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Application for Assistance HW 2000 | REV 08/14/2020 Food Assistance The Supplemental Nutrition Assistance Program (SNAP) helps families buy food for good health. Eligible families get a debit-like card to buy food items. Participants may be required to participate in work programs and cooperate with Child Support Services. Benefits are prorated from your application date. Cash Assistance The Temporary Assistance for Families in Idaho program (TAFI) provides cash assistance for emergency situations to families with children. Eligible families receive a one-time or ongoing payment, depending on the needs of the household. The Aid to the Aged, Blind, and Disabled (AABD) program provides cash assistance to individuals eligible for SSI and who meet other guidelines. Health Coverage Assistance Health Coverage Assistance (HCA) is available according to individual needs. Eligible families may qualify for Medicaid or Advance Payment of Premium Tax Credit (APTC) to help pay health coverage premiums or affordable private health insurance plans. Child Care Assistance The Idaho Child Care Program (ICCP) helps parents and caretakers pay for a part of their child care costs while working, going to school, or participating in approved training activities. Eligible families receive a portion of child care costs paid to the provider. WHO can use this application Anyone can use this application to: • Apply for assistance for themselves and/or their household members • Apply for just one type of assistance or for multiple types of assistance WHAT you may need to apply Attaching proof of the household's income to this application may help us determine your eligibility faster. We may need other proof, such as verification of resources or expenses, to process your application, but we will ask for this only if we need it. RESOURCES to help with this application Online : healthandwelfare.idaho.gov Phone: 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice) Email : [email protected] In person: Visit our website or call using the number above to find a local office. Language interpretation is available at 1-877-456-1233. See the back of this page for more information on accessibility and interpretation services. WHY we ask for this information We keep all information private and secure, as required by law. We ask for this information for a few reasons: • To figure out what types of assistance you qualify for • To figure out how much assistance you qualify for • To make sure you get the right amount of assistance based on your situation Equal opportunity for applicants In accordance with federal law and U.S. Department of Agriculture (USDA) and Health and Human Service (HHS) policy, the Idaho Department of Health and Welfare is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited on the basis of religion or political beliefs. To file a complaint of discrimination, contact USDA or HHS at: U.S. Department of Agriculture U.S. Department of Health & Human Services Office of the Assistant Secretary for Civil Rights Room 506F, 200 Independence Avenue, SW 1400 Independence Avenue, SW Washington, D.C. 20201 Washington, D.C. 20250-9410 Fax: 202-690-7442 Email: [email protected] Email: [email protected] Phone: 202-619-0403 (Voice) 202-619-3257 (TTY) HOW to submit this application Send your complete, signed application to: Self-Reliance Programs - Statewide Application Team Fax: 1-866-434-8278 PO Box 83720 Email: [email protected] Boise, ID 83720-0026 Eligibility determinations are based on the rules and requirements which pertain to the program you are applying for. We will tell you if you're eligible or not, or give you further instructions for completing your application. You also can check the status of your application online at idalink.idaho.gov. English ATTENTION: Language assistance services, free of charge, are available to you. Call 1-877-456-1233. Tagalog (Tagalog/ Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-456-1233. Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-456-1233. Русский (Russian) ВНИМАНИЕ : Если вы говорите на русском языке , то вам доступны бесплатные услуги перевода . Звоните 1-877-456-1233. 繁體中文 (Chinese) ၄ᛧ൓፿܍אױΔ൞֮᜗᧯խشࠌ࣠൞ڕࣹრΚ ߢགܗࣚ೭Ζᓮીሽʳ 1-877-456-1233 Ζ Français (French) ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-456-1233. Srpsko- hrvatski (Serbo- Croatian) OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezi č ke pomo ć i dostupne su vam besplatno. Nazovite 1-877-456-1233. 日本語 (Japanese) 1-877-456-1233 (Korean) : , . 1-877-456-1233 . Român ă (Romanian) ATEN Ț IE: Dac ă vorbi ț i limba român ă , v ă stau la dispozi ț ie servicii de asisten ță lingvistic ă , gratuit. Suna ț i la 1-877-456-1233. न े पाली (Nepali) Úयान Ǒदन ु होस ् : तपार ् इ ं ल े न े पाली ब ? ोãन ु ह ु Ûछ भन े तपार ् इ ं को िनǔàत भाषा सहायता स े वाहǾ िनःश ु ãक Ǿपमा उप ? लÞध छ । फोन गन [ ? ु होस ् 1-877-456-1233 । Ikirundi (Bantu- Kirundi) ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-877-456-1233. Ti ế ng Vi ệ t (Vietnamese) CHÚ Ý: N ế u b ạ n nói Ti ế ng Vi ệ t, có các d ị ch v ụ h ỗ tr ợ ngôn ng ữ mi ễ n phí dành cho b ạ n. G ọ i s ố 1-877-456-1233. فارسی (Farsi) رایگان بصورت زبانی تسھیلات کنید، می گفتگو فارسی زبان بھ اگر : توجھ 1233-456-877-1 تماس بگیرید . شما برای . العربية (Arabic) اللغوية المساعدة خدمات فإن اللغة، اذكر تتحدث كنت إذا : ملحوظة 1233-456-877-1 برقم اتصل . بالمجان لك تتوافر Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-456-1233. Accessibility and interpretation services The Idaho Department of Health and Welfare (IDHW) offers the following services free to you. Please ask if you need the followi ng assistance to communicate more effectively with us: • Assistance in understanding this form • Accommodation for a disability • Language Interpreter To access any of these services, please call: 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice) for those with a hearing impairment. Appeal/Hearing rights You have the right to ask for a hearing if you disagree with the decision made by the Idaho Department of Health and Welfare. You have 90 days to ask for a hearing for SNAP, and 30 days for Temporary Assistance for Families in Idaho (TAFI), Idaho Child Care Program (ICCP), Aid to the Aged, Blind, and Disabled (AABD) cash, Medicaid, and Advance Payment of Premium Tax Credit (APTC). T hese timeframes start the day after IDHW gave or mailed you a notice of the action with which you disagree. Please be advised that a re-evaluation of eligibility will be assessed for all members of the household at the time this appeal is considered. To request a hearing or a legal aid referral: • Call 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice) • Email us at [email protected] • Fill out and submit the Fair Hearing Request Form at mybenefitforms.dhw.idaho.gov. At the hearing, you may represent yourself or use legal counsel, a relative, a friend, or other spokesperson to represent you. idalink idalink is Idaho's online self-service website where you can view information about the benefits you receive, report a change, and apply for other programs offered by IDHW. Registering is easy. Visit idalink.idaho.gov to get started today! Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 1 of 14 Tell us about yourself You will be the primary contact person for this application, even if you may not be applying for assistance for yourself. Would you like to name someone as your authorized representative? If applying for SNAP, you may start the application process immediately by filling out your name and address in the questions a bove and signing below. You must complete the rest of the application and submit it as soon as possible to receive a benefit determinati on. Your filing date is the date we receive an application with your name, address, and signature. You may give a trusted friend, partner, or third party representative permission as an "authorized representative" to talk to the Department, see your information, and act on your behalf for all matters relating to your case. No Yes, complete Appendix A If applying for SNAP , does your household meet one of the following situations? (check all that apply) Your household will have less than $150 income and less than $100 liquid resources (cash, checking, savings) this month Your household's income and resources are less than your monthly housing and utility costs Your household includes a migrant or seasonal farm worker Signature of applicant/authorized representative requesting SNAP Date Printed name of applicant/authorized representative requesting SNAP Which type of assistance are you requesting for yourself? ( check all that apply ) SNAP (Food Assistance) HCA (Health Coverage) TAFI/AABD (Cash Assistance) ICCP (Child Care) None Full name First Middle Last Former names (if any) Last Middle First Social Security number Date of birth Sex Male Female Marital status Married Divorced Separated Widowed Never been married Physical address County Zip State City Street Mailing address (if different) Email Primary phone County Zip State City Street Applying for Food Assistance 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Are you interested in the Medicaid for Workers with Disabilities program? No Yes If you qualify, emergency SNAP benefits can begin within 7 days of the date on this application. If none, what number may we use to leave a message? Phone type: Home Cell Work Information that is optional or not required : • Hispanic or Latino • U.S. citizen or national questions - optional for household members who are not applying for assistance • Race • Social Security number - optional for people not applying and for people applying for emergency health coverage or child care assistance only. However, failure to provide a SSN may result in the denial of SNAP benefits to everyone failing to provide a SSN. • Immunization or federal tax return questions - optional if applying for SNAP only. Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 2 of 14 Pregnant No Yes, complete a and b. a. Due date? b. How many are you expecting? Immunizations up-to-date No Yes Preferred language I nterpretation services are listed on the cover page of this application. Spoken Written Interpreter Do you want an interpreter if you are interviewed? (One will be provided at no cost to you) ¿Quiere usted un interprete si usted sea entrevistado? (Se le proparcionara uno sin costo alguno) No Yes Race White Asian Black/African American Native Hawaiian/Pacific Island, name of Tribe: American Indian/Alaska Native, name of Tribe: Hispanic or Latino? No Yes No Yes No Yes, complete a and b. a. Immigration document type: b. Document ID number: Alien status will be verified with USCIS. The response from USCIS may affect your household's eligibility and benefit amount. Do you plan to file a federal tax return for the CURRENT YEAR? No, skip to c below. Yes, complete a-c. a. Do you plan to file jointly with a spouse? No Yes. If yes, complete i and ii. i. Name of spouse: ii. Name of primary account holder: If your household is approved for Advance Payment of Premium Tax Credit (APTC) and you decide to purchase insurance through Your Health Idaho (YHI), one adult tax filer will be assigned as the primary account holder. Choose which spouse you wish to be assigned as the primary account holder for your household. b. Will you claim dependents? No Yes, complete i. i. Name of dependents c. Will you be claimed as a dependent on someone else's tax return? No Yes, complete i. i. Name of tax filer: Continue telling us about yourself U.S. Citizen or national 21. 19. 18. 17. 16. 15.. 14. 13. If not a U.S. citizen, do you have eligible immigration status? 20. Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 3 of 14 Tell us about everyone in your household Read the questions down the center of the page and fill in the answers and information under each Person. Who you need to include on this application: • Regardless of the types of assistance you apply for, we need information about everyone in your household. • If applying for health coverage assistance for anyone under 65 and not disabled, we need information about everyone you plan to include on your federal tax return this year, even if they don't live with you. Note: You do not need to file taxes to get health coverage. Person 1 First TAFI/AABD None HCA ICCP SNAP Middle Last Female Male Separated Never Married Widowed Divorced Married No Yes No Yes, complete a and b. No Yes No Yes No Yes, complete a and b. American Indian/Alaska Native Native Hawaiian/Pacific Island Black/ African American White Asian No, skip to c. Yes, complete a-c. No Yes. If yes, complete i and ii. No Yes. If yes, complete i. No Yes. If yes, complete i. Person 2 First TAFI/AABD None HCA ICCP SNAP Middle Last Female Male Separated Never Married Widowed Divorced Married No Yes No Yes, complete a and b. No Yes No Yes No Yes, complete a and b. American Indian/Alaska Native Native Hawaiian/Pacific Island Black/ African American White Asian No, skip to c. Yes, complete a-c. No Yes. If yes, complete i and ii. No Yes. If yes, complete i. No Yes. If yes, complete i. Question Types of assistance requested (check all that apply) Relationship to you Name Former names, if any Social Security number Date of birth Sex Marital status Immunizations up-to-date Pregnant Due date How many are you expecting? Hispanic or Latino US citizen or national If not a citizen, has eligible immigration status Immigration document type Document ID number Race Name of Tribe (if applicable) File federal tax return for CURRENT YEAR File jointly with a spouse Name of spouse Name of primary account holder Claiming dependents Name of dependents Claimed as a dependent Name of tax filer 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a. b. 11. 12. 13. a. b. 14. a. 15. a. i. ii. b. i. c. i. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a. b. 11. 12. 13. a. b. 14. a. 15. a. i. ii. b. i. c. i. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a. b. 11. 12. 13. a. b. 14. a. 15. a. i. ii. b. i. c. i. Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 4 of 14 Continue telling us about everyone in your household Read the questions down the center of the page and fill in the answers and information under each Person. Person 3 First TAFI/AABD None HCA ICCP SNAP Middle Last Female Male Separated Never Married Widowed Divorced Married No Yes No Yes, complete a and b. No Yes No Yes No Yes, complete a and b. American Indian/Alaska Native Native Hawaiian/Pacific Island Black/ African American White Asian No, skip to c. Yes, complete a-c. No Yes. If yes, complete i and ii. No Yes. If yes, complete i. No Yes. If yes, complete i. Person 4 Question Types of assistance requested (check all that apply) Relationship to you Name Former names, if any Social Security number Date of birth Sex Marital status Immunizations up-to-date Pregnant Due date How many are you expecting? Hispanic or Latino US citizen or national If not a citizen, has eligible immigration status Immigration document type Document ID number Race Name of Tribe (if applicable) File federal tax return for CURRENT YEAR File jointly with a spouse Name of spouse Name of primary account holder Claiming dependents Name of dependents Claimed as a dependent Name of tax filer 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a. b. 11. 12. 13. a. b. 14. a. 15. a. i. ii. b. i. c. i. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a. b. 11. 12. 13. a. b. 14. a. 15. a. i. ii. b. i. c. i. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. a. b. 11. 12. 13. a. b. 14. a. 15. a. i. ii. b. i. c. i. First TAFI/AABD None HCA ICCP SNAP Middle Last Female Male Separated Never Married Widowed Divorced Married No Yes No Yes, complete a and b. No Yes No Yes No Yes, complete a and b. American Indian/Alaska Native Native Hawaiian/Pacific Island Black/ African American White Asian No, skip to c. Yes, complete a-c. No Yes. If yes, complete i and ii. No Yes. If yes, complete i. No Yes. If yes, complete i. Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 5 of 14 Tell us about your household situation 1. Is anyone in your household applying for or already receiving tribal commodities? No Yes, who? 2. Is anyone in your household applying for or already receiving foster care or adoption assistance? No Yes, who? 3. Was anyone in your household in Idaho foster care when they turned 18? ( If applying for SNAP only, skip this question ) No Yes, who? 4. Is anyone in your household currently receiving assistance from another state? No Yes, complete a-c. a. Dates of assistance From (month/year): To (month/year): b. Where assistance is received from c. Type of assistance received 5. Is anyone in your household 65 or older? No Yes, who? 6. Is anyone in your household disabled? No Yes, who? 7. Does anyone who is applying have a pending application for Social Security Disability? No Yes, who? 8. Is anyone in your household working and believe that they would meet disability status as determined by the Social Security Administration? No Yes, who? 9. If applying for HCA, does anyone who is applying need medical services in the home? ( If applying for SNAP only, skip this question ) No Yes, who? 10. Does anyone who is applying live in a medical care facility or receive in-home care? ( If applying for SNAP only, skip this question ) 1. Did any member of your household recently lose or expect to lose health insurance coverage within the next 60 days? 2. Did any member of your household recently become a citizen or lawful immigrant in the US? 3. Did any person move into or leave your household? 4. Did any existing tax filer in your household recently gain a new tax dependent? 5. Did your household recently move to Idaho? 6. Did your household recently move within Idaho? 7. Did your household income recently change? Tell us about your qualifying life event Complete this section if anyone in the household is applying for Health Coverage Assistance. This information may be necessary as part of your eligibility determination for Advance Payment of Premium Tax Credit (APTC). If applying for SNAP only, skip to page 6. Complete the questions below based on any life events within the last 60 days, unless otherwise noted. Increase Decrease How ? No Yes, who? No Yes, who? No Yes, when? No Yes, when? No Yes, when? No Yes, who? No Yes, who? Why? Other Divorced Got married Had a baby Adopted or is fostering a child No Yes, complete a-d. a. Who? City County State Other: Child care Medicaid AABD TANF/Cash SNAP c. Facility/provider name d. Facility/provider phone b. Facility/provider type Certified Family Home Assisted Living Facility Nursing home In-home care Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 6 of 14 Continue telling us about your household situation 1. Has anyone in your household been disqualified from public assistance due to an intentional program violation? No Yes, who? 2. Has anyone in your household been convicted of a felony? No Yes, who? 3. Is anyone in your household fleeing to avoid felony prosecution or jail time? No Yes, who? 4. Has anyone in your household been convicted of trading Food Stamp benefits for guns, ammunitions, or explosives? No Yes, who? 5. Has anyone in your household been convicted of buying or selling SNAP benefits over $500? 6. Has anyone in your household been convicted of receiving duplicate SNAP benefits in any state? No Yes, who? 7. Is anyone in your household currently violating conditions of probation or parole? 8. If applying for ICCP, is anyone in your household participating in a work/training program provided by a homeless shelter? 9. Has anyone in your household received $3,500.00 or more in lottery or gaming winnings (at one time) within the last 12 months? No Yes, date of winning: 10. Is anyone listed on this application currently incarcerated? No Yes, who? Tell us about students Tell us about any applicant between the ages of 16 and 49 who is attending school (high school or higher education). Student name School name How many hours per week does the student attend school? Anticipated graduation date School type (check one) a. Degree type b. Status c. Was the student awarded work study? d. Are all classes online? Question Person 2 Person 1 Read the questions down the center of the page and fill in the answers and information under each Person. High School College, complete a-d. Undergraduate Graduate Full time Half time Less than half time No Yes No Yes Are they in compliance with their sentencing requirements? No Yes High School College, complete a-d. Undergraduate Graduate Full time Half time Less than half time No Yes No Yes When? State: No Yes, who? No Yes, who? No Yes, have the agency complete the Child Care Activity Form . This form can be found at mybenefitforms.dhw.idaho.gov. If applying for health coverage only, and all household members are under 65 and not disabled, skip to question 10. (dd/mm/yyyy) Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 7 of 14 Other Parent 1 Child's name Name of parent not in the home Former names of parent not in home, if any Social Security number and sex Date of birth and/or approximate age Physical address Mailing address (if different) Email address Phone number Last known employer Last known employer city Other Parent 2 Question First MI DOB SSN Last Age M F City Street State County Street Zip State City Zip First MI DOB SSN Last Age M F City Street State County Street Zip State City Zip 1. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. Child's name 1. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. Complete the following for each child who has a parent (or parents) NOT living with them. Any information will be provided to Child Support Services in order to pursue a child support case if eligible. You must cooperate with Child Support Services. If you do not wish to open a child support case, you must contact us by dialing 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice). Tell us about parents not in the home Read the questions down the center of the page and fill in the answers and information under each Parent. Other Parent 3 Name of parent not in the home Former names of parent on in home, if any Social Security number and sex Date of birth and/or approximate age Physical address Mailing address (if different) Email address Phone number Last known employer Last known employer city Other Parent 4 Question First MI DOB SSN Last Age M F City Street State County Street Zip State City Zip First MI DOB SSN Last Age M F City Street State County Street Zip State City Zip 1. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. Child's name 1. Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 8 of 14 Number of years in business Average hours worked each week Income from a job - Tell us about any income this person gets from working a job. Employer's name Employer's phone number Average hours worked each week Name of person with income: Wages/tips ( before taxes) How often paid? (check one) Is income expected to change? No Yes, why? (raise, hours changes, etc.) Name of business Type of work Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is zero, indicate this by writing "0" or "none" for the estimated gross income question. Estimated gross income this month Source of income Amount Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits, cash gifts, and gaming/lottery winnings. How often paid? (check one) Income from alimony - Tell us about any alimony this person receives. Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Alimony source How often paid? (check one) Semi-monthly, which days (i.e.: 5th & 20th)? Every 2 weeks Yearly Monthly Weekly Alimony amount Date ordered by judge (month/year ) Source of income Amount How often paid? (check one) Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Income 2 Number of years in business Average hours worked each week Income from a job - Tell us about any income this person gets from working a job. Employer's name Employer's phone number Average hours worked each week Name of person with income: Wages/tips ( before taxes) How often paid? (check one) Is income expected to change? No Yes, why? (raise, hours changes, etc.) Name of business Type of work Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is zero, indicate this by writing "0" or "none" for the estimated gross income question. Estimated gross income this month Source of income Amount Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits, cash gifts, and gaming/lottery winnings. How often paid? (check one) Income from alimony - Tell us about any alimony this person receives. Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Alimony source How often paid? (check one) Semi-monthly, which days (i.e.: 5th & 20th)? Every 2 weeks Yearly Monthly Weekly Alimony amount Date ordered by judge (month/year ) Source of income Amount How often paid? (check one) Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Note: If applying for health coverage only, and all household members are under 65 and not disabled , report your taxable income . For all other programs, tell us about all income your household receives. This includes any money received by an adult, or by children, aged 16 or older, and not attending high school. We want to know about the last 30 days, as well as any money received quarterly or annually. We also want to know about income from any job you have just started or will start within the next 30 days. Types of income include: Tell us about your household income Earned Wages or salary from: • Unemployment benefits • Gaming/lottery winnings • Rental income • Social Security/Veterans • Disability income • Retirement/Pension income Unearned Income from sources such as: Income 1 • Job • Self-employment (including owning your own business, odd jobs, baby-sitting, collecting cans, donating plasma, etc.). • Cash gifts • Child Support Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 9 of 14 Number of years in business Average hours worked each week Income from a job - Tell us about any income this person gets from working a job. Employer's name Employer's phone number Average hours worked each week Name of person with income: Wages/tips ( before taxes) How often paid? (check one) Is income expected to change? No Yes, why? (raise, hours changes, etc.) Name of business Type of work Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is zero, indicate this by writing "0" or "none" for the estimated gross income question. Estimated gross income this month Source of income Amount Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits, cash gifts, and gaming/lottery winnings. How often paid? (check one) Income from alimony - Tell us about any alimony this person receives. Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Alimony source How often paid? (check one) Semi-monthly, which days (i.e.: 5th & 20th)? Every 2 weeks Yearly Monthly Weekly Alimony amount Date ordered by judge (month/year ) Source of income Amount How often paid? (check one) Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Continue telling us about your household income Applying for Health Coverage Assistance Tell us about your Anticipated Annual Income. Your Anticipated Annual Income (AAI) is the gross (before deductions or taxes), taxable income (earned and unearned) you expect to receive for your entire household for the current year (Jan.-Dec.) . If you know your AAI please enter it here: $ If you do not know your AAI for this year, you can calculate it using the worksheet in Appendix C. Number of years in business Average hours worked each week Income from a job - Tell us about any income this person gets from working a job. Employer's name Employer's phone number Average hours worked each week Name of person with income: Wages/tips ( before taxes) How often paid? (check one) Is income expected to change? No Yes, why? (raise, hours changes, etc.) Name of business Type of work Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is zero, indicate this by writing "0" or "none" for the estimated gross income question. Estimated gross income this month Source of income Amount Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits, cash gifts, and gaming/lottery winnings. How often paid? (check one) Income from alimony - Tell us about any alimony this person receives. Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Alimony source How often paid? (check one) Semi-monthly, which days (i.e.: 5th & 20th)? Every 2 weeks Yearly Monthly Weekly Alimony amount Date ordered by judge (month/year ) Source of income Amount How often paid? (check one) Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)? Monthly Yearly Income 4 Income 3 Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 10 of 14 Current value Owner Year, make, model Primary use (choose one) Used for self-employment business Medical reasons/transport disabled person(s) Travel to and from work Recreational Residence Income producing (taxi, ride-sharing, deliveries, etc.) Personal/Everyday use Seeking employment Other Tell us about all vehicles, including cars, trucks, motorcycles, trailers, boats, snowmobiles, and other recreational vehicles that your household owns. Motor Vehicles Current value Owner Year, make, model Primary use (choose one) Used for self-employment business Medical reasons/transport disabled person(s) Travel to and from work Recreational Residence Income producing (taxi, ride-sharing, deliveries, etc.) Personal/Everyday use Seeking employment Other I f applying for health coverage only, and all household members are under 65 and not disabled, skip to page 13. Otherwise, complete this section. Tell us about your vehicles and bank accounts Current Balance Account Type Current Balance Tell us about all bank accounts your household has. Checking/Savings Primary Account Holder Name of Financial Institution Account Number Account Type Current Balance Primary Account Holder Name of Financial Institution Account Number Account Type Current Balance Primary Account Holder Name of Financial Institution Account Number Account Type Primary Account Holder Name of Financial Institution Account Number Current value Owner Year, make, model Primary use (choose one) Used for self-employment business Medical reasons/transport disabled person(s) Travel to and from work Recreational Residence Income producing (taxi, ride-sharing, deliveries, etc.) Personal/Everyday use Seeking employment Other Current value Owner Year, make, model Primary use (choose one) Used for self-employment business Medical reasons/transport disabled person(s) Travel to and from work Recreational Residence Income producing (taxi, ride-sharing, deliveries, etc.) Personal/Everyday use Seeking employment Other Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 11 of 14 What asset What asset Amount received Fair market value What asset Amount received Fair market value Owner Date of Transaction Sale or transfer of resources and property Tell us about everyone in your home who has sold, transferred, or given away cash, property, vehicles, or other assets within the last five years. Owner Date of Transaction Resource Type Current Value Resource Type Current Value Tell us about all resources your household owns, including cash on-hand, stocks, bonds, mutual funds, 401Ks, IRAs, trusts, CDs, life insurance policies, burial funds, etc. Resources Owner Name of Financial Institution Account Number Owner Name of Financial Institution Account Number Resource Type Current Value Owner Name of Financial Institution