de elegibilidad de asistencia pública y/o cupones para alimentos o para mantener dicha elegibilidad, usted debe proporcionar los documentos y/o datos indicados más abajo, junto con el presente formulario, a más tardar en la fecha de presentación. Si no puede conseguir los documentos/datos necesarios para dicha fecha, comuníquese con su Trabajador y pida una extensión. Si le es imposible conseguir los documentos/datos necesarios comuníquese con su Trabajador de inmediato, puesto que éste puede ayudarle a obtener los documentos/datos necesarios. El W-119D (S), que lista los documentos comunes que pueden servir para comprobar los factores de elegibilidad, se encuentra adjunto.

Fecha de Presentación:

fec Tiene que reunirse con el Trabajador al regresar.

Recordatorio de Formularios (Favor de devolver el/los siguiente(s) formulario(s) de la Agencia, llenado(s) y firmado(s) si necesario.)

cef M-15 Inquiry Regarding Veteran's Benefits/Allotment cef W-133D Social Security Number Verification

cef W-146W Verification of Tenant's Rent in Section 8 Housing

cef W-147M Landlord's Statement (Regarding Broker's Fee)

fec W-274U (S) Atestación de Empleo como Proveedor de Cuidado Infantil Informal

cef W-451 NYPD – New York Police Department Report/Referral

cef cef

cef

cef

cef

M-30t Verification of Employment

W-146E Request to Pay Rent Arrears in Excess of PA Maximum Shelter Allowance W-147CC (S) Certificación Respecto a Declaración de Mudanza

W-147Q (S) Declaración del Inquilino Principal con Respecto a la Ocupación del Inquilino Secundario

W-299 (S) Aviso a Solicitantes y Participantes con Respecto a Seguros de Salud de Tercera Persona

Recordatorio de Cita de Asistencia Pública

fec BEV – (Bureau of Eligibility Verification)

Cita en la Oficina de Verificación de Elegibilidad fec OCSE – (Office of Child Support Enforcement)

Cita en la Oficina de Aplicación de Manutención de Niños

cef Cita con el Contratista de Regreso al Trabajo (Back to Work) de Evaluación de Habilidades/Colocación

cef

cef

cef

SACC – (Substance Abuse Case Control) Cita de Control de Caso de Abuso

de Sustancias

WeCARE – (Wellness, Comprehensive Assessment, Rehabilitation and Employment) Cita con el Proveedor Médico de Bienestar, Evaluación Total, Rehabilitación y Empleo

ACS – (Administration for Children's Services) Cita en la Agencia de Servicios al Niño

Form W-113K (S) (page 2) LLF

Human Resources Administration

Rev. 3/22/07

Family Independence Administration

El/los siguiente(s) miembro(s) del hogar tiene(n) que regresar en persona por la razón indicada más abajo:

cef Para que se le tomen imágenes digitales

Nombre del Miembro del Hogar

fec Para una

fec Para firmar la solicitud

evaluación

de asistencia pública

de empleabilidad

 

cef Para que se le tomen imágenes digitales

Nombre del Miembro del Hogar

fec Para una

fec Para firmar la solicitud

evaluación

de asistencia pública

de empleabilidad

 

Documentación pendiente – vea el W-119D (S) para una lista de documentos que pueden usarse para verificar los factores de elegibilidad pendiente.

ArtículosNombreFactor de Eligibilidad Recibidos

cef

cef

cef

cef

cef

cef

fec fec

cef

cef

Si este aviso no indica que usted (jefe del caso) tiene que reunirse con su Trabajador al regresar, puede enviar los documentos/información por correo. Sin embargo, sigue siendo su reponsabilidad que la información requerida llegue a la Agencia a más tardar para la fecha de entrega.

EL NO PRESENTAR VERIFICACIÓN/DOCUMENTACIÓN O NO COMUNICARSE CON NOSOTROS A MÁS TARDAR EN LA FECHA DE PRESENTACIÓN PUEDE RESULTAR EN LA PÉRDIDA DE SU ELEGIBILIDAD RESPECTO A ASISTENCIA PÚBLICA Y/O CUPONES PARA ALIMENTOS, O PUEDE CAUSARLE UNA REDUCCIÓN EN SUS BENEFICIOS DE ASISTENCIA PÚBLICA Y/O BENEFICIOS NPA DE CUPONES PARA ALIMENTOS DURANTE UN PERÍODO DE TIEMPO ESPECÍFICO.

Firma del Solicitante/Participante

Fecha

 

 

 

Firma del Trabajador

Fecha

Número de Teléfono del Trabajador

Form W-119D (page 1) LLF (LDSS-2642)

Rev. 3/22/07

Eligibility Factors and Suggested Documentation Guide

Eligibility Factor

To prove this factor, provide:

 

 

Eligibility Factor

To prove this factor, provide:

 

 

 

ONE of the following

OR

TWO* of the following:

 

ONE of the following

OR

TWO* of the following:

 

 

 

 

 

 

 

 

 

 

 

 

Identity

•

Photo I.D.

