Form Sfn 958 - Health Care Application For The Elderly And Disabled Page 4
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10SFN 958 (4-2017)
Page 4 of 10
Tell Us About The People In Your Home
Check the boxes below for all the people who live in your home, including members temporarily out of your home (working
away from home, attending school or boarding school, in the military, etc.)
Yourself
Your husband or wife
Your children
Other adults or children living in your home
For each person checked, fill in the boxes below. These people make up your household.
If you need additional space, continue on a separate sheet of paper.
You are asked to provide information about the race and the ethnic background for all persons for whom you want assistance.
This information is voluntary and is used to make sure that benefits are provided without regard to race, color, or national
origin. Providing this information will not affect your eligibility or benefit amount.
You are also asked to provide information about the sex, last grade completed and marital status of all persons for whom you
want assistance. This information is voluntary.
You will be asked to provide Social Security Numbers (SSNs) for all persons whom you want assistance. Providing your SSN
can be helpful if you don't want health coverage too since it can speed up the application process. If someone wants help
getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. If you are applying
only for emergency Medicaid because of your citizenship or immigration status, you do not need to give us information about
your SSN. (See the 'General Information Section' of the Application for Assistance Guidebook for additional
information regarding use of Social Security Numbers.)
Household Members
Relation
Social
Date of
Age
Sex
U. S.
Hispanic
Race
Marital
(Enter Legal Name)
Security
Citizen
or Latino
To You
Birth
Status
Middle
Number
(Yes or
(Yes or
Use
Use
First
Initial
Last
No)
No)
Codes
Codes
Below
Below
Self
Race Codes:
AI - American Indian/Alaska Native
AP - Asian
BL - Black/African American
HP - Native Hawaiian/Pacific Islander
WH - White
Marital Status Codes:
DI - Divorced
MA - Married
NM - Never Married
SE - Separated
WI - Widowed
If you do not want Health Care Coverage for all members of the household listed above, please list members you DO NOT want Health Care
Coverage for:
If any household members are enrolled member in a federally-recognized Indian tribe, list enrolled members, the name of the tribe and their
tribal enrollment numbers:
If you are applying for Health Care Coverage you may be eligible for no enrollment fees or premium payments under certain Health Care Coverage.
Tell Us About Your Household
I/We have lived in North Dakota since (month, day, and year):
Do you intend to remain in North Dakota?
Yes
No
List other names that have been used by household members (maiden name, prior married name or nickname):
List household members temporarily out of the home:
Why are they out of the home?
Date Expected to Return:
List household members who are disabled:
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