Healthcare Application For The Elderly And Disabled Page 6
Download a blank fillable Healthcare Application For The Elderly And Disabled in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Healthcare Application For The Elderly And Disabled with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10SFN 958 (3-2016)
Page 6 of 10
Tell Us About the Income/Money Your Household Receives (continued)
Self-Employment
If yes, complete the following:
Are any household members self-employed?
Yes
No
Name of Household Member:
Name and Type of Business:
Date Business Started:
Employment
Are any household members employed?
Yes
No
If Yes, list information about pay from employment such as wages, commissions, bonuses, and incentives for all household
members. If employment stopped last month or this month, also list income received this month here.
How
Day or
Hours
Often
Dates
This Month's
Next Month's
Worked
Date of
Paid
Paid
Amount
Pay Before
Pay Before
Per
Next
Hourly
Household Member
Employer
Use Codes
Taxes (Gross)
Taxes (Gross)
of Tips
Week
Check
Pay
Below
How Often Paid Codes:
M - Monthly
2X - Twice a Month
W - Weekly
EX - Every Two Weeks
Other, specify:
Day Paid Codes:
M - Monday
T - Tuesday
W - Wednesday
TH - Thursday
F - Friday
S - Saturday
SU - Sunday
Have any household members received commissions, bonuses or
Yes
No
If yes, complete the following:
incentives other than those included above within the last year?
Name of Household Member:
Date Received:
Amount Received:
Unearned Income or Other Money Received
The following is a list of different kinds of unearned income. Check yes for each unearned income or other money received by household
members. Check no, if not received.
BIA/Tribal General Assistance
Oil/Mineral Rights/Royalties
Yes
No
Yes
No
Bingo/Gambling Winnings
Pension/Retirement Benefits
Yes
No
Yes
No
Child Support or Spousal Support
Railroad Retirement Benefits
Yes
No
Yes
No
Contract Sale or Rental Income
Social Security Benefits
Yes
No
Yes
No
Income from Tribes
Supplemental Security Income (SSI)
Yes
No
Yes
No
Income from Roomer/Boarder
TANF-Temporary Assistance for Needy Families
Yes
No
Yes
No
Insurance/Lawsuit Settlement
Unemployment Benefits
Yes
No
Yes
No
Interest/Dividend Income
Veteran's/Military Benefits
Yes
No
Yes
No
Money from Friends, Relatives or Others
Workers' Compensation
Yes
No
Yes
No
Other, specify:
For all items checked yes, fill in the information below:
Type of Unearned Income or
How Often
Amount This
Amount
Household Member
Month
Other Money Received
Received
Next Month
Have household members applied for benefits not yet received (Social Security, SSI,
Yes
No
If yes, explain:
Worker's Compensation, Unemployment Compensation, Veterans/Military Benefits?)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Pt 38a - Application For Property Tax Reduction From Municipal Taxes For The Elderly And Disabled
Financial
Form Pt 38a - Application For Property Tax Reduction From Municipal Taxes For The Elderly And Disabled - 2004
Financial
Sd Eform 1295 V12 - Application For Property Tax Reduction From Municipal Taxes For The Elderly And Disabled
Financial
Application For Group Long Term Disability Income Insurance For Members Of The American Postal Workers Union (apwu) - New York Life Insurance Company
Legal
Application For The America The Beautiful - The National Parks And Federal Recreational Lands Access Pass
Legal
Related Categories
Parent category: Medical