 

•

Statement from another

Absence/Death of Parent(s)

•

Death certificate

 

•

Newspaper notice

You must establish identity for each

•

Driver's license

 

•

person

If the parent(s) of any child in your

•

Survivor's benefit

 

•

Insurance company

•

U.S. passport

 

Birth/baptismal

 

records

 

 

records

person listed.

 

 

certificate

home is not living with you, you must

•

 

•

•

Naturalization Certificate

 

Hospital records

 

Institutional records

 

•

prove this.

 

 

Validated Social

•

VA or military records

 

•

Agency case records

 

•

Hospital/Doctor's Records

 

 

 

Security number

 

 

 

 

(not required for Food Stamps)

•

Divorce papers

 

 

and burial payment

 

•

Adoption papers

 

 

 

 

 

 

 

 

 

•

Proof of remarriage

 

 

files

 

 

 

 

 

 

 

 

•

 

 

 

 

 

 

 

 

 

 

Statement from

 

 

 

 

 

 

 

 

 

 

 

another person

 

 

 

 

 

 

 

 

 

 

 

Marital Status

•

Marriage/Death

 

•

Statement from clergy

Absent Parent Information

•

Pay stubs

 

NA

You must prove if you are married,

•

certificates

 

•

Census records

If the parent(s) of any child in your

•

Tax returns

 

 

 

Separation agreement

 

•

Newspaper notice

• Social Security or VA

 

 

 

divorced, separated or widowed.

 

home is not living with you, you must

 

 

 

•

Divorce decree

 

•

Statement from another

 

records

 

 

 

 

 

provide information you have about

•

 

 

 

(not required for Food Stamps)

•

Social Security records

 

person

Monetary determination

 

 

 

the individual’s: name, address,

 

 

 

•

Veterans Administration

 

 

 

letters

 

 

 

 

 

 

Social Security number, birth date,

•

 

 

 

 

 

(VA) records

 

 

 

ID cards (health

 

 

 

 

 

 

 

 

employment.

 

 

 

 

 

 

 

 

 

 

insurance)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(not required for Food Stamps)

•

Driver's license or

 

 

 

 

 

 

 

 

 

 

 

registration

 

 

 

 

 

 

 

 

 

 

 

 

Relationship

• Birth certificate (long form)

•

Applicant’s statement

Social Security Number

•

Social Security card

 

NA

If you are related to a child in the

• Adoption papers/records

•

Newspaper Notice

For Temporary Assistance, Food

•

Official correspondence

 

 

• Court records

 

•

 

 

 

household, you must prove the

 

Statement from Clergy

Stamp Benefits and Medical

 

from SSA

 

 

 

• Medical records

 

 

 

 

 

relationship.

 

•

Statement from another

Assistance only, you do not have to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

person

provide proof of your Social Security

 

 

 

 

 

 

 

 

 

 

 

Number (SSN) unless the SSN you

A Social Security number is

 

 

 

•

 

 

•

 

 

 

Residence

Statement from

 

Statement from another

give does not match with SSA’s

not required for aliens who

 

 

 

records or cannot be verified by the

 

 

You must verify your place of

 

landlord/primary tenant

 

person

are seeking Medical

 

 

 

•

Current rent receipt or

 

•

Current mail

agency.

Assistance for emergency

 

 

residence (if applicable).

 

lease

 

•

School records

 

treatment only or are

 

 

 

 

•

 

 

 

 

 

 

Mortgage records

 

 

 

 

Medical Assistance–only

 

 

 

 

 

 

 

 

 

 

applicants who are

 

 

 

 

 

 

 

 

 

 

pregnant.

 

 

 

Household Composition/Size

•

Statement from

 

•

Statements from other

 

 

 

 

 

 

 

 

 

 

 

You must prove who is living with you.

 

nonrelative landlord

 

 

persons

 

 

 

 

 

 

•

School records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Age

•

Birth certificate

 

•

Insurance policy

 

 

 

 

 

 

You must prove the age of each

•

Baptismal

 

•

Census records

 

 

 

 

 

 

 

records/certificate

 

•

School records

 

 

 

 

 

 

person applying for assistance, where

•

 

 

 

 

 

 

 

Hospital records

 

•

Statement from another

 

 

 

 

 

 

appropriate.

 

 

 

 

 

 

 

•

Adoption papers/records

 

person

 

 

 

 

 

 

 

•

 

 

 

 

 

 

 

•

Naturalization certificate

Physician statement

 

 

 

 

 

 

 

•

Driver's license

 

•

Official correspondence

 

 

 

 

 

 

 

 

 

 

 

from SSA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* If you are applying for Food Stamp Benefits or Medical Assistance only, you need to bring only one form for each eligibility factor checked.

