2003 Application & Renewal Form (Page 6 of 6) in pdf

Section G:

Other Income Information

In this section be sure to include all unearned income received by the individuals listed in Sections C and D of the application. Also, include your unearned

income if you are a parent who lives with the children or if you are another relative who is responsible for the children and you want HUSKY health insurance for

yourself. Do not include information about yourself if you do not live with the children. Attach additional sheet(s) if necessary.

Section H:

Day Care Expense Information

Day care expenses may be used to reduce the amount of household income that we count. A day care deduction may make a difference in whether or not you may

have to pay premiums or co-payments. Day care expenses may be for a child or for a disabled adult. We give you credit for day care expenses even if they are

paid by the state, so list these payments too. (If you need help with day care, please call the toll free Child Care InfoLine number at 1-800-505-1000.) Send us a

letter from your day care provider showing the amount you pay for day care.

Section I:

Health Insurance Information

In the first part list only those individuals who currently have insurance. In the second part list only those individuals who have terminated health insurance in the

last two months. In the third part, be sure to show information about your medical bills. If you qualify for HUSKY A, we may be able to help pay for medical

expenses incurred in the three months before you applied. Also, we may use your medical bills to determine your eligibility for HUSKY A.

Section J:

Immigration

Verification - Please provide immigration information and documentation for anyone who is not a U.S. citizen and who is applying for HUSKY health insurance.

Documentation may be a copy of his or her alien registration card (I-94 or I-551) or another form showing his or her status. If the non-citizen is a member of the

United States armed forces or a US veteran check yes in the last box. Also, if the non-citizen is a spouse, widow or minor child of someone who is a member of

the US armed forces or a US veteran, check yes in the last box.

Other household members - You are not required to provide this information for anyone who does not want HUSKY health insurance. You can get HUSKY for

eligible family members even if your family includes other members who are not eligible because of immigration status. For example, immigrant parents may

receive HUSKY for children who are U.S. citizens even though the parents may not qualify because of their immigration status.

INS and HUSKY - We will not share any information you give us with the Immigration and Naturalization Service (INS).

Public Charge - INS CANNOT use this application or your children’s enrollment in HUSKY to deny you admission to the U.S., harm your permanent residence

status or deport you.

Section K:

Tribal Membership

If you or any of the children, for whom you are applying, are members of a federally recognized tribe, please identify tribal membership. Members of federally

recognized American Indian tribes and Alaskan Natives, who qualify for the subsidized HUSKY coverage, do not have to pay premiums and co-payments.

Section L:

Read Carefully and Sign/Signatures

This section lists legal terms that you agree to. You should read this carefully before signing this application. If you applied for the children, you should sign your

name on the applicant's "Signature" line. If you sign with an "X", someone else must sign his or her name as a witness on the "Witness' Signature" line. If

someone helped you complete the form, he or she should sign on the "Helper" line. If an interpreter helped you read or complete the application, he or she should

sign on the "Interpreter" line. If you cannot fill out the application and sign your name, you may have a "representative" do this for you. The "Representative"

should sign on the "Representative" line.

Verification

We will use the information that you give us to determine your family’s eligibility for HUSKY. Please provide complete and accurate information. We will only

ask for additional information if the information that you give us is incomplete or inaccurate.

Through our computer system, we have access to information from the Social Security administration, labor department, motor vehicle department and other

sources. We use this information to confirm the information that you give us.

W-1HUS (Revised 4/2003)

2003 Application & Renewal Form Page 6

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