Fillable Application For Health Coverage & Help Paying Costs (Hawaii)

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Application For Health Coverage & Help Paying Costs (Hawaii)

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NEED HELP WITH YOUR APPLICATION? Visit mybenefits.hawaii.gov or call us at 1-800-316-8005. If you need help in a language
other than English, call 1-800-316-8005 and tell the customer service representative the language you need. We will get you help
at no cost to you. TTY users should call 711 or 1-800-603-1201.
DHS 1100 (REV. 12/17) v.2
T H I N G S T O K N O W
State of Hawaii, Department of Human Services
Federal Health Insurance Marketplace
Application For Health Coverage & Help Paying Costs
Who can use this
application?
• Use this application to apply for you or anyone in your family.
• Apply even if you or your child already have health coverage. You
could be eligible for lower-cost or free coverage.
• Families that include immigrants can apply. You can apply for your
child even if you are not eligible for coverage. Applying will not affect
your immigration status or chances of becoming a permanent resident
or citizen.
• If someone is helping you fill out this application, you may need to
complete Appendix C.
Apply faster online
• Apply faster online at mybenefits.hawaii.gov.
• If you want to purchase insurance without help, apply directly at
www.healthcare.gov.
What you may
need to apply
• Social Security Numbers (or document numbers for any legal
immigrants who need insurance).
• Employer and income information for everyone in your family (for
example, from pay stubs, W-2 forms, or wage and tax statements).
• Policy numbers for any current health insurance.
• Information about any job-related health insurance available to your
family.
Why do we ask for
this information?
• We ask about income and other information to let you know what
coverage you qualify for and if you can get any help paying for it. We
will keep all the information you provide private and secure, as
required by law. To view the Privacy Act Statement, go to
mybenefits.hawaii.gov However, if you do not have online access and
would like a copy or need it in a larger font, you may contact customer
service at 1-800-316-8005 (TTY: 711 or 1-800-603-1201) or pick one up
at any of our MQD offices across the state.
What happens
next?
Send your complete, signed application to the address on page 9. If
you do not have all the information we ask for, sign and submit
your application anyway. We will follow-up with you within 1-2 weeks.
You will get instructions on the next steps to complete your health
coverage. If you do not hear from us, visit mybenefits.hawaii.gov or call
1-800-316-8005 (TTY: 711 or 1-800-603-1201). Filling out this
application does not mean you have to buy health insurance.
Get help with this
application
• Online: mybenefits.hawaii.gov
• Phone: Call the Customer Service at 1-800-316-8005 (TTY: 711 or
1-800-603-1201) for assistance with completing and submitting an
application or getting information on the status of your application.
• In person: There may be counselors in your area who can help. Visit
our website or call 1-800-316-8005 (TTY: 711 or 1-800-603-1201) for
more information.
Use this
application to see
what coverage
choices you
qualify for
• Affordable private health insurance plans that offer comprehensive
coverage to help you stay well.
• A new tax credit that can immediately help pay your premiums for
health coverage.
• Free or low-cost insurance from Medicaid or the Children’s Health
Insurance Program (CHIP).
Do you need help in another language? We will get you a free interpreter. Call 1-800-316-8005 to tell us which
language you speak. (TTY: 711 or 1-800-603-1201).
English
您需要其它語言嗎？如有需要, 請致電 1-800-316-8005, 我們會提供免費翻譯服務 (TTY: 711 或 1-800-603-
1201).
Cantonese
En mi niit alilis lon pwal eu kapas? Sipwe angei emon chon chiaku ngonuk ese kamo. Kokori 1-800-316-8005
omw kopwe ureni kich meni kapas ka ani. (TTY: 711 ika 1-800-603-1201).
Chuukese
Avez-vous besoin d'aide dans une autre langue? Nous pouvons vous fournir gratuitement des services d'un
interprète. Appelez le 1-800-316-8005 pour nous indiquer quelle langue vous parlez. (TTY: 711 ou 1-800-603-1201).
French
Brauchen Sie Hilfe in einer andereren Sprache? Wir koennen Ihnen gern einen kostenlosen Dolmetscher
besorgen. Bitte rufen Sie uns an unter 1-800-316-8005 und sagen Sie uns Bescheid, welche Sprache Sie
sprechen.
(TTY: 711 oder 1-800-603-1201).
German
Makemake `oe i kokua i pili kekahi `olelo o na `aina `e? Makemake la maua i ki`i `oe mea unuhi manuahi. E kelepona
1-800-316-8005 `oe ia la kaua a e ha`ina `oe ia la maua mea `olelo o na `aina `e. (TTY: 711 a 1-800-603-1201).
Hawaiian
Masapulyo kadi ti tulong iti sabali a pagsasao? Ikkandakayo iti libre nga paraipatarus. Awaganyo ti
1-800-316-8005 tapno ibagayo kadakami no ania ti pagsasao nga ar-aramatenyo. (TTY: 711 wenno 1-800-603-1201).
Ilokano
貴方は、他の言語に、助けを必要としていますか ? 私たちは、貴方のために、無料で 通訳を用意で
きます。電話番号の、
1-800-316-8005
に、電話して、私たちに貴方の話されている言語を申し出てください。
(TTY: 711 または 1-800-603-1201).
Japanese
다른언어로 도움이 필요하십니까? 저희가 무료로 통역을 제공합니다. 1-800-316-8005 로 전화해서
사용하는 언어를 알려주
십시요
(TTY: 711 또는 1-800-603-1201).
Korean
您需要其它语言吗？如有需要,请致电 1-800-316-8005, 我们会提供免费翻译服务 (TTY: 711 或 1-800-603-
1201).
Mandarin
Kwoj aikuij ke jiban kin juon bar kajin? Kim naj lewaj juon am dri ukok eo ejjelok wonen. Kirtok
1-800-316-8005 im kwalok non kim kajin ta eo kwo melele im kenono kake.
(TTY: 711 ak 1-800-603-1201).
Marshallese
E te mana'o mia se fesosoani i se isi gagana? Matou te fesosoani e ave atu fua se faaliliu upu mo oe. Vili mai i le
numera lea 1-800-316-8005 pea e mana'o mia se fesosoani mo se faaliliu upu. (TTY: 711 po o le 1-800-603-1201).