Form W-119D (page 2) LLF (LDSS-2642)

 

 

 

 

Human Resources Administration

Rev. 3/22/07

 

Eligibility Factors and Suggested Documentation Guide

 

Family Independence Administration

 

 

 

 

 

 

 

 

Eligibility Factor

To prove this factor, provide ONE of the

Eligibility Factor

To prove this factor, provide ONE of the

 

following:

 

following:

Citizenship or Current Alien Status

•

Birth certificate

Unearned Income (continued)

•

 

Status – U.S. citizens are eligible for Temporary

•

Baptismal certificate/records

Veterans' Benefits

Veterans Administration official

•

Hospital records

 

correspondence

Assistance, food stamps and medical

 

 

•

U.S. passport

 

•

Current award certificate/letter

assistance. Aliens must be in satisfactory

 

•

Military service records

 

•

Current benefit check

immigration status in order to be eligible for

 

•

Naturalization certificate

 

 

 

Temporary Assistance, food stamps and

 

 

 

•

USCIS documentation

 

 

 

medical assistance. Immigration status is not an

 

•

Award certificate/letter

•

 

Workers' Compensation

eligibility factor for pregnant women or

Evidence of continuous U.S. residence since

•

Check stub

 

immigrant children applying for Child Health

 

prior to 1/1/72

 

•

Statement from school

Plus B. Undocumented immigrants and

 

 

 

 

 

Education Grants and Loans

•

Statement from bank

temporary nonimmigrants are eligible only for

 

 

 

 

 

• Statement from agency administering

the treatment of an emergency medical

 

 

 

condition.

 

 

 

 

grant/award letter

 

 

 

Interest/Dividends/Royalties

• Statement from bank or credit union

 

 

 

•

Statement from broker/financial

 

 

 

 

 

 

 

 

 

institution/agent

 

 

 

Private Pension/Annuity

•

Current award letter

 

 

 

•

Current benefit check

Earned Income

•

Current wage stubs and statements of tips

 

 

•

Official correspondence from source of

From employer

•

Pay envelopes

 

•

income

 

•

Contact with employer

 

Contact with source of income

 

•

On letterhead, rate of pay per hour; hours

Other Unearned Income

•

Current contribution check

 

 

 

 

 

worked per week; date of first pay, if new; and

 

 

 

 

 

 

 

 

 

employer’s phone number

 

 

 

 

•

Business records

 

 

 

 

From self-employment

•

Tax records

 

 

 

 

 

Resources

•

Statement from household

 

•

Records and related materials concerning

 

 

 

(For Medical Assistance only, resource

•

Statement from nursing home

 

 

self-employment earnings and expenses

 

 

•

 

information is not requested from pregnant

 

 

 

Current income tax return

 

women, children under the age of 19 and

 

 

 

 

 

 

persons eligible for Family Health Plus.)

 

 

Income from rent or room/board

•

Current contribution check

 

Bank Accounts: Checking, Savings,

•

Current bank records

 

•

Statement from roomer, boarder, tenant

 

 

 

Retirement (IRA and Keogh), Credit Union

•

 

 

•

Income tax records

 

Current credit union records

 

 

 

 

 

 

 

Stocks, Bonds, Certificates and Mutual Funds

•

Stock/bond certificate

Unearned Income

•

Statement from Family Court

 

 

•

Statement from financial institution

• Statement from person paying support

 

 

 

 

 

 

Life Insurance

•

Insurance policy

 

•

Check stubs

 

Child Support

 

 

•

Statement from insurance company

•

Official correspondence from the Child

 

 

 

 

 

•

 

 

 

Support Enforcement Unit

 

 

Bank records

Unemployment Insurance Benefits (UIB)

•

Current award certificate

 

Burial Trust or Fund, Burial Plot or Funeral

•

Burial agreement

 

Agreement

•

Burial plot deed

 

•

Official correspondence with New York

 

 

 

•

Statement from funeral director

 

 

State Department of Labor

 

 

 

 

 

 

Income Tax Refund or Earned Income Tax

•

Refund or EITC check

Social Security benefits (including SSI)

•

Current award certificate/letter

 

Credit (EITC)

•

Statement from tax office

 

•

Current benefit check

 

 

 

 

 

 

•

Deed

 

•

Official correspondence from SSA

 

Real Estate other than Residence

 

 

•

Statement from real estate broker

 

 

 

 

 

 

 

 

 

 

•

Broker’s appraisal/estimate of

 

 

 

 

 

 

current value by broker

Form W-119D (page 3) LLF (LDSS-2642)

 

 

 

Human Resources Administration

Rev. 3/22/07

 

 

 

