Il 444-4765 - Redetermination Application
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1
2State of Illinois
Department of Human Services
REDETERMINATION APPLICATION
2(Permanent)
Case I.D. Number:
Date of Notice:
Caseload Number:
Phone:
Write your name and address in the space below if not on form:
. To keep getting benefits on your regular availability date, complete, sign and:
Your SNAP benefits will end
return this form in the enclosed envelope by:
(Due Date); or
bring the form with you to your scheduled appointment.
To be considered a valid application, this form must be signed. If you receive TANF Cash, this form must be completed
for your cash benefits to continue.
1. LIST ALL PERSONS LIVING WITH YOU, INCLUDING YOURSELF.
EATS WITH YOU
FULL NAME
BIRTH DATE
RELATIONSHIP
YES
NO
For additional persons, please attach a separate sheet.
No
2. If you receive an HFS Medical Card, has your health insurance changed? Yes
3. Does anyone get paid for working? Yes
No
If Yes, enter their name below. Attach copies of the last four pay stubs if paid weekly, last two pay stubs if paid every other week or
twice a month, and the last pay stub if paid monthly.
If self employed, attach your income and expense statement. If someone received tips that are not on their pay stubs, tell us:
Who?
and total amount of tips received in the last 30 days.
Total Tips $
List the Name of
Employer
How often is the person paid?
Hours Worked
Everybody Who is
If a person works more than
Rate of Pay
Weekly, every 2 weeks, twice a
Weekly
Working
one job list all the employers.
month, monthly, other?
4. Did anyone start a new job? Yes
No
If YES, complete the information above.
5. Did anyone stop working, or did their job end? Yes
No
If Yes, enter name, reason:
Enter final date of pay:
IL 444-4765 (R-05-16) Redetermination Application
Page 1 of 2
Printed by the Authority of Illinois
20,000 Copies PO#16-1785
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