Samoan
¿Necesita ayuda en otro idioma? Nosotros le ayudaremos a conseguir un intérprete gratuito. Llame al
1-800-316-8005 y diganos que idioma habla.
(TTY: 711 o 1-800-603-1201).
Spanish
Kailangan ba ninyo ng tulong sa ibang lengguwahe? Ikukuha namin kayo ng libreng tagasalin. Tumawag sa
1-800-316-8005 para sabihin kung anong lengguwahe ang nais ninyong gamitin. (TTY: 711 o 1-800-603-1201).
Tagalog
'Oku ke fiema'u tokoni 'iha lea makehe? Te mau malava 'o 'oatu ha fakatonulea ta'etotongi. Telefoni ki he
1-800-316-8005 'o fakaha mai pe koe ha 'ae lea fakafonua 'oku ke ngaue'aki. (TTY: 711 pe 1-800-603-1201).
Tongan
Bạn có cần giúp đỡ bằng ngôn ngữ khác không ? Chúng tôi se yêu cầu một người thông dịch viên miễn phí cho
bạn. Gọi 1-800-316-8005 nói cho chúng tôi biết bạn dùng ngôn ngữ nào. (TTY: 711 hoặc 1-800-603-1201).
Vietnamese
Việt Nam
Gakinahanglan ka ba ug tabang sa imong pinulongan? Amo kang mahatagan ug libre nga maghuhubad.
Tawag sa 1-800-316-8005 aron magpahibalo kung unsa ang imong sinulti-han. (TTY: 711 o 1-800-603-1201).
Visayan
(Cebuano)
Rev. 08/2019
DHS 1100 (REV. 12/17) v.2 Page 1 of 9
1. First name
Middle name
Last name
Suffix
2. Are you a resident or intend to be a resident of Hawaii?
Yes
No
3. Home address (If Homeless, please write “Homeless” here with appropriate city, state and zip code and mark this box )
4. Apartment or suite
number
5. City
6. State
7. ZIP code
8. County
9. Mailing address (if different from home address)
10. Apartment or suite
number
11. City
12. State
13. ZIP code
14. County
15. Home phone number
16. Work phone number
17. Other phone number
18a. What is your preferred method of contact? Mail Phone Email
18b. Would you like to receive notices regarding your application by email?
Yes
,
Email Address:_________________________________ No
If Yes, please provide your email address and complete Question 9 on this page. Your request to receive electronic notices cannot be
processed if you do not have a mailing address.
19. What is your preferred spoken language (if not English)?
20. What is your preferred written language (if not English)?
21. How many family members live with you?
22. Is any family member you usually live with incarcerated (detained or
jailed) or residing in the Hawaii State Hospital?
Yes
No
If yes
, please list their name(s):
STEP 2
Tell Us About Your Family.
Complete this step for each person in your family. Start with yourself, then add other adults and children. If you have more than
two (2) people in your family, you will need to make a copy of pages 4 and 5 for each additional person and attach the pages to this
application.
You do not need to provide immigration status, but you may need to provide a Social Security Number (SSN) for family members
with income who do not need health coverage. Providing their SSN can help speed up the application process as we use SSNs to
check income and other information to see who is eligible for help with health coverage costs. Without their SSN, we may need to
ask you for more information. We will keep all the information you provide private and secure as required by law.
Who do you need to include on this application?
The following people should be included if they live with you or you are responsible for their care, even if they are temporarily
away (college, deployment, etc.):
• You and your spouse (if married)
• Natural, adoptive, or step children under age 19 years old
• Unmarried partner
• Anyone you include on your tax return (even if they do not live with you)
• Anyone else you take care of under age 19 years old
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
STEP 1
Tell Us About Yourself.
We need one adult in the family to be the contact person for this application.
NEED HELP WITH YOUR APPLICATION? Visit mybenefits.hawaii.gov or call us at 1-800-316-8005. If you need help in a language other than
English, call 1-800-316-8005 and tell the customer service representative the language you need. We will get you help at no cost to you.
TTY users should call 711 or 1-800-603-1201.
CLEAR FORM
DHS 1100 (REV. 12/17) v.2 Page 2 of 9
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
STEP 2: PERSON 1
Start With Yourself
Complete Step 2: PERSON 1 for yourself.
1. First name
Middle name
Last name
Suffix
2. Relationship to PERSON 1
SELF
3. Date of birth (mm/dd/yyyy) / /
4. Gender Male
Female
5. Name of spouse if married
6. Social Security Number (SSN) - -
We need this if you want health coverage and have a SSN. Providing your SSN can be helpful if you do not want health coverage since it can speed up
the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone wants
help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778.
7. Do you plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you do not file a federal income tax return.)
Yes
. If
yes
,
please answer questions a–c.
No. If no,
skip to question c.
a. Will you file jointly with a spouse?
Yes
No
If
yes
, write name of spouse
:
b. Will you claim any tax dependents on your tax return?
Yes
No
If
yes
, write name(s) of dependents:
c. Will you be claimed as a tax dependent on someone’s tax return?
Yes
No
If
yes
, write the name of the tax filer: ___________________________________________
How are you related to the tax filer?
8. Are you pregnant? Yes No If yes, how many babies are expected during this pregnancy? ____ Expected Due Date: ________________
9. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.)
Yes
. If
yes
, answer all the questions below.
No. If no,
SKIP to the income questions on page 3.
Leave the rest of this page blank.
10. Do you have a disability that will last more than twelve (12) months?
Yes
No
a.
Do you currently receive long-term care nursing services?
Yes
, in a nursing facility
Yes
, in my home in the community
No
b.
Have you received long term care nursing services in the last three (3) months?
Yes
. If yes
, what dates(s)?
No
c.
Do you think you need long term care nursing services now?
Yes
No
d.
Do you receive Supplemental Security Income (SSI)?
