Form Fa-001 - Application For Benefits Page 22
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31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Resources: Answer the following questions if anyone in your household is applying for Nutrition Assistance and /or
Cash Assistance
Does anyone you are applying for have any type of
If Yes, total value:_________________________________
Yes
No
bank account?
Who owns?_______________________________________
Does anyone you are applying for have any:
Yes
No
If Yes, total value: $_________________________________
•
Cash
•
Uncashed checks
•
Money on a pre-paid debit card?
If Yes, total value: $_________________________________
Does anyone you are applying for have any:
Yes
No
Who owns? _______________________________________
Name of financial institution:__________________________
•
Retirement account
If Yes, total value: $_________________________________
•
Annuity?
Who owns? _______________________________________
Name of financial institution:___________________________
Do you or anyone in your household own or have
their name on:
Yes
No
If Yes, total value: $_________________________________
•
stock
Who owns? _______________________________________
•
bond
Name of financial institution:__________________________
If Yes, total value: $_________________________________
•
money market account,
Who owns? _______________________________________
•
Certificates of Deposit (CDs)
Name of financial institution:__________________________
•
trust funds
•
life insurance?
If Yes, total value: $_________________________________
Yes
No
Does anyone you are applying for own any other
Who owns? _______________________________________
land or buildings anywhere?
Where? __________________________________________
If no one has income, explain how you pay your bills below:
No Income:
Living off credit cards
Living with friends
Using money from savings or checking accounts
Working odd jobs
Monthly income: $_____________
Other________________________________
Are you:
Getting loans from people Having someone give you money
Having someone pay bills directly Working in exchange for rent
If Yes, complete the section below:
Telephone number: _________________________
Name of person helping: _____________________
Email: ___________________________________
If loan, amount: $__________ When does it need to be paid back? _________________
If gift, amount: $__________________________
If paying bills, which ones? ____________________
If working in exchange, amount of rent: $________________
Answer the following questions for everyone applying for help with health
Medical Assistance Questions:
insurance costs and/or help with Medicare costs.
Do any applicants have an injury or illness due to an
Yes
No
If Yes, who? __________________________________
accident or medical malpractice?
Are any applicants currently admitted to a hospital?
Yes
No
If Yes, who? __________________________________
Name of the Hospital: __________________________________________
FA-001 (12-17)
Page 13
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