Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 5
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13H. DEPENDENT CARE
If anyone in your household pays someone to care for a child or disabled adult, fill in this section:
Name of Care Provider
Telephone
Name of Care Provider
Telephone
Number
Street
Number
Street
City
State
Zip code
City
State
Zip code
Household Member Receiving Care
Under 2 years
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
old? □ Yes □ No
Who Pays?
Cost
Who Pays?
Cost
$
$
Household Member Receiving Care
Under 2 years
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
old? □ Yes □ No
Who Pays?
Cost
Who Pays?
Cost
$
$
I. CHILD SUPPORT/ALIMONY EXPENSE
Does any household member pay court ordered child support to a NON-HOUSEHOLD member? □ Yes □ No If yes, who?
(Includes current payments, arrearages, health insurance)
PERSON OR AGENCY
HOW OFTEN
DEPENDENT’S NAME, ADDRESS AND PHONE NUMBER
AMOUNT PAID
PAID
PAID
J. OTHER INCOME AND BENEFITS
If anyone in your household receives, applied for or was denied any benefit listed below, place a check in the box next to
the benefit
□ Alimony
□ Child Support
□ Social Security
□ SSI
□ Railroad Retirement
□ Veteran’s Pension/Benefit
□ Unemployment Benefits
□ Education Grants or Loans
□ Worker’s Compensation
□ Pension or Retirement
□ Union Benefits
□ Disability, Sick or Maternity Benefits
□ Military Allotment
□ Money from Rental Income
□ Black Lung Benefits
□ Money from Friends or Relatives
□ Lump Sum Cash Amounts □ Civil Service Annuity
□ Temporary Cash Assistance
□ TDAP
□ Social Security Disability
□ Interest Dividends from Stocks, Bonds, Savings or Other Investments
□ Other ______________________________________
Do you agree to apply for all benefits you may be entitled to receive? □ Yes □ No
If you checked yes to receiving, applying for or being denied any benefits, fill in below:
HOUSEHOLD MEMBER
TYPE OF BENEFIT
Applied
CLAIM NUMBER
Received
Amount
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
DHR/FIA CARES 9701 Revised 9/09
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