Yes
No
11. Did you receive any medical services in the past three (3) months immediately prior to the date of this application?
Yes
. If yes, what date(s)? No
12. Are you a U.S. citizen or U.S. national?
Yes
. If yes, skip to Question 15. No
13. If you are not a U.S. citizen or U.S. national, do you have eligible immigration status?
If
Yes
, enter document type and ID number.
Immigration document type (i.e. I-551, Visa, etc.)
Status type (optional)
Write your name as it appears on your immigration document
Alien or I-94 number
Passport number or other card number
SEVIS ID or Expiration Date (optional)
Other (category code or country of issuance)
14.
Provide the date of entry to the U.S. found on your immigration document listed in question 13. (mm/dd/yyyy)
a. Are you a citizen of the
Federated States of Micronesia,
Republic of the Marshall Islands, or
Republic of
Palau?
Yes
No
b. Are you, your spouse or parent, a veteran or an active-duty member of the U.S. military?
Yes
No
15. Were you in Foster Care, or receiving Kinship or State Adoption assistance and receiving Medicaid in Hawaii when you turned 18 or older?
Yes
No
16. Are you a full-time student?
Yes
No If Yes, When is your expected graduation date? _________________
17. If Hispanic/Latino, ethnicity (OPTIONAL: mark all that apply.)
Mexican Mexican American
Chicano/a
Puerto Rican
Cuban
Other
18. Race (OPTIONAL: mark all that apply)
White
Black or African American
Filipino
Vietnamese
Guamanian or Chamorro
Asian Indian
American Indian or Alaska Native
Japanese
Other Asian
Other Pacific Islander
Chinese
Native Hawaiian
Korean
Samoan
Other:
CLEAR FORM
DHS 1100 (REV. 12/17) v.2 Page 3 of 9
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
STEP 2: PERSON 1
(Continue With Yourself)
Job & Income Information
If there are more people to include, please make a copy of pages 4 and 5.
Complete and attach additional pages to this application.
If this is not applicable skip to page 6 of 9.
Employed
If you are currently employed, tell us about
your income. Start with question 19.
Self-employed
Skip to question 27.
Not employed
Skip to question 28.
JOB 1:
Changed jobs Stopped working Started working fewer hours
None of these
Start Date: End Date:
19. Employer name and address:
20. Employer phone number:
21. Wages/tips (before taxes): Hourly Weekly Every 2
weeks
Twice a m
onth
Monthly
$
22. Average hours worked each WEEK:
JOB 2: If you have more jobs and need more space, attach another sheet of paper.
Changed jobs Stopped working Started working fewer hours
None of these
Start Date: End Date:
23. Employer name and address:
24. Employer phone number:
25. Wages/tips (before taxes): Hourly Weekly Every 2 weeks
Twice a m
onth
Monthly
$
26. Average hours worked each WEEK:
27. If self-employed, answer the following questions:
a. Type of work:________________________________
b. How much net income (gross income minus allowable expenses) will
you get this month from self-employment?
$_________________________________________________________
28. OTHER INCOME THIS MONTH: Check all that apply, the amount, and how often received.
NOTE: You do not need to tell us about child support or veteran’s payment.
Unemployment $___________ How often? ________ Net farming/fishing $___________ How often? ________
Pensions $___________ How often? ________ Net rental/royalty $___________ How often? ________
Social Security $___________ How often? ________ Educational Grant/Work Study $_______________________
Retirement accounts $___________ How often? ________ Other Type of income ______________________________
Alimony received $___________ How often? ________ $ __________ How often? ________
29. DEDUCTIONS: Check all the deductions that were filed on your federal income tax return.
NOTE: You should not include a cost that you already considered in your answer to net self-employment (question 27b)
Alimony paid $________ How often? ________ Other Type of deductions __________ How often
?
________
Student loan interest $________ How often? ________ $ ________________
30. NET YEARLY INCOME: Complete if your net income changes a lot from month to month.
If you do not expect changes to your monthly income, skip to the next person.
Your total income this year:
$
Your total income next year (if you think it will be different)
$
CLEAR FORM
DHS 1100 (REV. 12/17) v.2 Page 4 of 9
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
STEP 2: PERSON 2 Complete Step 2 PERSON 2 for your spouse/partner and/or children who live with you and/or
anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you do not file a tax return,
complete Step 2 PERSON 2 for anyone in your household /family (refer to Page 1 of 9, Step 2)
1. First name
Middle name
Last name
Suffix
2. Relationship to PERSON 1
3. Date of birth (mm/dd/yyyy) / /
4. Gender Male
Female
5. Name of spouse if married
6. Social Security Number (SSN) - -
We need this if PERSON 2 wants health coverage and has a SSN. Providing your SSN can be helpful if you do not want health coverage since it
can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs.
7. Does PERSON 2 live at the same address as PERSON 1?
Yes
No
8. Are you a resident or intend to be a resident of Hawaii?
Yes
No
9. If no, Home address (If Homeless, please enter “Homeless” here with appropriate city, state and zip code and mark this box )
10. Does PERSON 2 plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you do not file a federal income tax return.)
Yes
If
yes
,
please answer questions a–c.
No. If no,
skip to question c.
a. Will PERSON 2 file jointly with a spouse?
Yes
No
If
yes
,
write
name of spouse:
b. Will PERSON 2 claim any tax dependents on his/her tax return?
Yes
No
If
yes
, write name(s) of dependents:
c. Will PERSON 2 be claimed as a tax dependent on someone’s tax return
Yes
No
If
yes
, write the name of the tax filer: ______________________How is PERSON 2 related to the tax filer?
11. Is PERSON 2 pregnant? Yes No If
yes
, how many babies are expected during this pregnancy?_______ Expected Due Date:__________
12. Does PERSON 2 need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.)
Yes
. If
yes
, answer all the questions below.
No. If no,
SKIP to the income questions on page 5.
Leave the rest of this page blank.
13.
Does PERSON 2 have a disability that will last more than twelve (12) months?
Yes
No
a.
Does PERSON 2 currently receive long-term care nursing services?
Yes
, in a nursing facility
Yes
, in my home in the community
No
b.
Has PERSON 2 received long term care nursing services in the last three (3) months?
Yes
. If
yes
, what date(s)?
No
c.
