Medicaid And Kid Care Chip Renewal Form (Page 12 of 12) in pdf

Helpful information about immigration statusand

Attachment D

document types, and self-employment business

expenses

To help you fill out Section 3, page 3 and Section 6, page 6

Eligible immigration status list

If you see the person’s status below, go back to Section 3, page 3 and check the Yes box.

Lawful Permanent Resident (LPR or Greencard holder)

Applicant for Special Immigrant Juvenile Status

Asylee

Applicant for Adjustment to LPR Status

Refugee

Applicant for Asylum

Cuban or Haitian entrant

Applicant for Withholding of Deportation or Withholding of

Removal, under the immigration laws or under the Convention

Paroled into the U.S.

against Torture (CAT)

Conditional entrant granted before 1980

Registry Applicants (with Employment Authorization)

Battered spouse, child and parent

Order of Supervision (with Employment Authorization)

Victim of Trafficking and his/her spouse, child, sibling or parent

Applicant for Cancellation of Removal or Suspension of Deportation

Granted Withholding of Deportation or Withholding of Removal,

(with EAD Employment Authorization)

under the immigration laws and under the Convention against

Torture (CAT)

Applicant for Legalization under IRCA (with Employment

Authorization)

Individual with Non-immigrant Status (includes worker visas, student

visas, and citizens of Micronesia, the Marshall Islands, and Palau)

Legalization under the LIFE Act (with Employment Authorization)

Temporary Protected Status (TPS) and Applicant for Temporary

Lawful Temporary Resident

Protected Status (TPS)

Member of a federally-recognized Indian tribe or American Indian

Deferred Enforced Departure (DED)

Born in Canada

Family Unity beneficiary

Resident of American Samoa

Administrative order staying removal issued by the Department of

Deferred Action Status (Deferred Action for Childhood

Homeland Security

Arrivals (DACA) is not an eligible immigration status for applying for

health insurance

Immigration document types

Eligible non-citizens applying for health coverage also need to list their immigration document.

Below are some common types. If the document you have is not listed, you can still write its name. If you

are not sure, or you have an eligible status but no document, call 1-800-123-4567 so we can help.

Permanent Resident Card (I-551, also known as Green Card)

Refugee travel document (I-571)

Temporary I-551 Stamp (on passport or I-94, I-94A)

Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)

Immigrant Visa (with temporary I-551 language)

Certificate of Eligibility for Exchange Visitor (J-1) Status (DS2019)

Employment Authorization Card (EAD or I-766)

Notice of Action (I-797)

Arrival/Departure Record (I-94 or I-94A)

Other document with an Alien Number or I-94 number,

Arrival/Departure Record in foreign passport (I-94)

or other document showing you have an eligible immigration

Foreign passport

status listed above

Reentry Permit (I-327)

Self-employment business expenses

You can subtract the business expenses listed below from your gross income to get

an amount for your net self-employment income.

Car and truck expenses (for travel during the workday, not

Advertising

commuting)

Contract labor

Depreciation

Repairs and maintenance

Employee wages and fringe benefits

Certain business travel and meals

Property, liability, or business interruption insurance

Deductible self-employment taxes

Interest (including mortgage interest paid to banks, etc.)

Cost of self-employed health insurance

Legal and professional services

Contributions to a self-employed SEP, SIMPLE, or qualified

Rent or lease of business property and utilities

retirement plan

Commissions, taxes, licenses and fees

Questions?

Call our customer service center at 1-855-294-2127 (TTY/TDD: 1-855-329-5204).

The call is free. You can call 7:00 a.m. to 6:00 p.m. Monday to Friday. Or visit

Medicaid And Kid Care Chip Renewal Form Page 12

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