Medicaid And Kid Care Chip Renewal Form Page 2
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Your contact information
Review your contact information here.
Correct any wrong or missing information here.
Name (first, middle, last & suffix)
[name]
Home address
Apartment #
Home address:
[address]
City (home)
State
ZIP code
[city, st zip]
Mailing address
Apartment #
Mailing address:
[address]
city, st zip]
City (mailing)
State
ZIP code
Best phone number to reach you:
Home
Cell
Work
Phone:
Number:
Home: [phone number]
Other:
Other phone number, if you have one:
Home
Cell
Work
Number:
Email address, if you have one:
We need information about who files tax returns.
You can still renew even if you did not file tax returns.
Will anyone in the household file a federal tax return next year to report income earned this year?
Yes If yes, answer all of the questions below.
No If no, answer the question marked with a star
below
Person 1:
Name (first, middle, last & suffix)
If this person is filing a joint return, write the name of the spouse:
If this person will claim dependents, write the names of the dependents:
Person 2:
Name (first, middle, last & suffix)
This is for a second tax filer in the household
If this person is filing a joint return, write the name of the spouse:
If this person will claim dependents, write the names of the dependents:
If anyone will be claimed as a dependent on someone else's tax return, write the name of the filer
and the dependents. Answer only if different than what you reported above.
Name of filer:
Name of dependents:
?
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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
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