Does PERSON 2 think you need long term care nursing services now?
Yes
No
d.
Does PERSON 2 receive Supplemental Security Income (SSI)?
Yes
No
14. Did PERSON 2 receive any medical services in the past three (3) months immediately prior to the date of this application?
Yes
. If
yes
, what date(s)? No
15. Is PERSON 2 a U.S. citizen or U.S. national?
Yes
. If
yes
, skip to Question 18. No
16.
If PERSON 2 is not a U.S. citizen or U.S. national, does he/she have eligible immigration status?
If
Yes
, enter document type and ID number.
Immigration document type (i.e. I-551, Visa, etc.)
Status type (optional)
Write your name as it appears on your immigration document
Alien or I-94 number
Passport number or other card number
SEVIS ID or Expiration Date (Optional)
Other (category code or country of issuance)
17.
Provide the date of entry to the U. S. found on your immigration document listed in question 16. (mm/dd/yyyy)
a. Is PERSON 2 a citizen of the
Federated States of Micronesia,
Republic of the Marshall Islands, or
Republic of
Palau?
Yes No
b. Is PERSON 2, PERSON 2’s spouse or parent, a veteran or an active-duty member of the U.S. military? Yes No
18. Was PERSON 2 in Foster Care, or receiving Kinship or State Adoption assistance and receiving Medicaid in Hawaii when they turned 18 or older?
Yes
No
19. Is PERSON 2 a full-time student?
Yes
No If Yes, When is your expected graduation date? _________________
20. If Hispanic/Latino, ethnicity (OPTIONAL: mark all that apply.)
Mexican
Mexican American
Chicano/a
Puerto Rican
Cuban
Other
21. Race (OPTIONAL: mark all that apply)
White
Black or African American
Filipino
Vietnamese
Guamanian or Chamorro
Asian Indian
American Indian or Alaska Native
Japanese
Other Asian
Other Pacific Islander
Chinese
Native Hawaiian
Korean
Samoan
Other:
Now, tell us about any income from PERSON 2 on the back.
CLEAR FORM
DHS 1100 (REV. 12/17) v.2 Page 5 of 9
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
STEP 2: PERSON 2
Current Job & Income Information
Employed
If PERSON 2 is currently employed, tell us
about his/her income. Start with question 22.
Self-employed
Skip to question 30.
Not employed
Skip to question 31.
JOB 1:
Changed jobs Stopped working Started working fewer hours
None of these
Start Date: End Date:
22. Employer name and address:
23. Employer phone number:
24. Wages/tips (before taxes): Hourly Weekly Every 2
weeks
Twice a
month
Monthly
$_____________________________________
25. Average hours worked each WEEK:
JOB 2: (If PERSON 2 has more jobs and need more space, attach another sheet of paper.)
Changed jobs Stopped working Started working fewer hours
None of these
Start Date: End Date:
26. Employer name and address:
27. Employer phone number:
28. Wages/tips (before taxes): Hourly Weekly Every 2
weeks
Twice a
month
Monthly
$
29. Average hours worked each WEEK:
30. If PERSON 2 is self-employed, answer the following questions:
a. Type of work:________________________________
b. How much net income (gross income minus allowable
expenses) will you get this month from self-employment?
$__________________________________________________
31. OTHER INCOME THIS MONTH: Check all that apply, the amount and how often PERSON 2 receives it.
NOTE: You do not need to tell us about child support or veteran’s payment.
Unemployment $___________ How often? ________ Net farming/fishing $___________ How often? ________
Pensions $___________ How often? ________ Net rental/royalty $___________ How often? ________
Social Security $___________ How often? ________ Educational Grant/Work Study $________________________
Retirement accounts $___________ How often? ________ Other type of income ________________________________
Alimony received $___________ How often? ________ $ __________ How often? _________
32. DEDUCTIONS: Check all the deductions that were filed on PERSON 2 federal income tax return.
NOTE: You should not include a cost that you already considered in your answer to net self-employment (question 30b)
Alimony paid $__________ How often? ________ Other type of deductions __________ How often
?
________
Student loan interest $__________ How often? ________ $ ________________
33.
NET YEARLY INCOME: Complete if PERSON 2’s net income changes a lot from month to month.
If you do not except changes to PERSON 2’s monthly income, skip to the next section.
PERSON 2’s total income this year:
$
PERSON 2’s total income next year (if you think it will be different)
$
If there are 2 or more people to include, please make a copy of STEP 2: PERSON 2 (Pages 4 and 5).
Once completed, attach additional pages to this application and continue to STEP 3
CLEAR FORM
DHS 1100 (REV. 12/17) v.2 Page 6 of 9
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
STEP 3
Household Relationships
List all the individuals included on this application and identify how each member is related to each other. Use the following
relationships to identify relationships to household members.
• Married
• Under Primary Care
• Sibling (including step)
• Niece/Nephew (including step)
• Parent (including step)
• Child (including step)
• Foster Parent
• Foster Child
• Grandparent
• Grandchild
• Not Related
• Other Related (i.e. in law living
in home)
• Uncle/Aunt
• Cousin
• Unmarried Partner or Domestic
Partnership
If you have more than six (6) people in your family, you will need to make a copy of this page and continue with Person 7
and attach to this application.
Name of Person 1:
Primary Individual
SELF
Name of Person 2:
Relationship to Person 1:
Is Person 2 primarily responsible for the care of a
child(ren) under age 19 years old in this household?
Yes, name of child(ren): ____________________________________
No
Name of Person 3:
Relationship to Person 1:
Relationship to Person 2:
Is Person 3 primarily responsible for the care of a
child(ren) under age 19 years old in this household?
Yes, name of child(ren): ____________________________________
No
Name of Person 4:
Relationship to Person 1:
Relationship to Person 2:
Relationship to Person 3:
Is Person 4 primarily responsible for the care of a
child(ren) under age 19 years old in this household?
Yes, name of child(ren): ____________________________________
No
Name of Person 5:
Relationship to Person 1:
Relationship to Person 2:
Relationship to Person 3:
Relationship to Person 4:
Is Person 5 primarily responsible for the care of a
child(ren) under age 19 years old in this household?
