Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 17
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29DWS-ESD 741
ATTACHMENT B
10/2013
TAX DEPENDENTS NOT LIVING WITH YOU
(Required only for Medical Assistance)
Case Name: _________________________________ Case #: _______________________
Complete for dependents listed on your tax returns but NOT living in your household (if you have
multiple dependents, please make copies of this page and attach it to your application).
D34314000241729
1. Name: ______________________________________________________________________
First
Middle
Last
2. Relationship to you? ______________________
3. Date of Birth: _____________________
4. Sex:
Male
Female 5. Social Security # (optional): ____________________________
6. Is your dependent pregnant? ……………………………………………………..
Yes
No
If yes, how many babies are expected during this pregnancy? _______________________
7. Does your dependent have earned income? ........................................................................................
Yes
No
If yes, complete all columns:
Hourly Rate
Additional
How Often
Hours
Employer address and
Date of
or Monthly
Income
Paid
Employer Name
Worked
phone #
Hire
Salary
(Ex: Tips, Bonus,
(Ex: weekly,
(Ex:
Weekly
Commission)
monthly)
$900/mo, $8/hr)
8. In the past year, did your dependent change jobs, stop working or start working fewer hours? ..........
Yes
No
9. Does your dependent have self-employment income? ........................................................................
Yes
No
If yes, complete all columns:
Hours
Gross
Net income this month
Type of Business
Business
Company Name
% Owned
Worked
Monthly
(
profit once business
(Ex: LLC, S-Corp,
Start Date
1099, etc.)
Monthly
Income
)
expenses are paid
Are there any self-employment expenses? ....................................................................................
Yes
No
10. Does your dependent receive any of the following unearned income? …………………………………..
Yes
No
If yes, complete all that apply.
Type
Amount
How Often
Type
Amount
How Often
Unemployment
$
Alimony received
$
Pensions
$
Other income Type:
$
Social Security
$
None
Retirement accounts
$
11. Deductions: Check all that apply, give the amount and how often your dependent gets it. If they pay for certain things
that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little
lower.
Note: You should not include a cost that you already considered in your answer to net self-employment (question 9).
Alimony paid
$
How often?
Student loan interest
$
How often?
Other deductions
$
How often?
12. Other income: Check all that apply, give the amount and how often your dependent gets it.
Net farming/fishing
$
How often?
Net rent/royalty
$
How often?
13. Yearly Income: Complete only if your dependent’s income changes from month to month.
Total income THIS year:
$
Total income NEXT year:
$
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162
Page 17
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal