Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency Page 9
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10State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
INSTRUCTIONS FOR COMPLETING
THE GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP)
INITIAL/ANNUAL INCOME VERIFICATION FORM
Please print clearly so your application can be processed as quickly as possible.
Please fill out each section completely. If you do not provide all the information requested, the GHPP will be unable to proceed with
your application. If you need help in filling out this form, please contact the GHPP at 1 (916) 327-0470 or toll free at 1 (800) 639-0597.
Once the application is completed, mail it to the GHPP. PLEASE REMEMBER TO SIGN AND DATE THE FORM.
Section A: Personal Information: This includes identifying information and other information necessary to process this form.
1.
Name: Write your last name, first name, and middle initial.
2.
Social Security Number (OPTIONAL): Write your nine-digit Social Security Number.
3.
Address: Write your residence street number, street name, apartment number, city,
county, and zip code. Do not use a P.O. Box.
4.
Daytime telephone number: Write the telephone number where you can be reached
during the day including the area code.
5.
Evening telephone number: Write the telephone number where you can be reached in
the evening including the area code.
Section B: Income Verification: Follow the instructions for each number below. Your enrollment fee, if any, will be based upon the
information you provide.
6.
Family gross income: This is information found on your tax forms 1040 and 540. You can also use your forms W-2 and/or
other documents listed below in Item 7. You must include income from members of your family who are dependent on the
family income. Use the income amount from the previous year. Examples:
If you are not claimed on anyone else’s tax returns and you earn your own income, this is the amount you must
report.
If you are married you must report both your income and the income of your spouse, even if you file separately.
If you live with a family member who claims you on their tax returns, you must use their income amount and supply
copies of their tax returns.
YOU DO NOT have to include the income from members of your household such as roommates or siblings.
If you have questions about what income you must report, please contact the GHPP.
7.
List income data source(s) and attach copies: This means the document(s) you used to calculate the amount listed in Item
6. Attach a copy of your Federal Tax Form 1040 and any of the following documents used to calculate your family gross
income.
Social Security income statement
Disability income statement
Forms W-2
Pay stubs
Other (please specify)
8.
Family size: List members of your household who are dependent on the family income. Your family size is considered when
calculating your enrollment fee. Attach an additional sheet if more space is needed.
Employment information: List your employer’s name, telephone number, and address.
9.
DHCS 4000 B (2/08)
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