Family Independence Administration2

 

 

Eligibility Factors and Suggested Documentation Guide

 

 

 

 

 

 

Eligibility Factor

 

To prove this factor, provide ONE of the following:

Eligibility Factor

To prove this factor, provide ONE of the following:

 

 

 

 

 

Resources (continued)

•

Registration (older models)

Unpaid Bills

• Copy of each bill showing amount owed,

Motor Vehicle

•

Title of ownership

Rent, Utility

period of services and provider

•

Appraisal of current value by dealer

 

 

 

 

 

•

Financing data

 

 

 

 

 

 

 

Lump Sum Payment

•

Statement from the source of payment

Referral

• Statement from provider of treatment

•

Lump sum check

 

 

 

Drug/Alcohol Treatment Program

 

 

 

 

 

 

 

 

 

 

Employment Service

• Statement from employment service

 

 

 

 

 

 

•

 

 

 

 

Other Resources

Household statement of current value

Other Expenses/Dependent Care

•

Court order

•

Sales slips

• Statement from day care center or other child

 

Cost

 

•

 

 

care provider

 

Insurance appraisal

You must provide proof if you pay court-

 

 

• Statement from aide or attendant

 

 

 

ordered support, child care, recurring loans

 

 

 

• Canceled checks or receipts

 

 

 

or for the services of a home health aide or

 

 

 

attendant.

 

 

Shelter Expenses

•

Current rent receipt/lease/mortgage book/records

School Attendance

•

School records (current report card)

 

•

Property and school tax records

You must prove who is in school.

• Statement from school or higher education

You must prove how much it costs you to

•

Landlord statement

 

 

institution

live where you do (You may need to provide

•

Sewer and water bills

 

 

 

 

 

separate documentation for each item of

•

Garbage/trash collection bills or receipts

 

 

 

shelter expense.)

•

Homeowner's insurance records

 

 

 

Medical Assistance does not require

•

Fuel bills/shut-off notice

 

 

 

documentation of shelter expenses.

•

Nonheating utility bills

 

 

 

•Telephone bills (or a statement from the household that the expense is incurred)

Medical Expenses

•

Statement from provider of health insurance

Past Management

• Letter from employer giving dates of

For FS, for aged/disabled individuals only

•

premiums

(For Safety Net Assistance)

employment, amount earned and

Copies of medical bills (paid and unpaid)

 

Earned Income

reason(s) for leaving

 

•

Medicare prescription drug card

 

 

 

 

 

 

 

 

Other

If you were not supporting yourself from

 

 

 

 

employment/earned income, please bring

 

 

 

 

 

 

 

 

 

(For public assistance only)

verification of how you were able to support

Health Insurance

•

Insurance policy/card

 

yourself in the past such as:

•

Statement from provider of coverage

 

• Bankbook/bank statement

 

 

 

 

• Verification of expiration of benefits

If you or anyone applying has health

•

Medicare card

 

 

(workers’ compensation, disability,

insurance coverage (even if paid for by

•

Separation or divorce agreement with court-ordered

 

someone else), you must prove this.

 

health coverage

 

Social Security, UIB, etc.)

 

 

• Statement from person(s) who provided

 

 

 

 

 

 

 

 

 

 

support

 

 

 

 

 

 

Disabled/Incapacitated/Pregnant

•

Statement from doctor, clinic or hospital verifying

Potential Benefits

Statement from person(s) who provided support

If you or anyone living with you is sick or

•

pregnancy, expected date of birth

 

• If you or anyone in the household has

Statement from medical professional

 

applied for and been denied or has been

pregnant, you must provide proof.

 

•

Proof of SSA/SSI benefits for disability/blindness

 

accepted for benefits from any of the

 

 

(For MA only, resource information is not

 

 

 

 

following sources, bring the award letter,

 

 

 

 

check or other correspondence: Social

requested from pregnant women, children

 

 

 

 

 

 

 

 

Security, court payments, SSI, veteran’s

and persons eligible for Family Health Plus)

 

 

 

 

 

 

 

 

benefits, workers’ compensation, union

 

 

 

 

 

 

 

 

 

 

benefits, pension, military allotment,

 

 

 

 

 

railroad retirement, NYS disability or

 

 

 

 

 

other source

 

 

 

 

Other

 

Form W-119D (S) (page 1) LLF (LDSS-2642)

Rev. 3/22/07

Guía de Factores de Elegibilidad y Documentación Sugerida

Factor de Elegibilidad

Para probar este factor, provea:

O

DOS* de los siguientes:

Factor de Elegibilidad

Para probar este factor, provea:

DOS* de los siguientes:

 

UNO de los siguientes

 

UNO de los siguientes

O

 

 

 

 

 

 

 

 

 

 

 

 

Identidad

•

Identificación con foto

 

•

Declaración por parte

Ausencia/Muerte del

•

Certificado de

 

•

Anuncio del periódico

 

•

Licencia de conducir

 

 

de otra persona

Padre o de la Madre

•

defunción

 

•

Expedientes de la

Usted tiene que establecer la

 

•

Acta de nacimiento/

Expedientes de

 

•

Pasaporte de EE.UU.