Yes, name of child(ren): ____________________________________
No
Name of Person 6:
Relationship to Person 1:
Relationship to Person 2:
Relationship to Person 3:
Relationship to Person 4:
Relationship to Person 5:
Is Person 6 primarily responsible for the care of a
child(ren) under age 19 years old in th
is household?
Yes, name of child(ren): ____________________________________
No
CLEAR FORM
DHS 1100 (REV. 12/17) v.2 Page 7 of 9
STEP 4
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
American Indian Or Alaska Native (AI/AN) Family Member(s)
1. Are you or is anyone in your family American Indian or Alaska Native?
Yes. If yes, also complete Appendix B.
No. If No, skip to Step 5.
Your Family’s Health Coverage
1. For every year that you got a premium tax credit, did your household file a tax return and reconcile any premium tax credit you used?
Yes, premium tax credits were reconciled. Check this box only if ALL of these below apply to you:
• You used advance payments of premium tax credits (APTC) in one or more past years to help lower your costs for
Marketplace coverage.
• The tax filer for your household filed a federal income tax return for each of these years.
• The tax return filed compared the amount of APTC used to the rest of the tax return information for each year.
No
2. Was anyone on this application found not eligible for Medicaid or CHIP in the past 90 days? (Select yes only if someone was found not eligible
for this coverage by Med-QUEST, not by the Marketplace.)
Yes Who:
No
3. Was anyone on this application found not eligible for Medicaid or CHIP due to their immigration status since October 1, 2013?
Yes Who:
No
4. Did anyone on this application apply for coverage during the Marketplace open enrollment period?
Yes Who:
No
5. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job. Like a
parent or spouse, even if they do not accept the coverage.
Yes Continue and then complete Appendix A. Is this a state employee benefit plan? Yes No
No
6. Is anyone enrolled in health coverage now?
Yes If yes, continue to Family Health Coverage PERSON 1
No If no, SKIP to Step 6.
Name of person 1 enrolled in health coverage:
Type of Coverage(s): Employer Insurance COBRA Medicare TRICARE VA health care program Peace Corps Other
If it is an employer insurance: (You will also need to complete Appendix A.)
Name of health insurance company:
Policy/ID number
Where you ever in an accident? Yes No If Yes, are you still incurring medical expenses because of it? Yes No
If it is another kind of coverage:
Name of health insurance company:__________________________________
Policy/ID number: ___________________________________
Is this a limited-benefit plan, like a school accident policy? Yes No
Includes Medical? Includes Dental? Includes Vision?
STEP 5
CLEAR FORM
DHS 1100 (REV. 12/17) v.2 Page 8 of 9
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
Name of person 2 enrolled in health coverage:
Type of Coverage(s): Employer Insurance COBRA Medicare TRICARE VA health care program Peace Corps Other
If it is an employer insurance: (You will also need to complete Appendix A.)
Name of health insurance company:
Policy/ID number
Where you ever in an accident? Yes No If Yes, are you still incurring medical expenses because of it? Yes No
If it is another kind of coverage:
Name of health insurance company:
Policy/ID number
Is this a limited-benefit plan, like a school accident policy? Yes No
Includes Medical? Includes Dental? Includes Vision?
Name of person 3 enrolled in health coverage:
Type of Coverage(s): Employer Insurance COBRA Medicare TRICARE VA health care program Peace Corps Other
If it is an employer insurance: (You will also need to complete Appendix A.)
Name of health insurance company:
Policy/ID number
Where you ever in an accident? Yes No If Yes, are you still incurring medical expenses because of it? Yes No
If it is another kind of coverage:
Name of health insurance company:
Policy/ID number
Is this a limited-benefit plan, like a school accident policy? Yes No
Includes Medical? Includes Dental? Includes Vision?
Name of person 4 enrolled in health coverage:
Type of Coverage(s): Employer Insurance COBRA Medicare TRICARE VA health care program Peace Corps Other
If it is an employer insurance: (You will also need to complete Appendix A.)
Name of health insurance company:
Policy/ID number
Where you ever in an accident? Yes No If Yes, are you still incurring medical expenses because of it? Yes No
If it is another kind of coverage:
Name of health insurance company:
Policy/ID number
Is this a limited-benefit plan, like a school accident policy? Yes No
Includes Medical? Includes Dental? Includes Vision?
Name of person 5 enrolled in health coverage:
Type of Coverage(s): Employer Insurance COBRA Medicare TRICARE VA health care program Peace Corps Other
If it is an employer insurance: (You will also need to complete Appendix A.)
Name of health insurance company:
Policy/ID number
Where you ever in an accident? Yes No If Yes, are you still incurring medical expenses because of it? Yes No
If it is another kind of coverage:
Name of health insurance company:
Policy/ID number
Is this a limited-benefit plan, like a school accident policy? Yes No
Includes Medical? Includes Dental? Includes Vision?
Name of person 6 enrolled in health coverage:
Type of Coverage(s): Employer Insurance COBRA Medicare TRICARE VA health care program Peace Corps Other
If it is an employer insurance: (You will also need to complete Appendix A.)
Name of health insurance company:
Policy/ID number
Where you ever in an accident? Yes No If Yes, are you still incurring medical expenses because of it? Yes No
If it is another kind of coverage:
Name of health insurance company:
Policy/ID number
Is this a limited-benefit plan, like a school accident policy? Yes No
Includes Medical? Includes Dental? Includes Vision?
If you have more than (6) six people who have health coverage now, make a copy of this page and continue with PERSON 7
in the Family Health Coverage PERSON 2 section of this page.
CLEAR FORM
NEED HELP WITH YOUR APPLICATION? Visit mybenefits.hawaii.gov or call us at 1-800-316-8005. If you need help in a language
other than English, call 1-800-316-8005 and tell the customer service representative the language you need. We will get you help
at no cost to you. TTY users should call 711 or 1-800-603-1201.
DHS 1100 (REV. 12/17) v.2 Page 9 of 9
STEP 6
STEP 7
Please print using black or dark ink only.
Mark each box [ ] as appropriate, with an “X”, like this .
