Medicaid And Kid Care Chip Renewal Form Page 6
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12Tell us about work
(continued)
If anyone in your household is self-employed, we need to know about their work.
1.
Name (first, middle, last & suffix):
Type of work:
$
How much net income will this person get from self-employment this month? Amount:
Net income means the profits left over after business expenses are paid. For more information about business expenses, see Attachment D on page 12.
2.
Name (first, middle, last & suffix):
Type of work:
$
How much net income will this person get from self-employment this month? Amount:
Net income means the profits left over after business expenses are paid. For more information about business expenses, see Attachment D on page 12.
Tell us about other income
Cross out any information that is not correct about members of your household. Write in any new information.
Unemployment
How much?
How often?
Hourly
Every two weeks
Monthly
Name (first, middle, last & suffix):
$
Yearly
Weekly
Twice a month
How much?
How often?
Social Security
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Yearly
Twice a month
Pensions
How much?
How often?
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Yearly
Twice a month
Retirement accounts
Name (first, middle, last & suffix):
Hourly
Every two weeks
Monthly
$
Weekly
Twice a month
Yearly
Section 7 continued on next page
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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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