Form Sfn 958 - Health Care Application For The Elderly And Disabled Page 2

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SFN 958 (4-2017)
Page 2 of 10
To speed up the processing of your application, turn in proof of the following items with your application. Your county
social service office may be able to help you obtain these things if needed.
Proof of Alien or Citizenship Status such as (original documents required if applying for Health Care
Coverage):
·
·
Resident Alien Card (Form I-551)
Temporary Resident Card (Form I-688)
· Employment Authorization Card (Form I-688A)
·
Arrival-Departure Record (Form I-94)
·
·
American Indian/Alaskan Native Tribal Document
Passport
· Birth Certificate (if born in the United States)
You will be asked to provide information about the citizenship or immigration status for all persons for whom
you want to receive assistance. This information may be subject to verification by the United States
Citizenship and Immigration Service (USCIS), and that the submitted information received from USCIS may
affect the household's eligibility and level of benefits. For HCC, verification will be required if not
available through electronic notifications. If any of these persons do not want to give information about
their citizenship or immigration status, they will not be eligible for benefits. These persons must provide their
financial information to determine eligibility for other household members. Other household members may
still get benefits if they are otherwise eligible. We will not share alien or citizenship information about non-
applicants with the United States Citizenship and Immigration Service (USCIS).
Proof of the value of current assets such as:
· Annuities
· Life Insurance
· Business Accounts
· Real Property (Land, Rental Property, etc.)
· Certificates of Deposit
· Savings Bonds
· Checking/Savings/Credit Union Accounts
· Stocks/Bonds/Mutual Funds
· IRA/401K/KEOGH plans
· Trusts
Proof of expenses such as:
· Court Ordered Payments (Child/Spousal Support, Medical Support)
· Health Insurance Premiums
Proof of income such as:
· Bonuses
· Self-employment Income (most recent copy of Federal
Income Tax Return)
Child Support
·
· Commissions
· Social Security Benefits
· Lease Income
· Spousal Support
· Money from Friends, Relatives, or Others
· SSI (Supplemental Security Income)
· Pay (Pay Stubs or Employer Statement)
· Unemployment Benefits
· Pension/Retirement Benefits
· Veteran’s/Military Benefits
· Rental Income
· Workers Compensation
Proof of Other Information such as:
·
Identity (Birth Certificate, Driver's License, Work or School ID, American Indian/Alaskan Native Tribal
Document, Passport)
·
Age (Birth Certificate, Driver's License)
·
Social Security Numbers (card or proof of applicant for SSN)
To learn when you may get assistance, go to the General Information section of the Guidebook. If
you have questions, contact your local county social service office.

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