Account Number Property type Value Property type Value Tell us about all other property (including your home) owned by anyone in your household. This includes land, buildings, rental properties, etc. Property Owner Property address Primary use Home Rental income Business/Self-employment Other: Owner Property address Primary use Home Rental income Business/Self-employment Other: I f applying for health coverage only, and all household members are under 65 and not disabled, skip to page 13. Otherwise, complete this section. Tell us about your resources and property Property type Value Owner Property address Primary use Home Rental income Business/Self-employment Other: Property type Value Owner Property address Primary use Home Rental income Business/Self-employment Other: What asset Amount received Fair market value Owner Date of Transaction What asset Amount received Fair market value Owner Date of Transaction Amount received Fair market value Owner Date of Transaction Resource Type Current Value Owner Name of Financial Institution Account Number Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 12 of 14 Amount you pay How often you pay If applying for health coverage only, and all household members are under 65 and not disabled, skip to page 13. Otherwise, complete this section. Tell us about your household expenses Tell us about your shelter expenses. When telling us the amount of each expense, include only the amount YOU pay. Shelter expenses Rent (for residence) Space rent Mortgage No Yes, monthly amount: No Yes, monthly amount: No Yes, monthly amount: Does your mortgage amount include any of the following expenses: If you do not pay a mortgage expense, indicate this by writing "0" or "none" in the expense field. Yes No, monthly amount: Irrigation Property tax HOA fees Homeowners insurance Yes No, monthly amount: Yes No, monthly amount: Yes No, monthly amount: Check the boxes for each utility you pay that is NOT included in your rent or mortgage Heating Cooling Water Sewer Trash Telephone 2nd Mortgage No Yes, monthly amount: Phone number Landlord's Name Amount you pay Amount you pay Amount you pay Provider's phone number Tell us about any child care, adult disabled care, or elderly care you pay. If applying for ICCP, your provider must also complete a Child Care Provider form, found at mybenefitforms.dhw.idaho.gov. Dependent care expenses Dependent's name Provider's name Provider's address Total charge for care How often you pay Provider's phone number Dependent's name Provider's name Total charge for care How often you pay Provider's phone number Dependent's name Provider's name Provider's address Total charge for care How often you pay Provider's address Amount you pay How often you pay How often you pay Amount you pay Tell us about any court ordered child support expense or arrears you pay to someone who is not in your household. Child Support Expense Name of person with expense Who receives payment? Name of person with expense Who receives payment? Tell us about any individual expenses ONLY for the individuals in your household who are 65 or older (60 if applying for SNAP) or disabled. Allowable expenses include some medical expenses and health insurance premiums you pay. Individual Expenses Name of person with expense Expense type Amount paid How often paid Name of person with expense Expense type Amount paid How often paid Name of person with expense Expense type Amount paid How often paid Name of person with expense Who receives payment? Name of person with expense Expense type Amount paid How often paid Your Food Stamps may increase if you have expenses such as child or adult care costs, child support paid for children not livin g with you, housing costs, medical costs (including prescriptions) for people with disabilities or who are over 65, and utility costs. However, if you do not repo rt or verify any of these expenses, it will mean that you do not want a deduction for the unreported or unverified expenses. Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 13 of 14 If applying for SNAP or ICCP only, skip to page 14 . Tell us about your health coverage situation Does anyone who is applying for HCA want help paying for medical costs from the last three (3) months ? 1. No Yes, complete a and b. a. Name of person with costs: b. For which of the last 3 months do you need assistance? Include the gross household income (before taxes) received by your family in each of those months. Month name: Gross income for month: Month name: Gross income for month: Month name: Gross income for month: 2. Is anyone who is applying for HCA currently receiving coverage from any of the following: CHIP Medicare TRICARE VA Health Care Employer Insurance Peace Corps Other No Yes, who? No Yes, who? No Yes, who? No Yes, who? No Yes, who? No Yes, who? No Yes, who? Insurance carrier: Was this coverage purchased from the insurance marketplace? No Yes Does anyone have access to health insurance from a job? 3. No Yes, complete Appendix B. Are any children (under the age of 19) who are applying, currently receiving health coverage? 4. No Yes, complete a and b for each child receiving coverage. b. Which of the following services are covered by this child's health insurance? (check all that apply) a. Name of child: X-ray services Lab services Physicians medical/ surgical services Inpatient/outpatient hospital services (Check "yes" even if the coverage is from someone else's job, such as a parent or spouse). b. Which of the following services are covered by this child's health insurance? (check all that apply) a. Name of child: X-ray services Lab services Physicians medical/ surgical services Inpatient/outpatient hospital services b. Which of the following services are covered by this child's health insurance? (check all that apply) a. Name of child: X-ray services Lab services Physicians medical/ surgical services Inpatient/outpatient hospital services Copy this page or attach another sheet if you need to provide more information than space allows. HW2000 | Rev. 08/14/2020 Page 14 of 14 Read and initial each statement below if anyone is applying for HCA Read and initial the statement below if anyone is applying for TAFI or AABD Rights and Responsibilities I understand that all adult household members may be responsible for repaying benefits if