Application For Gap Assistance Pharmacy Program For Seniors (Gaps) Page 2
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4The following information is needed to process your APPLICATION FOR GAPS.
This application will be processed based on the information you provide
We will compare this information to other government agency
computer systems for verification.
The results of that verification could affect your eligibility for GAPS.
Application Type:
Individual (Single, Separated, Divorced, or Widowed)
(Please check one.)
Joint (Married – you and your spouse)
YOUR INFORMATION (APPLICANT)
First Name:
MI:
Last Name:
Social Security Number:
Medicare Number:
Date of Birth:
Male
Female
Race:
o White
o Mexican
o Puerto Rican
o Asian American/Oriental
o African American/Black
o Native American/
o Cuban
o Other/Unknown
American Indian
o Hispanic
IF MARRIED, YOUR SPOUSE’S INFORMATION IS REQUIRED
First Name:
MI:
Last Name:
Social Security Number:
Medicare Number:
Date of Birth:
Male
Female
Race:
o White
o Mexican
o Puerto Rican
o Asian American/Oriental
o African American/Black
o Native American/
o Cuban
o Other/Unknown
American Indian
o Hispanic
YOUR HOME ADDRESS AND TELEPHONE
Address:
(Include Apartment Number, if applicable.)
City:
State:
Zip Code:
County:
Telephone Number:
(
)
YOUR MAILING ADDRESS
(
Fill out this section only if your mailing address is different from your home address.)
Address:
(Include Apartment Number, if applicable.)
City:
State:
Zip Code:
DHHS Form 942 (January 2010)
Page 2 of 4
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