Il 444-4765 - Redetermination Application Page 2
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1
2State of Illinois
Department of Human Services
REDETERMINATION APPLICATION
2(Permanent)
6. During the last 30 days did anyone receive any other income such as Child Support, Social Security, SSI, Unemployment,
VA, Worker's Compensation, contributions, or any other money? Yes
No
If YES, complete the box below.
Name
Type of Income
Amount
How Often
7. Do you expect any changes in anyone's income or employment? Yes
No
If Yes, what is the change?
When do you expect this change to happen?
8. Have you moved or changed your address? Yes
No
If Yes, what is the new address?
9. How much is your Rent? $
Lot Rent? $
Mortgage? $
Enter any taxes and homeowner's insurance paid separately: $
Yes
No
Are any of the taxes or homeowner's insurance paid by someone else?
If yes, tell us who and how much.
10. Did you receive an energy assistance payment of $21.00 or more this month or in any of the last twelve months from the
Low Income Home Energy Assistance Program (LIHEAP) (in Chicago paid through CEDA)?
Yes
No
Answering yes will not reduce your benefits.
If no, are you billed separately from your rent or mortgage for heat or air
conditioning, or excess cost for heat or air conditioning?
Yes
No
Note: Air conditioning is a window air or central air conditioning unit.
If NO, do you pay any other utilities? Yes
No
If YES, what utilities?
Does anyone help pay your utilities? Yes
No
If YES, who and what utilities?
11. Does anyone pay child support?
Yes
No
If Yes, who makes the payments, how much, and how often? (enter below)
12. Do you pay for someone to care for a child or disabled adult so you can work, look for a job, or receive training?
Yes
No
If YES, who is the care for, who provides the care, how much do you pay for the care, and how often?
Yes
No
13. Does anyone who is age 18 or over attend school, other than high school, half-time or more?
If yes, who?
14. Does someone in your unit who is 60 or older or disabled have monthly medical expenses of $36 or more? Yes
No
15. Has any person who is receiving Cash assistance from DHS been convicted of a felony involving drugs? Yes
No
See enclosed page for important information about your application
SIGNATURE
By signing below, I swear or affirm, under penalty of perjury, the answers on this application are true and correct to the
best of my knowledge.
Printed
Daytime or Cell
Name:
Phone Number:
Signature:
Date:
IL 444-4765 (R-05-16) Redetermination Application
Page 2 of 2
Printed by the Authority of Illinois
20,000 Copies PO#16-1785
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