Form 94 - Medicaid Application Form (Page 2 of 3) in pdf

INCOME, RESOURCES and DEPENDENT CARE

List all income received by persons on page 1 of this application. Be sure to show the amount before deductions. Attach an extra sheet if necessary. We will decide, based on the type of Medicaid, whose

income must be counted and whose may be excluded. If you are applying for Children Only or Pregnant Woman Medicaid, you do not have to complete the Resources/Vehicles sections below.

How Often?

Gross Amount per Pay

Amount in

Who Owns

(weekly, every 2-weeks,

Check

Income

Name of Person Receiving

Resources

Account/Value

Resource?

monthly, etc.?)

(amount before deductions)

Wages/Earnings

Cash

Current Employer:

Checking Account

Wages/Earnings

Savings Account

Current Employer:

Credit Union

Social Security

401K/Retirement

Income/SSI

Account

Worker’s

Compensation

Other

Pensions or

Vehicle(s):

Cars, trucks, motorcycles (licensed)

Retirement Benefits

Child Support/

Amount

Make

Model

Year

Contributions

Owed?

Unemployment

Benefits

Other Income, please

specify:

Do you pay for dependent care (daycare for a child or care for an adult who cannot care for himself/herself) so that someone in your household can work?

How Often? (weekly, 2-weeks,

Name of Parent who works

Name of child or adult cared for

Name of care provider

Amount of Payment

monthly, etc)

If you are applying for Medicaid for children and one or both of their parents are not in the home, please provide the following information:

Do they have Medical Coverage on the Child?

If Yes to Medical Coverage, please list name

Child’s Name

Absent Parent’s Name (Mother/Father)

Yes/No

of insurance company & group number

I understand that this information may need to be verified to determine eligibility. I understand wage and salary information supplied by the Georgia Department of Labor may be obtained to

verify and determine eligibility for Medicaid. I agree to assign to the state all rights to medical support and third party support payments (hospital and medical benefits). I agree to give the

State the right to require an absent parent provide medical insurance, if available. I understand I must get medical support from the absent parent if it is available and must cooperate with the

Division of Child Support Services in obtaining this support. If I do not cooperate, I understand I may lose my Medicaid benefits, and only my children will receive benefits unless good

cause is established. I understand that I must report changes in my income and circumstances within ten (10) days of becoming aware of the change.



I certify under penalty of perjury that I am a U.S. Citizen and/or lawfully present in the United States. If I am a parent or legal guardian, I certify that the applicant(s) is a U.S. Citizen



and/or lawfully present in the United States.

I certify to the best of my knowledge and belief that the person(s) for whom I am applying for Medicaid is/are U.S. citizen(s) or are lawfully

present in the United States. I further certify that all of the information provided on this application is true and correct to the best of my knowledge.

Signature (Required): ______________________________________________________________________________

Date: ______________________________

Form 94 (11/10)