 

Si el padre o la madre o

 

 

compañía de seguros

identidad de cada persona

 

 

bautismo

 

beneficios de

 

•

Expedientes

•

Certificado de Naturalización

•

ambos de cualquier niño(a)

 

 

listada.

Número de Seguro

 

sobrevivientes

 

 

institucionales

•

Expedientes

 

en su hogar no vive con

•

 

 

 

 

 

Social con validación

Expedientes

 

•

Expedientes de caso

 

 

Hospitalarios/Médicos

 

 

usted, tiene que probarlo.

 

hospitalarios

 

 

 

 

 

 

 

 

 

de la Agencia y de pagos

 

 

 

 

 

 

•

 

 

 

•

 

 

 

 

 

Expedientes militares o de la

 

 

Documentos de adopción

 

 

 

(No se requiere para

 

de entierro

 

 

 

 

 

 

Cupones para Alimentos)

 

Administración de Veteranos

• Declaración por parte de

 

 

 

 

 

 

 

 

(VA)

 

 

otra persona

 

 

 

 

 

 

 

•

Documentos de divorcio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Prueba de nuevo

 

 

 

 

 

 

 

 

 

 

 

matrimonio

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Estado Civil

•

Certificado de

 

•

Declaración por parte

Información

•

Talones de paga

 

No corresponde

Usted tiene que probar si está

•

Defunción/Matrimonio

 

•

de un clérigo

Respecto al Padre o

•

Declaración de impuestos

 

 

Acuerdo de separación

 

Expedientes del censo

•

Documentos de Seguro

 

 

 

 

Madre Ausente

 

 

 

casado(a), divorciado(a),

 

 

 

 

•

Sentencia de divorcio

 

•

Anuncio del periódico

 

Social o de la

 

 

 

separado(a), o enviudado(a).

 

 

 

 

 

 

• Registros de Seguro Social

 

•

Declaración por parte

Si el padre o la madre de

 

Administración

 

 

 

 

 

 

de otra persona

cualquier niño(a) en su hogar

 

 

 

 

(No se requiere para Cupones

•

Registros de la Administración

 

 

de Veteranos

 

 

 

para Alimentos)

 

de Veteranos (VA)

 

 

 

no vive con usted, usted

 

(Veteran’s

 

 

 

 

 

 

 

 

 

tendrá que proporcionar la

 

Administration – VA)

 

 

 

 

 

 

 

 

 

información que tenga acerca

•

Cartas de determinación

 

 

 

 

•

 

 

•

 

 

 

 

Parentesco

Acta de nacimiento (versión

 

Declaración del solicitante

de esas personas: nombre,

 

monetaria

 

 

 

 

•

larga)

 

•

Anuncio del periódico

dirección, número de Seguro

•

Tarjetas de

 

 

 

Si usted es familiar de un niño

Documentos/registros de

 

Social, fecha de nacimiento,

 

 

 

 

• Declaración de un clérigo

 

Identificación (seguro

 

 

 

en el hogar, tiene que probar el

 

adopción

 

empleo.

 

 

 

 

•

 

 

médico)

 

 

 

Actas judiciales

 

• Declaración por parte de

 

 

 

 

parentesco.

 

 

 

 

 

 

 

(No se requiere para

• Licencia de conducir o

 

 

 

•

 

 

 

 

 

 

Expedientes médicos

 

 

otra persona

 

 

 

 

 

 

Cupones para Alimentos)

 

matrícula

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Domicilio

•

Declaración del

 

•

Declaración por parte

 

 

 

 

 

 

Usted tiene que comprobar su

 

casero/inquilino principal

 

 

de otra persona

 

 

 

 

 

 

•

Recibo actual de alquiler o

 

•

Correspondencia actual

 

 

 

 

 

 

domicilio (si corresponde).