the household received benefits it was not entitled to receive. This applies to an over-issuance of benefits as a result of an agency error, an inadvertent household error, and intentional program violations. If a there is an overpayment of benefits to your household, the information on this application, including all adult SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies for collection action. I am required to report when my household's monthly income exceeds the gross limit for my household size. Information available through the Income Eligibility Verification System (IEVS), and other online sources, is used and may be verified through a third-party contact when differences are discovered between the system and what you report. This information may affect your eligibility and level of benefits. I will be notified of the right to appeal Department decisions and I can contact the Department for information on the appeal process. I may be required to cooperate with state or federal reviewers who are making sure my benefits are correct. I may not be eligible to receive benefits if I do not cooperate. I consent to the gathering, use, and disclosure of my information, including my SSN, by the Idaho Department of Health and Welfare or its designees. I understand the information is needed for the purpose of providing benefits or services, obtaining payment for my benefits or services, and for normal business operations of the Department. My signature indicates I have received a copy of the Department Privacy Practices. This information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials, for apprehending persons fleeing to avoid the law. My signature certifies that the information on this application is true and accurate. I could be sanctioned and required to return any benefit I receive if my information is not true. Sanctions may include administrative, civil, or criminal actions against me, including prosecution. I have the right to revoke this consent, in writing, at any time, except to the extent the Department has already used and disclosed my information. If I revoke this consent, the Department will not provide further benefits or services. I consent to the gathering and use of income data, including information from the Internal Revenue Service (IRS), for determining eligibility for help paying for health coverage in future years (up to 5 years). I will receive notice when this occurs, be able to make changes, and may opt out at any time. I have the right to revoke this consent, in writing, at any time except to the extent the Department has already used and disclosed my information in reliance on this consent. If I revoke this consent, I will not be eligible for APTC. If I receive Medicaid after age 55, my estate may be subject to recovery of medical expenses paid on my behalf, and that any transfer of assets may be set aside by a court if I do not receive adequate value. I have the right to choose a Healthy Connections primary care doctor to request referrals for services, and to change the doctor/clinic if my circumstances change. My signature or the signature of my representative authorizes state offices to communicate with insurance companies related to my/my child's medical assistance. If I am determined eligible for Medicaid, the plan I will be enrolled in depends on my individual needs. If I am determined eligible to receive a tax credit (also known as APTC) and use these funds towards the purchase of a Qualified Health Plan (QHP), any discrepancies between my reported income, which was used to determine eligibility, and the amount of the tax credit, will be reconciled with the final income reported on my taxes at the end of the calendar year. The IRS will be responsible for conducting this reconciliation, and any discrepancies may result in an adjustment of the tax credit, including entitlement to additional credits or re-payment of credits received by me. It is illegal to give my EBT card away or to trade the benefits on my card for cash, firearms, drugs, or other goods and services. Penalties include fines, imprisonment, and disqualification from future benefits. The benefits I receive are for me and members of my household only. I may not use my SNAP benefits on individuals outside of my household. To receive SNAP, I may be required to participate in work programs. Failure to do so may result in a loss or decrease in benefits. If I receive cash assistance (TAFI or AABD), I may not withdraw cash benefits or use cash benefit funds to purchase products and services in gambling establishments, liquor and tobacco stores, adult entertainment venues, other establishments prohibiting persons under the age of 18, or tattoo, body piercing, or other branding parlors. If I am determined eligible for the Idaho Child Care Program (ICCP), I may be responsible for paying part of my child care costs. Read and initial each statement below for all types of assistance. Read and initial each statement below if anyone is applying for SNAP , formerly Food Stamps. Read and initial the statement below if anyone is applying for ICCP Printed name of applicant/authorized representative Printed name of applicant/authorized representative Date Date As part of my application, I understand that IDHW will open a Child Support case and I must cooperate with Child Support Services. Signature (must be completed) Under penalty of perjury, I swear or affirm the information I have provided is true and complete. My signature confirms that I have read and understand the Rights and Responsibilities listed on this page and my reporting requirements. Signature of applicant/authorized representative Signature of applicant/authorized representative Phone type Authorized Representative Form Appendix A You may give a trusted person, such as a friend, partner, third party caseworker or an organization permission to talk about th is application with us, see your information, and act for you on all matters related to this application, including getting information about your applicat ion and signing your application and/or renewal information on your behalf. This person is called an "authorized representative." If you ever need to change your authorized representative or revoke the access to your information, contact the Department to c omplete a new Authorized Representative Form or to update your information about who can access your account. If you are a legally appointed representative for someone on this application, you must submit proof, such as Power of Attorney , with the application. Full name First Middle Last Social Security number Date of birth 1. 