Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 5
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16(Continue with yourself)
STEP 1: PERSON 1
22. If Hispanic/Latino, ethnicity (OPTIONAL)
23. Race (OPTIONAL—check all that apply)
Mexican
Mexican-American
Chicano/a
Puerto Rican
White
Native Hawaiian
Filipino
Korean
Black/African American
Cuban
Other:
Chinese
Japanese
Vietnamese
Asian Indian
Other Asian
Samoan
American Indian or Alaska native
Guamanian or Chamorro
Other Pacific Islander
Other:
Current job & income information
Employed
Not Employed
Self-Employed
If you’re currently employed, tell us about
SKIP to question 36.
SKIP to question 35.
your income. Start with question 24.
CURRENT JOB 1:
24. Employer name and address
25. Employer phone number
26. Wages/tips (before taxes)
Hourly
Weekly
Every 2 weeks
Twice a month
Monthly
Yearly
$
27. Average hours worked each week
28. Start date
CURRENT JOB 2:
(If you have more jobs and need more space, attach another sheet of paper)
29. Employer name and address
30. Employer phone number
31. Wages/tips (before taxes)
Hourly
Weekly
Every 2 weeks
Twice a month
Monthly
Yearly
$
32. Average hours worked each week
33. Start date
34. In the past year, did you:
Change jobs
Stop working
Start working fewer hours
None of these
35. If self-employed, answer the following questions:
a. Type of work
b. How much net income (profits once business expenses are paid
will you get from this self-employment this month?)
$
OTHER INCOME THIS MONTH:
36.
Check all that apply, and give the amount and how often you get it.
NOTE: You don’t need to tell us about child support, veteran’s payments or Supplemental Security Income (SSI).
None
Unemployment $
How often?
Net farming/fishing: $
How often?
Pensions
$
How often?
Net rental/royalty:
$
How often?
Social Security
$
How often?
Other income:
Retirement acc’ts $
How often?
Type:
$
How often?
Alimony received $
How often?
Type:
$
How often?
DEDUCTIONS:
37.
Check all that apply, and give the amount and how often you get it.
If PERSON 1 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health
coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 35b).
Alimony paid
$
How often?
Other deductions:
$
How often?
Student loan interest $
How often?
Type:
YEARLY INCOME:
38.
Complete only if PERSON 1’s income changes from month to month.
If you don’t expect changes to PERSON 1’s monthly income, add another person on the following pages.
PERSON 1’s total income this year
PERSON 1’s total income next year (if you think it will be different)
$
$
THANKS! This is all we need to know about you.
NEED HELP WITH YOUR APPLICATION?
SCDHHS.gov
or call us at 1-888-549-0820. Para obtener una copia de este formulario
Visit
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (June 2016)
Application for Medicaid and Affordable Health Coverage
Page 5 of 13
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