Mad 023 - Medicaid Application For Women, Children, And Families (Page 4 of 5) in pdf

Page 4

3. Tells us About Your Income

Have you or has anyone living with you received income or expect to receive income this month?

Yes

If yes, please complete the chart below.

$ Monthly Amount

How Often Received?

Person with income

Income from?

(Before Tax Deductions)

(Monthly, Biweekly, Weekly, etc)

Have you paid Dependent Care for a child this month? If yes, list the members and the amount paid per month.

_________________________________________________________________________________________

Yes

Amount paid per month: $___________________________________________________________

Yes

Do you get help paying for Dependent Care?

4. Parents Not Living with their Children

By accepting medical assistance for your children, you assign (give) HSD rights to collect child support from an absent parent.

Please list all the information for your children’s parent(s) that are not living with you:

Child Name

Absent Parent Name

5. Register to Vote

Yes

If YOU are NOT registered to vote where you live now,

Would you like to register to vote here today?W

(Please check one)

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

The NATIONAL VOTER REGISTRATION ACT provides you with the opportunity to register to vote at this location. If you would like help in filling out a voter registration application form,

we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.

IMPORTANT: Applying to register or declining to register to vote WILL NOT AFFECT the amount of assistance that you will be provided by this agency.

Signature

Date

CONFIDENTIALITY: Whether you decide to register to vote or not, your decision will remain confidential. IF YOU BELIEVE THAT SOMEONE HAS INTERFERED with your right to

register or to decline to register to vote, or your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political

party or other political preference, you may file a complaint with the Office of the Secretary of State, 419 State Capital, Santa Fe, NM, 87503, (phone: 1-800-477-3632).

6. Your Signature (Your authorized representative may also sign here)

BY SIGNING THIS APPLICATION, I AGREE TO THE FOLLOWING:

To provide all information and proof needed to determine eligibility.

To provide a Social Security Number for every household member who is applying for benefits.

To permit the Human Services Department (HSD) to contact persons or agencies to verify needed information if I am not able to provide the

information.

To allow all information I give to HSD to be matched by computer with other federal, state, and local agencies.

To allow HSD to examine medical records needed for eligibility decisions and/or for payment of benefits.

I am declaring the identity of my children under age 16.

If I knowingly give false, incorrect or incomplete information, I may be prosecuted for that crime.

I understand that I must pay back any benefits that I am not eligible to receive.

HSD will use the information I give to decide on my eligibility, so the information must be as correct as possible.

► Sign Here ______________________________ Today’s Date ____________

MAD 023 Revised 03/05/12

Mad 023 - Medicaid Application For Women, Children, And Families Page 4

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