!!!SIGNATURE REQUIRED BELOW!!!
Read & Sign This Application
• I am signing this application under penalty of perjury which means, I have provided true answers to all the questions on this form to the best of my
knowledge. I know that I may be subject to penalties under state or federal law if I provide false and/or untrue information.
• I understand I must tell the Department of Human Services or the Federal Health Insurance Marketplace if anything changes (and is different
than) what I wrote on this application. I can visit mybenefits.hawaii.gov or call 1-800-316-8005 (TTY: 711 or 1-800-603-1201) or visit
www.healthcare.gov or call 1-800-318-2596 (TTY: 1-855-889-4325) to report any changes. I understand that a change in my household’s
information could affect the eligibility for member(s) of my household.
• The Department of Human Services (DHS) complies with applicable Federal and State civil rights laws and does not discriminate, exclude or
treat people differently on the basis of race, color, national origin, age, disability, or sex/gender (expression or identity) or any protected class
under federal or state laws.
• DHS is able to provide aids and services (at no cost to the individual) to people with disabilities, such as: qualified sign language, and written
information in other formats. (large print, audio, accessible electronic formats) and language services (at no cost to the individual) to people
whose primary language is not English, such as: qualified interpreters and information written in languages other than English.
• If I believe that DHS or its service providers have failed to provide these services or discriminated in another way on the basis of race, color,
national origin, age, disability, or sex, I can file a discrimination complaint with: Civil Rights Compliance Officer by e-mail at
DHSCivilRightsBox@dhs.hawaii.gov or call (808) 586-4955 or 711 Hawaii Relay Service, fax (808) 586-4990 or write to: Civil Rights
Compliance Officer, P. O. Box 339, Honolulu, HI 96809-0339. DHS discrimination complaint forms are available at
https://humanservices.hawaii.gov in the Civil Rights Corner under Forms.
• I can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the
Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department
of Health and Human Services, Office for Civil Rights (OCR), 200 Independence Avenue SW., Room 509F, HHH Building, Washington,
DC 20201, Phone: 1(800) 368–1019, TDD: 1(800) 537–7697.
• I understand the Department of Human services and the Federal Health Insurance Marketplace will obtain information to verify eligibility with
electronic databases, to include but not limited to, the Internal Revenue Services (IRS), Social Security Administration (SSA), Department of
Homeland Security (DHS) or a consumer reporting agency. If the information does not match, we may ask to you send us proof.
If anyone on this application is eligible for Medicaid.
• I am assigning the Department of Human Services, my rights to payments for medical care from any third party, which may include but not
limited to, other health insurance or legal settlement. I am also assigning the Department of Human Services, my rights to pursue and get
medical support from a spouse or parent. I will cooperate in obtaining third party payments.
• Does any child on this application have a parent living outside of the home? Yes No If yes, I understand I will be asked to
cooperate with the Department of Human Services and the agency that collects medical support from an absent parent. If I think that
cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.
• I agree to cooperate with the Department of Human Services, Federal Quality Control reviewers or auditors if my case is selected for a
review.
My right to appeal
If I think the Department of Human Services or the Federal Health Insurance Marketplace has made a mistake, I can appeal its decision. To
appeal means to tell someone at the Department of Human Services or the Federal Health Insurance Marketplace that I think the action is wrong,
and ask for a fair review of the action. I know that I can find out how to appeal by contacting someone at 1-800-316-8005 (TTY: 711 or 1-800-603-
1201). I know that I can be represented in the process by someone other than myself. My eligibility and other information will be explained to me.
Sign this application. The person who filled out Step 1 must sign this application. If you are an Authorized Representative, sign here
and you must complete Appendix C.
Signature
Date (mm/dd/yyyy)
Mail Your Signed Application To:
MQD-Oahu Section
P.O. Box 3490
Honolulu, HI 96811-3490
MQD-Kapolei Unit
P.O. Box 29920
Honolulu, HI 96820-2320
MQD-Kauai Section
4473 Pahee Street, Suite A
Lihue, HI 96766-2037
MQD-East Hawaii Section
1404 Kilauea Avenue
Hilo, HI 96720-4670
MQD-Lanai Unit
P.O. Box 1619
Kaunakakai, HI 96748-1619
MQD-Maui Section
Millyard Plaza
210 Imi Kala Street, Suite 101
Wailuku, HI 96793-1274
MQD-Molokai Unit
P.O. Box 1619
Kaunakakai, HI 96748-1619
MQD-West Hawaii Section
Lanihau Professional Center
75-5591 Palani Road, Suite 3004
Kailua-Kona, HI 96740-3633
If you want to register to vote, you can complete the attached voter registration form or download a form from http://elections.hawaii.gov
CLEAR FORM
NEED HELP WITH YOUR APPLICATION? Visit mybenefits.hawaii.gov or call us at 1-800-316-8005. If you need help in a language
other than English, call 1-800-316-8005 and tell the customer service representative the language you need. We will get you help
at no cost to you. TTY users should call 711 or 1-800-603-1201.
DHS 1100 (REV. 12/17) v.2 Appendix Page 1 of 4
APPENDIX A
Health Coverage from Jobs
You do not need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page
for each job that offers coverage.
Tell us about the job that offers coverage.
Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer these questions. You only need to
include this page when you send in your application, not the Employer Coverage Tool.
EMPLOYEE Information
The employee needs to fill out this section.
1. Employee name (First, Middle, Last)
2. Employee Social Security Number
- -
EMPLOYER Information
Ask the employer for this section.
3. Employer name
4. Employer Identification Number (EIN)
5. Employer address (notice will be sent to this address)
6. Employer phone number
7. City
8. State
9. ZIP Code
10. Who can we contact about employee health at this job?
11. Phone number (if different from above)
12. Email address
13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next three (3) months?
Yes (continue)
a. If you are in a waiting or probationary period, when can you enroll in coverage?
mm/dd/yyyy
List the names of anyone else who is eligible for coverage from this job.
Name:
Name:
Name:
No (STOP and go to Step 6 in the application)
Tell us about the health plan offered by this employer.
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes No
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not include family plans): If the employer
has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation
program, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly
16. What change will the employer make for the new year (if known)?
Employer will not offer health coverage.