 

contrato del mismo

 

•

Expedientes escolares

 

 

 

 

 

 

 

•

 

 

 

 

 

 

 

 

Documentos hipotecarios

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Miembros/Tamaño del

•

Declaración del casero que no

•

Declaracion por parte

Número de Seguro

•

Tarjeta de Seguro Social

 

No corresponde

Hogar

 

es pariente

 

 

de otras personas

Social

•

 

 

 

 

•

 

 

 

 

Correspondencia oficial

 

 

 

Usted tiene que probar quién

Expedientes escolares

 

 

 

 

 

 

 

 

 

 

Para Asistencia Temporal,

 

de parte de la SSA

 

 

 

está viviendo con usted.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cupones para Alimentos y

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sólo Asistencia Médica,

El número de Seguro Social no

 

 

Edad

•

 

 

•

 

 

 

Acta de nacimiento

 

Póliza de seguro

usted no tiene que

se requiere a extranjeros que

 

 

Usted tiene que probar la edad

•

Certificado/documentos de

 

•

Expedientes del censo

proporcionar prueba de su

soliciten Asistencia Médica

 

 

 

 

bautismo

 

•

Expedientes escolares

Número de Seguro Social, a

sólo para emergencia o sean

 

 

de cada persona que solicite

•

 

 

 

Expedientes hospitalarios

 

•

Declaración por parte

menos que el Número de

solicitantes embarazadas de

 

 

asistencia, cuando

 

 

 

•

Documentos/registros de

 

 

de otra persona

Seguro Social que

sólo Asistencia Médica.

 

 

 

corresponda.

 

•

 

 

 

 

adopción

 

Declaración de médico

proporcione no corresponda

 

 

 

 

 

 

•

 

 

 

 

 

 

 

Certificado de naturalización

 

•

Correspondencia oficial

con los expedientes de la

 

 

 

 

 

 

•

Licencia de conducir

 

 

por parte de la

Administración del Seguro

 

 

 

 

 

 

 

 

 

 

Administración del

Social (Social Security

 

 

 

 

 

 

 

 

 

 

Seguro Social

Administration – SSA) o no

 

 

 

 

 

 

 

 

 

 

(Social Security

pueda ser verificado por la

 

 

 

 

 

 

 

 

 

 

Administration – SSA)

 

 

 

 

 

 

 

 

 

 

agencia.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Si usted está solicitando sólo Beneficios de Cupones para Alimentos o Asistencia Médica, tiene que traer sólo un documento para cada factor de elegibilidad marcado.

Form W-119D (S) (page 2) LLF (LDSS-2642)

Guía de Factores de Elegibilidad y Documentación Sugerida

Rev. 3/22/07

Human Resources Administration Family Independence Administration

Factor de Elegibilidad

 

Para probar este factor, provea UNO de los siguientes:

 

 

Factor de Elegibilidad

Para probar este factor, provea UNO de

 

 

 

los siguientes:

 

 

 

 

 

 

 

Ciudadanía o Estado

•

Acta de nacimiento

 

 

Ingreso No Salarial (continuación)

• Correspondencia oficial de la

•

Certificado/documentos de bautismo

 

 

 

Administración de Veteranos

Actual de Extranjero

 

 

Beneficios de Veteranos

•

•

Expedientes hospitalarios

 

 

Carta/certificado de asignación actual

 

 

 

Estado – Los ciudadanos de

•

Pasaporte de EE.UU.

 

 

 

 

• Cheque de beneficio actual

EE.UU. tienen derecho a Asistencia

•

Expedientes de servicio militar

 

 

 

 

• Carta/certificado de asignación actual

Temporal, cupones para alimentos,

•

Certificado de naturalización

 

 

 

 

y asistencia médica. Los extranjeros

•

Documentación de USCIS

 

 

 

 

•

Talón de paga

deben tener un estado satisfactorio

 

 

 

 

•

Prueba de residencia continua en EE.UU. desde antes de

 

 

Compensación Laboral

•

Declaración por parte de la escuela

de inmigrante para ser elegible para

 

 

 

1/1/72

 

 

 

 

• Declaración por parte del banco

Asistencia Temporal, cupones para

 

 

 

Subsidios y Préstamos Educacionales

 

 

 

 

• Declaración de la agencia que

alimentos y asistencia médica. El

 

 

 

 

 

 

estado migratorio no se toma en

 

 

 

 

 

 

 

administra subsidio/carta de beneficio

cuenta en casos de mujeres

 

 

 

 

 

 

• Declaración del banco o cooperativa

embarazadas o niños inmigrantes

 

 

 

 

 

 

• Declaración del corredor de

que estén solicitando Child Health

 

 

 

 

Intereses/Dividendos/Regalías

 

bolsa/institución financiera

Plus B. Los inmigrantes

 

 

 

 

 

 

 

 

 

• Carta de beneficio actual

 

 

 

 

 

 

indocumentados y los no

 

 

 

 

 

 

 

 

 

 

 

 

• Cheque de beneficio actual

inmigrantes temporarios sólo tienen

 

 

 

 

 

 

 

 

 

 

Pensión/Anualidad Privada

•

Correspondencia oficial por parte de

derecho a tratamiento en casos de

 

 

 

 

 

 

 

 

 

 

 

la fuente de ingreso

emergencias médicas.

