Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 4
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298. This question is not required for Food Stamps:
Is anyone in your household currently pregnant or has anyone been pregnant in
the past 3 months? ….........................................................................
Yes
No
If yes, who?________________________________________________________
Due date (if still pregnant): ____________________________________________
If yes, how many babies are expected during this pregnancy? ________________
D34314000240429
Has she smoked or used tobacco in the past 6 months? ..........
Yes
No
(This question is for survey purposes only and does not affect eligibility)
9. Is anyone in your household living in an institution? ……………….…
Yes
No
If yes, check which applies:
Hospital/Medical Facility
Shelter
Drug/Rehab Center
Group Home
Nursing Home
Jail - If yes, on work release? …………...
Yes
No
Who? ________________ Name of
institution:
___________________ Date entered the institution: ____________
10. Does anyone in your household have a disability (a physical, mental or emotional health condition
that causes limitations in activities like bathing, dressing, daily chores, etc.)? .......................................
Yes
No
If yes, who? ___________________________________ Start date of disability:____________________________
Is the disability permanent or temporary? ____________ If temporary, how long is it expected to last? __________
Disability/Incapacity determined by:
SSA Disability Recipient
SSI Recipient
(VA) Veterans Affairs
Medical Statement
Railroad Retirement Board
State Medical Disability Office
Other: _________________________
If the disabled person is the parent(s), is he/she able to care for their children? ..........................
Yes
No
Is the disabled person a child? ...................................................................................................
..
Yes
No
.
11. This question is not required for medical assistance:
Has anyone in your household ever applied for or received Food Stamp, Financial or Medical
Benefits in Utah or any other state? ………………………………….......................................................
Yes
No
Name
Type of Assistance
Where? (list all states)
When?
Date Ended?
12. Answer the following question only for individuals who are applying for benefits:
If anyone in your household is not a U.S. Citizen or U.S. National, do they have eligible immigration
status? ...................................................................................................................................................
Yes
No
If yes, complete all columns:
Alien Registration
Immigration
Have you lived in the
Document ID Number
Name
Number
Document Type
U.S. since 1996?
(if different from A#)
Yes
No
Yes
No
Yes
No
This part of the question is not required for Food Stamps or Child Care:
Is anyone listed in question #11 a Veteran, an active-duty member of the U.S. Military or has a
spouse or parent who is a Veteran or an active-duty member of the U.S. Military?.............................
Yes
No
If yes, who? __________________________________________________________________
13. Is anyone in your household attending school? ....................................................................................
Yes
No
If yes, complete all columns:
Expected Graduation Date
Name of Student
School Name / Type
Full Time / Part Time
(If Over 16 Years Old)
Page 4
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