Instructions For Completing The Application - Dhs County Office printable pdf download

Instructions For Completing The Application - Dhs County Office

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Instructions For Completing The Application

Mailing Information:

Mail the completed application to your local

DHS County Office

in your area.

View the DHS County Office in your area

Section 1. Head of Household:

As a parent or guardian, you are the Head of Household. In the top section, please

provide your name, address, and phone numbers. If you are applying because you

are pregnant, please include a written statement from your doctor of health care

provider saying you are pregnant and what your expected date of delivery is (use

the space provided on the back of this form or attach a separate statement).

Section 2. Household Members

List all the children, parents, step-parents or guardians in the household, yourself

first. It is important that you indicate the relationship of the person to you; i.e.,

spouse, son, daughter, etc. Put an “X” in one of the first two boxes to indicate you

are applying for that person (attach proof of age for children you are applying for,

such as a copy of birth certificates).

Note: You must provide the Social Security # for any person who wants to be

eligible for health benefits. The State will use the SSN to verify information such as

income and insurance coverage and to help maintain files regarding eligibility.

The SSN may be used to match with records in other agencies, such as the Social

Security Administration, Internal Revenue Service and Employment Security. If you

mark "No" to U.S. Citizen, Alien status for those applying for Medicaid must be

verified to determine qualified alien status.

Section 3. Income Information:

In order to determine your family’s eligibility , please complete this section. Attach a

sheet if more space is needed. It is important to list all earnings, wages or money

from self-employment that you, your spouse or children in your household receive

(attach proof of income for one (1) full month).

Note: Only the income of the legal parent(s) living in the home counts toward the

children applying.

Section 4. Child/Adult Care Expenses:

You may also be eligible for child care assistance. Under this section you should

list the name of the child care provider or day care center that takes care of your

children or dependent adult who lives with you while you work.

Section 5. Information About An Absent Or Deceased Parent Of Child:

Instructions For Completing The Application - Dhs County Office