Form Hc 201p - Pharmacy Programs Application - Vermont Department For Children And Families Page 2
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2Please list all current gross income (before taxes, Medicare, and other deductions) for yourself and your spouse or civil union
partner, if he or she lives with you. Please answer all questions.
APPLICANT
SPOUSE OR CIVIL UNION PARTNER
AMOUNT
HOW OFTEN?
AMOUNT
HOW OFTEN?
TYPE OF INCOME
(before deductions)
(check one)
(before deductions)
(check one)
Social security retirement
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
Social security disability
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
Railroad retirement
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
Veteran’s benefits
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
Pensions and annuities
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
Interest and dividends
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
Self-employment income
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
(If yes, please send copy of most recent federal income tax return including Schedules C, E, and F.)
Wages in last 30 days
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
If yes, please answer:
___________________________________ ___________________________________
EMPLOYER
HRS./WK.
HOURLY WAGE
EMPLOYER
HRS./WK.
HOURLY WAGE
Other income
Yes
No $
Mo.
Yr.
Yes
No $
Mo.
Yr.
______________
______________
(Such as unemployment, worker’s compensation, or alimony)
If yes, please describe
_______________________________________________ _______________________________________________
Do you pay for day care for a child or an incapacitated adult?
Yes
No $ ______________________
MONTHLY AMOUNT
Do you pay child support or alimony?
Yes
No $ ______________________
MONTHLY AMOUNT
Please read the following rights and responsibilities and sign below:
The information I have provided is correct to the best of my
prescription discounts I received and may subject me to civil or
knowledge. I understand this information may be verified. I
criminal prosecution. I understand that I have the right to treatment
understand that I must report all changes, such as changes in
that is fair and does not discriminate. I may not be treated
income, insurance, address, and household size. I understand the
differently because of race, color, national origin, marital status,
information I have given is private and cannot be seen by the public.
sex, sexual orientation, age, religion, political beliefs, place of birth,
I understand that federal regulation requires that I provide my
or because of physical, mental, or emotional conditions. If I have a
social security number and that it may be used to check my
complaint about being treated differently, I may contact the Office
statements with other agencies, such as the Social Security
for Civil Rights, Health and Human Services, Room 506-F, 200
Administration and the Internal Revenue Service, and for quality
Independence Avenue, S.W., Washington D.C. 20201. If I believe I
control reviews. This requirement may be waived for members of
have been discriminated against because of a disability, I may
a religious organization that objects to furnishing a social security
contact: Deputy Commissioner, Department for Children and
number. I understand that intentionally making a false or
Families, Economic Services Division, 103 South Main Street,
misleading statement, or concealing or withholding facts, may
Waterbury, VT 05671-1201.
result in paying the Department, in cash, the value of the
I have read or gone over the rights and responsibilities statement and understand them.
________________________________________________________________________________________________________________________
SIGNATURE OF APPLICANT
DATE
________________________________________________________________________________________________________________________
SIGNATURE OF PERSON WITNESSING OR HELPING TO FILL OUT THIS FORM
DATE
After signing this form, please mail it to:
Vermont Department of Taxes
109 State Street
Montpelier, VT 05609-1401
If you have questions or for current income levels, call Health Care Member Services at 1-800-250-8427.
To use telephone service for people with hearing disabilities, call 1-888-834-7898.
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