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that
meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15)
a. How much will the employee have to pay in premiums for that plan? $__________________
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly
Date of change (mm/dd/yyyy):_______________________________
*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit cost covered by the plan is no
less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
CLEAR FORM
NEED HELP WITH YOUR APPLICATION? Visit mybenefits.hawaii.gov or call us at 1-800-316-8005. If you need help in a language
other than English, call 1-800-316-8005 and tell the customer service representative the language you need. We will get you help
at no cost to you. TTY users should call 711 or 1-800-603-1201.
DHS 1100 (REV. 12/17) v.2 Appendix Page 2 of 4
EMPLOYER COVERAGE TOOL
Use this tool to help answer questions in Appendix A about any employer health coverage that you are eligible for (even if it is
from another person’s job, like a parent or spouse). The information in the numbered boxes below need to match the boxes on
Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.
Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one
tool for each employer that offers health coverage.
EMPLOYEE Information
The employee needs to fill out this section.
1. Employee name (First, Middle, Last)
2. Employee Social Security Number
- -
EMPLOYER Information
Ask the employer for this section.
3. Employer name
4. Employer Identification Number (EIN)
5. Employer address (notice will be sent to this address)
6. Employer phone number
7. City
8. State
9. ZIP Code
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)
12. Email address
13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next three (3) months?
Yes (continue)
a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage?
mm/dd/yyyy (continue)
No (STOP and go to Step 6 in the application)
Tell us about the health plan offered by this employer.
Does the employer offer a health plan that covers an employee’s spouse or dependent?
Yes Which people? Spouse Dependent(s)
No
(Go to question 14)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes No
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not include family plans): If the employer has
wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation program,
and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly
16. What change will the employer make for the new year (if known)?
Employer will not offer health coverage.
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that
meets the minimum value standard. *(Premium should reflect the discount for wellness programs. See question 15)
a. How much will the employee have to pay in premiums for that plan? $_________________________________
b. How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly
Date of change (mm/dd/yyyy):_______________________________
*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit cost covered by the plan is no
less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
CLEAR FORM
NEED HELP WITH YOUR APPLICATION? Visit mybenefits.hawaii.gov or call us at 1-800-316-8005. If you need help in a language
other than English, call 1-800-316-8005 and tell the customer service representative the language you need. We will get you help
at no cost to you. TTY users should call 711 or 1-800-603-1201.
DHS 1100 (REV. 12/17) v.2 Appendix Page 3 of 4
APPENDIX B
American Indian Or Alaska Native Family Member (AI/AN)
Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health
Coverage & Help Paying Costs.
Tell us about your American Indian or Alaska Native family member(s).
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health program, or urban Indian health
programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following
questions to make sure your family gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach.
AI/AN PERSON 1
AI/AN PERSON 2
1. Name (First name, Middle name, Last name)
First
Middle
First
Middle
Last
Last
2. Member of a federally recognized tribe?
Yes If yes, tribe name is:
No
Yes If yes, tribe name is:
No
3. Has this person ever gotten a service from
the Indian Health Service, a tribal health
program, urban Indian health program, or
through a referral from one of these
programs?
Yes
No If no, is this person eligible to get
services from the Indian Health services,
tribal health programs, urban Indian health
programs, or through a referral from one of
these programs?
Yes No
Yes
No If no, is this person eligible to get
services from the Indian Health services,
tribal health programs, urban Indian health
programs, or through a referral from one of
these programs?
Yes No
4. Certain money received may not be counted
for Medicaid or the Children’s Health
Insurance Program (CHIP). List any income
(amount and how often) reported on your
application that includes money from these
sources:
• Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties.
• Payments from natural resources,
farming, ranching, fishing, leases, or
royalties from land designated as Indian
trust land by the Department of Interior
(including reservations and former
reservations).
• Money from selling things that have
cultural significance.
$__________________________________
How often?__________________________
$__________________________________
How often?__________________________
CLEAR FORM
NEED HELP WITH YOUR APPLICATION? Visit mybenefits.hawaii.gov or call us at 1-800-316-8005. If you need help in a language
other than English, call 1-800-316-8005 and tell the customer service representative the language you need. We will get you help
at no cost to you. TTY users should call 711 or 1-800-603-1201.
DHS 1100 (REV. 12/17) v.2 Appendix Page 4 of 4
APPENDIX C
Assistance With Completing This Application
You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information, and act for you on matters related to this
application, including getting information about your application and signing your application on your behalf. This person is called an “Authorized
Representative.” If you ever need to change your Authorized Representative, call 1-800-316-8005. If you are a legally appointed representative for
someone on this application, submit proof with the application.
1. Name of authorized representative (First name, Middle name, Last name)
2. Mailing Address
3. Apartment or suite number
4. City
5. State
6. ZIP code
7. County
8. Phone number
9. Organization name
10. ID number (if applicable)
By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters with this
agency.
11. PERSON 1 or Primary Individual’s Signature
12. Date (mm/dd/yyyy)
Authorized Representative
As the designated Authorized Representative, by signing below I agree to maintain the confidentiality of any information provided to me by the
Department or it’s designee and I can be released as the Authorized Representative:
Signature of Authorized Representative
Telephone
Date
Mailing Address
City
State
ZIP Code
As applicable, I
, am a provider or staff member or volunteer
PRINT Name of Individual
of an organization:
PRINT Name of Provider/Organization
I understand and agree, as a condition of serving as the Authorized Representative, I will adhere to the regulations relating to
confidentiality of information and the prohibition against reassignment of provider claims as appropriate for a health facility
or an organization acting on the facility’s behalf, as well as other relevant State and Federal laws covering conflicts of
interest and confidentiality of information.
For certified application counselors, navigators, agents, and brokers only
Complete this section if you are a certified application counselor, navigator, agent, or broker filling out this application for someone else.
1. Application start date (mm/dd/yyyy)
2. First name, Middle name, Last name, & Suffix
3. Organization name
4. ID number (if applicable)
CLEAR FORM
STATE OF HAWAII
NATIONAL VOTER REGISTRATION ACT QUESTIONNAIRE
You may register to vote in Hawaii if:
1.
