Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 8
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29EXPENSES*
* If applying for Medical Assistance - 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.
30. Does anyone in your household pay alimony, child support or
daycare expenses? ..................................................................................
Yes
No
If yes, complete all columns:
D34314000240829
Person
How
Date
Amount
Type
Paying This
Who For?
Often
This
Paid
Expense
Paid?
Started
Alimony*
Court ordered?
Yes
No
*Not required for Food Stamps
Child Support
Court ordered?
Yes
No
Out-of-Pocket Daycare
Name of daycare provider:
I need child care so I can:
Accept/Continue Employment
Seek Employment
Attend School
Attend Training
Other:
31. Is anyone in your household responsible to pay any of the following expenses? …….................……
Yes
No
If yes, complete all columns:
Does this person
How often is
Amount
Who pays this
Date This
Type
live in your home?
this expense
Paid
expense?
Started
Yes/No
paid?
Rent, Subsidized Rent, Rental
Insurance
Mortgage, Second Mortgage, Home
Equity Loan, Property Taxes
Home Owners Insurance, HOA,
Condo Fees
Trailer/Lot Space
32. Is anyone in your household responsible to pay any of the following utility expenses separately from rent and/or
mortgage? ............................................................................................................................................
Yes
No
If yes, mark all that apply:
Gas or electricity for heating and/or cooling my
I received HEAT assistance in the last 12 months
home
I am homeless. However, I pay some monthly
Telephone
heating/cooling expenses
Electricity, Water, Sewer, Garbage
33. Does anyone in your household who is at least 60 years old or disabled have any medical expenses?
Yes
No
(Expenses must be reported and some expenses must be verified by your household to receive a deduction.)
If yes, complete all columns:
Person Paying
Amount
How Often
Date This
Type
Who For?
This Expense
Paid
Paid?
Started
Dental Care, Dentures
Medical / Medicare Insurance
Hearing Aids
Home Health Care
Hospitalization or Outpatient Care
Medical Services
Mental Health Services
Nursing Home Care
Prescription Drugs
Prescription Eye Glasses
Service Animal
(ex: Food, Veterinary
bills, etc.)
Other:
Page 8
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