Form Mdhs-Ea-901 Medi - Application Page 2
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43. INCOME INFORMATION
List all earnings from employment and money from self-employment that you, your spouse, and children in your household receive. ATTACH PROOF OF INCOME FOR
ONE (1) FULL MONTH. Send us the most recent full month’s earnings. Only income of the legal parent(s) living in the home counts toward the children applying.
Name of
Phone #
Gross
How Often
Beginning
Employed
of Employer
Amount
(weekly,
Date of
Name of Employer
Address of Employer
Person
(before
bi-weekly,
deductions)
monthly)
Weekly
Weekly
Weekly
Could you get health insurance for your children through any employer named above if you had the money to pay the premiums?
Yes
No
Which employer?
List any alimony, child support, pension, Social Security, rental income, retirement, strike benefits, unemployment, veterans, workers
compensation benefits that you, your spouse, and children in your household may receive. ATTACH PROOF OF INCOME.
Person Receiving Benefit
Type of Benefit
Amount Received
How Often?
Weekly
Select Source
Weekly
Select Source
Select Source
Weekly
Do you pay someone to take care of your child/children or to take care of a dependent adult who lives with you while you work?
Yes
No
If yes, fill out this section….
4. CHILD/ADULT CARE EXPENSES
Name of Child Care Provider
Who pays for this
Child’s Name
Phone #
Cost
or Day Care Center
(or Adult’s)
$
per
Other
$
per
Other
If any children (under 18) that you are applying for have a parent who does not live in the household or who is deceased,
fill out this section….
5. INFORMATION ABOUT AN ABSENT OR DECEASED PARENT OF CHILD
Absent or Deceased
Parent’s
Absent
Date
Parent’s Name
Social Security #
Parent’s
of
Child’s Name
Last Known Address Race Sex
(if known)
Employer
Death
Has child support been ordered by the court?
Yes
No
(If yes, tell us the place and date of the court order.)
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Parent category: Medical