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Food Stamp, Financial and Medicaid Information for Immigrants:



You can apply for and receive Food Stamp, Financial and Medicaid benefits for eligible

family members, even if your family includes other members who are not eligible because

of immigration status. For example, immigrant parents may apply for Food Stamp benefits

for their U.S. citizen or qualified immigrant children, even though the parents may not be

eligible for benefits.



You do not have to provide immigration status information, Social Security numbers,

or documents for any family members who are not eligible for Food Stamp benefits

because of immigrant status and who are not asking for Food Stamp benefits. Family

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members who are not eligible for Food Stamp, Financial or Medicaid benefits will still

need to answer other questions about their name, relationship, income, assets, etc.



Using Food Stamp, Medical and Financial benefits will not affect your immigration status

or the immigration status of your family. Immigration information is private and confidential.



Use of Medicaid benefits by you or your family members should not affect your ability to apply for permanent

resident status unless you use Medicaid to pay for long-term care (nursing home or other institutionalized care).

Use of Medicaid benefits will not affect your ability to apply for citizenship unless you committed fraud in getting

those services.

Medical Only Information



Who do you need to include on this application?

Tell us about all the family members who live with you. If you file taxes, we need to know about everyone

on your tax return. (You don’t need to file taxes to get health coverage). The amount of assistance or type

of program you qualify for depends on the number of people in your family and their incomes. This

information helps us make sure everyone gets the best coverage they can.



Affordable Private Health Insurance and Advanced Premium Tax Credits (APTC)

Information obtained from this application could also be used to determine your eligibility for affordable

private health insurance plans and APTC, which could immediately help you pay your premiums for health

coverage.



Assets and Expenses (Questions 24 - 33)

You are only required to answer these questions if there is anyone in your household who is applying for

Aged (65+), Blind or Disabled Medicaid, Spenddown Medicaid, Nursing Home, Waiver, Medicare Cost

Sharing, and/or Refugee Medical.

Expedited Food Stamp Information

The following households are entitled to expedited services:



Households whose combined monthly gross income and liquid resources are less than the household’s monthly

utilities and rent or mortgage.



Households with less than $150 in monthly gross income and whose liquid resources (cash, savings, checking

accounts, etc.) are no more than $100.



Some migrant and seasonal farm worker households.

Let us know if you disagree with the decision made on your case about Expedited Food Stamps and a meeting will be

scheduled for you within two (2) working days.

HOUSEHOLD AND GENERAL INFORMATION

4. List everyone who is living in your household and applying for benefits:

U.S. Citizen/

Utah Resident

Utah

Marital

Birth

Gender

First and Last Name

Relationship

Resident

Social Security #

National

Since

Race

Ethnicity

Date

M / F

Status

Yes/No

(ex: 1/1/2013)

Self

Social Security Number and Citizenship information are only needed for the people applying for benefits. If someone wants help getting a Social Security

Number, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.

Utah Resident Since is optional for all programs

Race (optional):

AI = American Indian or Alaska Native (For medical applicants only, complete Attachment A)

GC = Guamanian or Chamorro

ASI = Asian Indian

CH = Chinese

JA = Japanese

KO = Korean

OPI = Other Pacific Islander

FI = Filipino

VI = Vietnamese

AS = Asian

OA = Other Asian

BL = Black or African American

SA = Samoan

NH = Native Hawaiian

OT = Other

WH = White

Ethnicity (optional):

N = Not Hispanic , Latino or Spanish Origin

M = Mexican

MA = Mexican American

CH = Chicano/a

PR = Puerto Rican

CU = Cuban

AH: Another Hispanic, Latino or Spanish Origin

OT = Other

Marital Status is not required for Food Stamps

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Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 2

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