Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014
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29DWS-ESD 61APP
State of Utah
Rev. 10/2014
Department of Workforce Services
APPLICATION FOR FOOD STAMPS, FINANCIAL
ASSISTANCE, CHILD CARE, AND MEDICAL ASSISTANCE
Esta solicitud también se encuentra disponible en Español
For faster automated service, you can apply online at jobs.utah.gov
D34314000240129
Check The Services You Are Applying For:
Food Stamps
Cash/Financial Assistance
Child Care
Medical
Do you want help paying for medical bills from the last 3 months? .....................
Yes
No
If yes, for who? _______________________________
For which month(s)? _________________________________
1. Your Information:
Name:
First
Middle
Last
Home Address:
City:
Zip:
Mailing Address (If different from Home Address):
City:
Zip:
Phone #:
Other Phone #:
Birth Date:
Social Security #
(optional):
Primary language spoken in your home?
Would you like to receive your notices in English or Spanish?
English
Spanish
Case #
Signature:
(optional):
2. Do you have a Utah Horizon Card (Financial, Food Stamp and/or Child Care benefits)? ……............
Yes
No
If you mark No, a new card will be mailed. Any other cards you have will no longer work.
3. Do ALL individuals who are applying for medical assistance need a medical card? ..............……........
Yes
No
If no, who needs a card
? __________________________________________________________________________________
If you want to apply for unemployment benefits, log on to jobs.utah.gov.
Your Rights:
IF YOU NEED HELP FILLING OUT THIS APPLICATION, WE ARE HAPPY TO HELP.
YOU HAVE THE RIGHT TO AN INTERPRETER AT NO CHARGE.
Food Stamps and Medical:
You can turn in an incomplete application with only your name, address and signature; however, before we can
determine your eligibility for benefits, all questions will need to be answered. You can send in your application by:
fax: 877-313-4717, mail: PO Box 143245, SLC, UT 84114-3245 or drop off at your local office
o
We will issue your assistance based on the date we receive your application. If your application is received
outside business hours (Monday through Friday 8:00 a.m. to 5:00 p.m.) it will be effective the following
business day.
Financial and Child Care:
In order to file a Financial Assistance application you must complete questions 1, 4 – 6, 8 – 30, the
o
Financial Section AND sign page 13.
In order to file a Child Care Assistance application you must complete questions 1, 4 – 6, 8 – 23, the Child
o
Care Section AND sign page 13.
o
If you do not complete all of the required questions for Financial or Child Care, the application for Financial
and/or Child Care will be considered incomplete and no action will be taken.
o
If eligible for Financial and/or Child Care, benefits are effective the date that we receive the completed
application with the exception of the General Assistance financial program where benefits will be effective
the first day of the month following the month an application is completed.
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