3. 2. Tell us about yourself Full name First Middle Last Relationship to applicant Organization name Organization ID (if applicable) 1. 2. 1. 2. Tell us who you want to name as your authorized representative Mailing address County Zip State City Street 3. Phone 4. Email 5. Home Work Cell Date Signature of authorized representative Printed name of authorized representative As an authorized representative, I understand that I agree to maintain the confidentiality of any information regarding the app licant or beneficiary provided by the Department of Health and Welfare. For Healthcare programs, I understand that any person who knowingly and will fully uses or discloses information in violation of section 1411(g) of the Affordable Care Act will be subject to a Civil Monetary Penalty (CMP) of not more than $25,000 as adjusted annually under 45 CFR part 102 per person or entity, per use or disclosure, consistent with the bases and process for imposing civil penalties specified at §155.285, in addition to other penalties that may be prescribed by law. Signature Complete this section for an organization to be your authorized representative Mailing address County Zip State City Street 3. Phone 4. Email (if applicable) 5. Date Signature of applicant Printed name of applicant (In the case of an Organization, please provide a name of someone attesting to the terms and conditions of this form) a. If the employer has wellness programs, provide the premium amount that the employee would pay if he/she received the maximum discount for any tobacco-cessation programs, and did not receive any other discounts based on wellness programs. Please complete this section for the lowest-cost plan that meets the minimum value standard** offered only to the employee (do not include fami ly plans). Employee Information Complete this appendix if someone in the household has access to or is currently receiving health coverage from a job. Attach a copy of this page for each job that offers coverage. You do not need to complete this appendix if applying for SNAP or ICCP only. Full name Address Phone Social Security number Did you miss your employer's open enrollment period and do you have to wait until the next open enrollment period? a. If you're in a waiting or probationary period, when can you enroll in coverage? (MM/DD/YYYY): List everyone who is eligible for coverage from this plan Health Plan Information (must be completed by employer) No Yes $ Yearly Quarterly Monthly Twice a month Every 2 weeks Weekly Name of person completing form Who may we contact about employee health coverage at this job (if different) ? Employer Signature (must be completed) Signature of employer Date * An employer-sponsored health plan meets the "Minimum Essential Coverage" if it meets the essential health benefits as defined in 1302(a) of the Affordable Care Act. ** An employer-sponsored health plan meets the "Minimum Value Standard" if the plan's share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (section 36B9c09209C0(ii) of the Internal Revenue code of 1986. Health Coverage from Employers Appendix B First Middle Last Street Email Yes No, complete a. Does the plan meet Minimum Value Standard?** Does the plan meet Minimum Essential Coverage (MEC)?* No Yes, complete a. How much would the employee have to pay in premiums for this plan? How often is the premium paid? Employer Information Company name Email Phone number Under penalty of perjury, I swear or affirm the information I have provided is true and complete. City State Zip Name of person with income: Name of person with income: Include Social Security Disability and Social Security retirement benefits. DO NOT subtract any payments you make out of your entitlement amount. DO NOT include Social Security Survivors or Supplemental Social Security Income (also known as Title XVI) . Social Security income Recipient 1 name: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Complete this worksheet if anyone in your household is applying for health coverage assistance (HCA). We will use the informati on you provide to determine eligibility for the Advance Payment of Premium Tax Credit (APTC). You do not need to complete this appendix if you are only applying for SNAP. Anticipated Annual Income Worksheet Appendix C Your Anticipated Annual Income (AAI) is the gross, taxable income you expect to receive for the current (January-December) year . Use the tables below to enter gross income (before taxes) for all members of your household for each month of the current year. If you need help determining who to count in your household, see page one of this application. Ask for or make a copy of this worksheet if you have more than two household members with income. Income is money earned (wages or salary) from a job or self-employment (including owning your own business, doing odd jobs, babysitting, collecting cans, donating plasma, etc.). Enter any self-employment income as net (instead of gross) income. Earned income Income source 1: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Income source 2: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Income source 1: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Income source 2: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Recipient 2 name: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Name of person with income: Name of person with income: Include taxable income such as rental, retirement, unemployment, and gaming/lottery winnings. Unearned income Income source 1: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Income source 2: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Income source 1: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Income source 2: Jan: Feb: Mar: Apr: May: Jun: Jul: Aug: Sep: Oct: Nov: Dec: Add all figures together that you entered into the tables above. Enter the total here: $ This is your Anticipated Annual Income. Please enter this figure in the question box on the bottom of page 9 of this application.