 

 

 

 

 

 

 

 

 

 

 

 

 

• Contacto con la fuente de ingreso

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Cheque de contribución actual

 

 

 

 

 

Otros Ingresos no Salariales

 

 

 

 

 

 

 

 

 

 

 

Ingreso Salarial

• Talones salariales actuales y declaración de propinas

 

 

 

 

 

 

 

•

Sobres de paga

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

De parte del empleador

• Contacto con el empleador

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• En carta con membrete, paga por hora; número de horas

 

 

Recursos

 

 

 

 

 

 

 

 

 

 

 

trabajadas por semana; fecha del primer pago, si el trabajo

 

 

• Declaración por parte del hogar

 

 

(Para sólo Asistencia Médica, información

 

 

es nuevo; y número de teléfono del empleador

• Declaración por parte del hogar para

 

•

Registros comerciales

respecto a recursos no se requiere para

 

 

ancianos

De empleo por cuenta propia

•

Expedientes de impuestos

embarazadas, niños menores de 19 años de

 

 

 

 

 

•

Toda documentación o material relacionado con las

edad y personas elegibles para Family

•

Registros bancarios actuales

 

Health Plus.)

 

 

ganancias y gastos de trabajo por cuenta propia

• Registros actuales de cooperativa de

 

•

 

 

Cuentas bancarias: Corriente, de Ahorros,

 

Declaración actual de impuestos

 

 

 

crédito

Ingresos de alquiler o por

•

Cheque de contribución actual

Retiro (IRA y Keogh), Cooperativa de Crédito

 

 

 

servicios a huéspedes

•

Declaración del inquilino o huesped

 

 

 

 

•

Certificado de acciones/bonos

•

Expedientes de impuestos

 

 

 

 

 

 

 

Acciones, Bonos, Certificados y Fondos de

•

Declaración de institución financiera

 

 

 

 

 

Ingreso No Salarial

•

Declaración por parte del Tribunal Familiar

Inversión

 

 

 

 

 

 

 

•

Póliza de seguro

•

Declaración por parte de la persona que proporciona

 

 

Seguro de Vida

 

 

 

• Declaración de la compañía de seguros

 

 

manutención

 

 

 

 

 

 

 

 

 

 

 

 

 

Manutención de Niños

•

Talones de paga

 

 

Fideicomiso o Fondo de Entierro,

•

Expedientes bancarios

•

 

 

 

 

Correspondencia oficial de parte de Unidad de

Terreno de Entierro o Acuerdo

•

Acuerdo de entierro

 

 

Aplicación de Manutención de Niños

Funerario

• Escritura de terreno de entierro

 

 

 

• Declaración del director funerario

Beneficios de Seguro de

 

 

 

 

 

 

• Certificado de asignación actual

 

 

 

 

 

 

 

Desempleo (Unemployment

 

 

Reembolso o Crédito de Impuestos

•

 

 

•

Correspondencia oficial del Departamento de Trabajo del

 

 

Cheque de reembolso o EITC

Insurance Benefits – UIB)

 

 

 

Estado de Nueva York

(Earned Income Tax Credit – EITC)

• Declaración de la agencia de impuestos

 

 

 

 

 

 

 

 

•

Certificado/carta de asignación actual

 

 

 

 

•

Escritura

Beneficios de Seguro Social

 

 

 

 

• Declaración del agente de bienes

•

 

 

 

 

 

(incluyendo SSI)

Cheque de beneficios actuales

 

 

Bienes Raíces aparte del Domicilio

 

raíces

 

•

Correspondencia oficial de parte de SSA

 

 

 

 

• Tasación/estimación del valor actual

 

 

 

 

 

 

 

 

por parte del agente

 

 

 

 

 

 

 

 

 

 

Form W-119D (S) (page 3) LLF (LDSS-2642)

 

Guía de Factores de Elegibilidad y Documentación Sugerida

 

Human Resources Administration

Rev. 3/22/07

 

 

Family Independence Administration1

Factor de Elegibilidad

Para probar este factor, provea UNO de los siguientes:

Factor de Elegibilidad

Para probar este factor, provea UNO de los

siguientes:

 

 

 

 

 

 

 

 

 

 

Recursos (continuación)

 

 

Cuentas por Pagar

• Copia de cada cuenta en que figure la

 

 

 

 

•

Matrícula (modelos viejos)

Alquiler, servicios de electricidad y/o gas

 

cantidad que debe, período de servicio y

 

 

 

proveedor del mismo

Vehículo Motor

•

Título

 

 

 

Envío

• Declaración por parte del proveedor de

 

•

Tasación de valor actual del distribuidor

 

Programa de Tratamiento de

 

Tratamiento

 

•

 

 

 

Datos de financiamiento

Drogadicción/Alcoholismo

 

 

 

 

 

 

 

Pago de Suma Total

•

Declaración de la fuente de pago

Servicio de Empleo

• Declaración por parte del servicio de empleo

 

•

Cheque de pago total

 

