Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 8

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P. CHILD SUPPORT INFORMATION – Complete this section if you want TEMPORARY CASH ASSISTANCE OR MEDICAL
ASSISTANCE for a child who has an absent or deceased parent. Fill in a separate section for each absent or deceased parent.
#1
ABSENT PARENT (AP) INFORMATION
Name of Absent Parent (First, Middle, Last)
Relationship of absent parent to you.
Check one:
□ Absent
□ Deceased
CHILD’S NAME
MARITAL STATUS OF CHILD’S PARENTS AT BIRTH
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
Social Security Number
Other Name
Date of Birth
Age
Race
Sex
□ Male □ Female
AP’s Last
Number
Street
City
State
Zip Code
Telephone
Known Address
AP’s Parent's
Number
Street
City
State
Zip Code
Telephone
Address
Driver’s License State
Birth Place (City, State)
Current or Prior Military
Paying Military Allotment? □ Yes □ No
Military Branch
Dates: From:
To:
If yes, To whom?
Incarcerated
Institution Name
□ Currently
□ Previously
□ Never
ABSENT PARENT INCOME INFORMATION
Last Known
Name, Address & Telephone
Employer
Second
Name, Address & Telephone
Employer
Other Income/Benefits:
□ Social Security
□ SSI
□ Veteran’s Pension
□ Unemployment
□ Worker’s Compensation
□ Pension/Retirement
□ Union Benefits
□ Other, list__________________________________
ABSENT PARENT COURT ORDER INFORMATION
Paying Support?
To Whom?
Last Date Paid
Payment Amount
□ YES
□ NO
Court Ordered?
If yes, where was the court order issued?
Can you give us a copy?
□ YES
□ NO
□ YES
□ NO
#2
ABSENT PARENT (AP) INFORMATION
Name of Absent Parent (First, Middle, Last)
Relationship of absent parent to you.
Check one:
□ Absent
□ Deceased
CHILD’S NAME
MARITAL STATUS OF CHILD’S PARENTS AT BIRTH
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
Social Security Number
Other Name
Date of Birth
Age
Race
Sex
□ Male □ Female
AP’s Last
Number
Street
City
State
Zip Code
Telephone
Known Address
AP’s Parent's
Number
Street
City
State
Zip Code
Telephone
Address
Driver’s License State
Birth Place (City, State)
Current or Prior Military
Paying Military Allotment? □ Yes □ No
Military Branch
Dates: From:
To:
If yes, To whom?
Incarcerated
Institution Name
□ Currently
□ Previously
□ Never
ABSENT PARENT INCOME INFORMATION
Last Known
Name & Address:
Number
Street
City
State
Zip Code
Telephone
Employer
Second
Name & Address:
Number
Street
City
State
Zip Code
Telephone
Employer
Other Income/Benefits:
□ Social Security
□ SSI
□ Veteran’s Pension
□ Unemployment
□ Worker’s Compensation
□ Pension/Retirement
□ Union Benefit
□ Other, list___________________________________
ABSENT PARENT COURT ORDER INFORMATION
Paying Support?
To Whom?
Last Date Paid
Payment Amount
□ YES
□ NO
Court Ordered?
If yes, where was the court order issued?
Can you give us a copy?
□ YES
□ NO
□ YES
□ NO
DHR/FIA CARES 9701 Revised 9/09
7

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