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Applicant/recipient Claim For Hardship Exemption - Maryland Division Of Eligibility Waiver Services Page 2

I expect the hardship to prevent me from paying my premium and/or prevents me from

working for (circle one): 1 2 3 4 5 6 months. (Hardship cannot be granted for

more than six months.) Please include documentation to verify expenses, income and

resources for the months which a hardship is being requested.

Please list all sources of income you receive.

Monthly Income:

Social Security

$__________

Earnings (Before Taxes, Gross) $__________

V.A.

$__________

Other _______________

$__________

Other _______________

$__________

Total Monthly Gross Income

$__________

Please complete the information for the following expenses.

Monthly Expenses:

Mortgage or Rent

$___________

Medical Expenses

$___________

Food

$___________

Electric or Gas

$___________

Total Monthly Expenses

$___________

________________________________________

________________________

Signature

Date

The Department shall evaluate the claim of hardship and notify you of its decision within

30 days of the Department's receipt of the written claim of hardship. If the Department

determines that the applicant or recipient's claim of hardship is without merit, the

applicant or recipient shall pay the applicable premium within 10 days after the date the

Department's notice is issued.

DHMH EID 2A Claim for Hardship Exemption

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04/15/13

Applicant/recipient Claim For Hardship Exemption - Maryland Division Of Eligibility Waiver Services Page 2