 

 

 

 

 

Otros Recursos

 

 

Otros Gastos/Costo del Cuidado de

•

Decreto judicial

 

•

Declaración del hogar de valor actual

Dependientes

• Declaración por parte de la guardería de

 

•

Recibos de ventas

Si usted paga manutención de niños por

 

niños u otro proveedor de cuidado

 

• Declaración por parte del ayudante de salud

 

•

Tasación del seguro

decreto judicial, cuidado infantil, deudas

 

recurrentes, o para los servicios de un

• Cheques o recibos cancelados

 

 

 

 

 

 

ayudante de salud doméstico, tiene que

 

 

Gastos de Alojamiento

•

Recibo/contrato de alquiler/documentos

 

 

proporcionar prueba de dichos pagos.

 

 

 

hipotecarios actuales

 

 

Usted tiene que probar cuánto le cuesta

•

Asistencia Escolar

• Registros escolares (libreta de notas actual)

Registros de propiedad y registros de

vivir en su domicilio. (Puede ser que tenga

 

Impuestos escolares

Usted tiene que probrar quién asiste a la

• La declaración por parte de la escuela o

que proporcionar documentación por

•

Declaración del casero

 

universidad

escuela

 

separado para cada partida de los gastos

•

Cuentas de alcantarilla y de agua

 

 

 

 

 

de alojamiento.)

•

Recibos o cuentas de recogida de basura

 

 

 

 

• Carta por parte del empleador con fechas de

La Asistencia Médica no requiere

•

Expedientes de seguro de propietario o

Administración Previa

documentación de gastos de

 

V ivienda

(Para Asistencia Red de Seguridad [Safety Net

 

empleo, sueldo y razón(es) por haber dejado

alojamiento.

•

Facturas de combustible/aviso de

 

el trabajo

Assistance])

Si usted no se estaba manteniendo con

 

 

desconección

 

 

 

empleo/ingreso salarial, favor de traer

 

•

Facturas de electricidad y/o gas no

 

 

 

comprobantes de cómo pudo mantenerse en el

 

 

usados para calefacción

 

 

 

 

pasado, tales como:

 

•

Cuentas de teléfono (o una declaración

Ingreso salarial

 

•

Talón/estado de cuenta

 

 

del hogar respecto al gasto incurrido)

 

 

 

 

• Comprobante de vencimiento de

 

 

 

 

Gastos Médicos

•

Declaración por parte de quien paga

Otro

 

Beneficios (compensación de

 

cuotas de gastos médicos

 

 

Para FS, sólo para ancianos/incapacitados

•

(Sólo para asistencia pública)

 

trabajadores, seguro de

Copias de cuentas médicas (pagadas o por pagar)

 

 

incapacitados, Seguro Social,

 

•

Tarjeta para recetas de Medicare

 

 

UIB, etc.)

 

 

 

 

• Declaración por parte de

Seguro Médico

 

 

 

•

Tarjeta/póliza de seguros

 

 

persona(s) que brindaba(n)

 

 

 

apoyo económico

Si usted o cualquier otro solicitante tiene

•

Declaración por parte de quien provee

 

 

Posibles Beneficios

Declaración por parte de la(s) persona(s) que

cobertura médica (aún si pagada por otra

 

cobertura

 

brindaba(n) apoyo económico

persona), tiene que probarlo.

•

Tarjeta para recetas de Medicare

 

 

• Si usted o alguien en el hogar ha solicitado

 

•

Acuerdo de separación o divorcio con

 

 

 

 

y ha recibido o se le ha negado beneficios

 

 

cobertura médica por decreto judicial

 

 

 

 

 

 

de cualquiera de las fuentes a continuación,

 

 

 

 

 

 

 

 

 

 

traiga la carta de asignación, cheque u otra

Incapacitado(a)/Embarazada

 

 

 

 

•

Declaración del médico, clínica u hospital

 

 

correspondencia: Seguro Social, pagos del

Si usted o cualquier persona que viva con

 

 

tribunal, SSI, beneficios de veteranos,

 

que compruebe embarazo, fecha de

 

 

compensación laboral, beneficios de

usted está enfermo(a) o embarazada, tiene

•

nacimiento proyectada

 

 

sindicato, pensión, asignación militar, retiro

que proporcionar prueba de ello.

Declaración de profesional médico

 

 

ferroviario, beneficios para inc apacitados

(Sólo para MA, no se requiere información

•

Prueba de SSA/SSI por incapacidad/ceguera

 

 

del estado de Nueva York u otra fuente

sobre recursos por parte de mujeres

 

 

 

 

 

embarazadas, niños y personas elegibles

 

 

 

 

 

para Family Health Plus)

 

 

 

 

 

 

 

Otro

 

 

 

 

 

 

 

 

 

 

 

 

 

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