You are a United States citizen.
2.
You are a resident of the State of Hawaii.
3.
You are at least 16 years of age and understand that you must be 18 years of age by
election day to vote.
4.
You are not an incarcerated felon.
5.
You are not registered in any other state, unless you cancel that registration. (There is an
area on the Hawaii registration application for you to cancel if needed.)
If you are not registered to vote where you live now, would you like to apply to register
to vote here today? (Check one.)
YES NO
If you do not check either box, you will be considered to have decided not to
register to vote at this time.
Important Notices
Applying to register or declining to register to vote will not affect the amount of assistance
that
you will be provided by this agency.
If you would like help filling out the voter registration form, we will help you in person or you
can call: 1-800-316-8005 (TTY: 711 or 1-800-603-1201). The decision to seek or
accept
help is yours. You may fill out the application form in private.
Applying to register or declining to register to vote will remain confidential and will be used
only for your voter registration purposes.
If you need additional information about voting or if you believe that someone has interfered
with your right to register or not to register to vote; or your right to privacy in deciding whether
or not to register or applying to register to vote, you may contact:
Office of Elections
802 Lehua Avenue
Pearl City, Hawaii 96782
Phone: (808) 453-VOTE
(8683)
Neighbor Islands Toll Free: 1-800-442-VOTE (8683)
Name
Signature Date
State Agency I.D. # A 0 1 7
First Time Voters Mailing this
Application
If you are 1) registering to vote for the rst time in
the State of Hawaii; 2) mailing this application; and
3) do not have a HI Driver License, HI State ID, or
last 4-digits of a Social Security Number, you are
required to provide proof of identication.
Proof of identication includes a copy of:
• A current and valid photo identication; or
• A current utility bill, bank statement,
government check, paycheck, or other
government document that shows your name
and address.
Submitting Application
Mail or deliver your application to your Clerk’s
Ofce at the address below.
County of Hawaii
25 Aupuni St., Rm. 1502
Hilo, HI 96720
County of Maui
200 S. High St., Rm. 708
Wailuku, HI 96793
County of Kauai
4386 Rice St., Rm. 101
Lihue, HI 96766
City & County of Honolulu
530 S. King St., Rm. 100
Honolulu, HI 96813
Deadline to Submit Application
Registering to Vote: No later than 30 days prior to
the election.
Requesting a Permanent Absentee Ballot: No
later than 7 days prior to the election.
Language Assistance
若想獲得電子檔的翻譯材料，或者需要協助填表事
宜，請聯繫 選舉辦公室 (Ofce of Elections).
Contact Us
For voter registration and absentee voting
information, contact your Clerk’s Ofce.
County of Hawaii
..............................(808) 961-8277
County of Maui
..................................(808) 270-7749
County of Kauai
................................(808) 241-4800
City & County of Honolulu
...............(808) 768-3800
For additional voting information, contact the
Ofce of Elections.
(808) 453-VOTE (8683)
Toll Free: 1-800-442-VOTE (8683)
TTY: (808) 453-6150
Toll Free TTY: 1-800-345-5915
Email: elections@hawaii.gov
Website: www.elections.hawaii.gov
Voter
Registration
+
Permanent
Absentee
Application
Rev. 2017
English
Para kadagiti naipatarus a materiales a mainaig
iti eleksion wenno tulong iti lengguahe tapno
makompletoyo daytoy nga aplikasion, awagan ti
Opisina Dagiti Eleksion (Ofce of Elections).
Please print clearly in black ink.
This application can be used for:
• First time registration
• Request to vote by mail permanently
• Name change
• Address change
1
2
3
4
6
5
7
8
3b
6b
Last Name First Name M.I. Sufx (Jr., II)
HI Driver License or HI State ID Number
If you do not have either, complete box 3b.
Date of Birth Phone Number Email
Residence Address (P.O. Box, R.R., S.R. are not acceptable) Apt. Number City Zip Code
Apt. Number City Zip CodeMailing Address in Hawaii
Same as Residence Address
If your residence does not have a street address, describe the location (cross streets, landmarks).
Are you registered to vote in another state?
Last Registered Address, County, State, and Zip Code
Would you like to permanently receive absentee ballots by mail?
Yes. I hereby authorize cancellation of my previous registration.
Complete box 6b.
Yes. I request to permanently receive absentee ballots at the mailing address associated with my voter registration.
I understand that my permanent absentee voter status will be terminated if: 1) I request termination in writing; 2) I die, lose voting rights, register in another
jurisdiction, or am otherwise disqualied from voting; 3) my absentee ballot, voter notication postcard, or any other election mail is returned to the clerk as
undeliverable for any reason; or 4) I do not return my ballot by 6:00 PM on election day in both the primary and general election of an election year. If so, I understand
that I must reapply for permanent absentee status.
Warning: Any person who knowingly furnishes false information may be guilty of a Class C felony.
I hereby swear (or afrm) that all information furnished on this application is true and correct.
Date
If you are unable to sign, mark the signature line and have a witness provide signature, address, and phone number.
I do not have a HI Driver License, HI State ID, or SSN.
I do not have a HI Driver License or HI State ID.
Provide the last 4-digits of your Social Security Number.
Notice: The identity of the voter registration agency through which any particular voter was registered shall not be publicly disclosed. A person’s declination to register to vote is
also condential and is used for voter registration purposes only (National Voter Registration Act of 1993).
Ofce Use
Only
ID Number Location Code Document Number
Are you a citizen of the United States of America?
Are you at least 16 years of age? (Must be 18 to vote)
Are you a resident of the State of Hawaii?
1
If you answered “No” to any of the above, DO NOT complete this form.
Ye s
Ye s
Ye s
No
No
No
1
The residence stated in this afdavit is not simply
because of my presence in the State, but was acquired
with the intent to make Hawaii my legal residence with
all the accompanying obligations therein.
Hawaii Voter Registration &
Permanent Absentee Application
SIGN
HERE
A017
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Application For Health Coverage & Help Paying Costs (Hawaii)

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Completed 9 December 2020

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