Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency Page 7
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State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP)
INITIAL/ANNUAL INCOME VERIFICATION
Refer to the Instructions on Page 3 and 4 When Filling in this Application
The following information is required by the GHPP to determine your enrollment fee amount, if any. Your enrollment fee is based upon your
family gross income for the previous year. Your income information is reviewed annually, and therefore your enrollment fee may change
from year to year.
Section A: Personal Information
1. Name
(Last)
(First)
(MI)
2. Social Security Number (Optional)
______________________________________
_______________________________
_____
_____________________________
3. Address (number, street, apartment #)
City
County
Zip Code
_________________________________________________
___________________
__________________
__________________
4. Daytime Telephone Number (include area code)
5. Evening Telephone Number (include area code)
________________________________________
__________________________________________
Section B: Income Verification
6. Family Gross Income
$ _________________________
7. List Income Data Source(s) and Attach Copies
_________________________________________________
_______________________________________________________
_________________________________________________
_______________________________________________________
_________________________________________________
_______________________________________________________
8. Family Size ______ List Family Members, Including Yourself, Who Are Dependent on the Family Income
Name______________________________________________Relationship______________________________
Name______________________________________________Relationship______________________________
Name______________________________________________Relationship______________________________
Name______________________________________________Relationship______________________________
(Use additional paper if more space is needed)
9. Employment Information
Your Employer’s Name ____________________________________________________________________________________
Employer’s Telephone Number ______________________________________________________________________________
Employer’s Address_______________________________________________________________________________________
Section C: Enrollment Fee Information
NOTIFICATION OF ENROLLMENT FEE STATUS:
a.
When the GHPP has calculated the amount of your enrollment fee, you will be sent a written notification. The total enrollment fee will
be provided on an Enrollment Fee Agreement. The Enrollment Fee Agreement will specify the amount owed and two options for
payment:
th
i.
One lump sum due no later than the 60
day from the date of notification from the GHPP, or
th
th
th
ii.
Two or three payments which are due no later than the 60
, 120
, and 180
days from the date of notification
from the GHPP.
b.
FAILURE TO PAY THE ENROLLMENT FEE ACCORDING TO THE SIGNED AGREEMENT WILL RESULT IN CLOSURE OF
ST
ST
ST
YOUR CASE ON THE 61
, 121
, OR 181
DAY FROM THE DATE OF NOTIFICATION FROM THE GHPP.
DHCS 4000 B (2/08)
Page 1 of 4
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