Application For Kids, Pregnant Women, And Parents Page 3
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4MISSOURI DEPARTMENT OF SOCIAL SERVICES
•
MO HEALTHNET
APPLICATION FOR KIDS, PREGNANT WOMEN, AND PARENTS
FOR OFFICE USE ONLY
COMPLETE IN INK.
A. MAILING ADDRESS
DATE APPLIED
NAME (FIRST, MIDDLE, LAST)
ADDRESS (HOUSE NO., STREET OR RURAL ROUTE, P.O. BOX NO.)
CITY, STATE, ZIP CODE
COUNTY
DCN
HOME PHONE NUMBER
WORK PHONE NUMBER
MESSAGE PHONE NUMBER
ELIGIBILITY SPECIALIST/SUPV/LOAD
INSTRUCTIONS: Please answer each question completely. Attach an additional sheet if more space is needed in any section.
B. HOUSEHOLD INFORMATION
(LIST ALL CHILDREN, PARENTS/GUARDIANS AND STEPPARENTS WHO LIVE IN YOUR HOME, YOURSELF FIRST.)
RELATIONSHIP
(X)
NAME
RACE*/
HISPANIC
PLACE OF
SOCIAL SECURITY
TO
BIRTHDATE
APPLYING
(FIRST, MIDDLE, LAST)
(MAIDEN)
SEX
Y/N
BIRTH
NUMBER
PERSON a.
FOR
a.
SELF
b.
c.
d.
e.
f.
*(1 - WHITE
2 - BLACK/AFRICAN AMERICAN
4 - AMERICAN INDIAN/ALASKAN NATIVE
5 - ASIAN
6 - NATIVE HAWAIIAN/PACIFIC ISLANDER)
1. Are both parents of all the children in the home?
YES
NO
(If No, complete section E.)
2. Are all of the persons applying for MO HealthNet U.S. citizens?
YES
NO
If No, list the following information for persons apply-
ing for MO HealthNet who are not U.S. Citizens: Name, immigration status and registration number, date of entry: _______________________
_____________________________________________________________________________________________________________
3. You may qualify for coverage of unpaid bills for medical services received in the past three months. Did any of the persons listed above
If yes, who? ______________________________________
receive medical services in the past three months?
YES
NO
If yes, who? _______________________ Expected due date? __________
4. Is anyone in your household pregnant?
YES
NO
5. Is your net worth (Net worth is the value of everything you own minus any debt):
less than $50,000
$50,000-$100,000
$100,000-$150,000
$150,000-$200,000
$200,000 - $250,000
above $250,000
Please list your assets (bank accounts, stocks/bonds, vehicles, home, real and personal property, etc.) ____________________________
____________________________________________________________________________________________________________
C. INCOME (Please attach verification; i.e. paycheck stub, note from employer, federal income tax return, award letter, etc.)
If yes, name of employer __________________________________________________
1. Are you employed?
YES
NO
How much are you paid before taxes or deductions? $ ___________
Weekly
Every two weeks
Twice monthly
Monthly
If yes, who? _____________________________________________
2. Is anyone else in your home employed?
YES
NO
Name of employer ______________________________________________________________________________________________
How much are they paid before taxes or deductions? $ ___________
Weekly
Every two weeks
Twice monthly
Monthly
3. Does anyone in your home operate their own business or are they otherwise self-employed?
YES
NO
If yes, who? ____________________________ Describe what type of self-employment (baby-sitting, farm income, other) and amount
earned: ________________________________________________________________
Weekly
Monthly
Yearly
4. Childcare costs may be an allowable income deduction for working families. Do you pay someone to care for your child?
If yes, list names of children cared for: ___________________________________________________________
YES
NO
How much do you pay for childcare: $ ___________
Weekly
Every two weeks
Twice monthly
Monthly
CALL 1-888-275-5908 IF YOU HAVE QUESTIONS
IM-1UA (01-08)
MO 886-2726 (01-08)
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