Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 11
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2961. Are you homeless? ........................................................................................
Yes
No
62. Is anyone in your household receiving Food Stamps from another state? ....
Yes
No
If yes, who? __________________________ State: _______________
63. Is anyone in your household a boarder? ........................................................
Yes
No
If yes, explain: _____________________________________________
64. Is anyone in your household a foster child or foster adult? ............................
Yes
No
D34314000241129
If yes, who? _______________________________________________
65. Is anyone in your household a migrant or seasonal farm worker? .................
Yes
No
If yes, who? _______________________________________________
66. Have you or anyone in your household been convicted of any of the following after September 22, 1996:
Fraudulently receiving duplicate Food Stamp benefits in any state ....................................….
Yes
No
If yes, who? _________________________________ State: _____________________
Buying or selling Food Stamp benefits over $500 ……………………..................................…
Yes
No
If yes, who?
___________________________________________________________________________________________________
Trading Food Stamps for guns, ammunitions, or explosives ………..................................….
Yes
No
If yes, who? ____________________________________________________________
Trading Food Stamp benefits for drugs ………………………………...................................…
Yes
No
If yes, who? ____________________________________________________________
MEDICAL SECTION
67. Do you have child(ren) living in the home? ..........................................................................................
Yes
No
If yes, are you willing to cooperate with the Office of Recovery Services (ORS) regarding
establishment of medical support from an absent parent(s)? ...........................................................
Yes
No
68. Is anyone in your household enrolled in or eligible for COBRA coverage or continued health
insurance through an employer? ..........................................................................................................
Yes
No
69. Does anyone in your household currently have health insurance (including VA Health Care System benefits, Tricare or
Peace Corps), have insurance available but not enrolled, or has had insurance in the past 6 months?..
Yes
No
If yes, please complete the information below. (Do not list Medicaid, Medicare, CHIP or PCN)
Insurance 1:
Enrolled
Not Enrolled, but available
(Complete Attachment C)
Date Ended:
Name(s) of individual(s) covered:
Name of insurance company:
Phone #:
Address of insurance company:
Group #:
Policyholder name:
Policy #:
Policyholder birth date:
Policyholder SS#:
If insurance is through an employer, list employer’s name and phone #:
Premium cost:
$
Date due:
How often:
Start date:
Coverage:
Type of Insurance:
Medical
Limited
Dental
Comprehensive
Is this a retiree health plan? …………...
Yes
No
Page 11
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