Fillable Are you homeless? Yes No Request for Cash (Lake Land College)

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Are you homeless? Yes No Request for Cash (Lake Land College)

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Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 1 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Last Name:
First Name:
MI:
Maiden Name:
Present Address: Apartment Number:
City: State: County:Zip Code:
Mailing Address (if different from above):
City: State: Zip Code: County:
Telephone number(s)
Home: Work: Other:
Daytime phone:
Best time to call you:
Signing here will start your application. You must sign Page 18 before we approve you for any benefits.
Signature: Date:
Approved Representative
When you sign to have an approved representative it means you give permission for this person (1) to sign your application for
you, (2) to receive official information about this application, and (3) to act for you on all matters with this agency.
Do you want to name an approved representative?
Yes No
If yes, complete the following:
Name of approved representative:
Address:
Phone Number:
Organization Name:
ID # if applicable:
Signature of applicant:
Instructions to person(s) applying for Cash, Medical, and/or SNAP benefits
Cash -
Medical - SNAP -
1. Please print all of your answers on the application form so that we can read and understand your answers.
2. You have the right to immediately file the application as long as the top of this page (Page 1) is completed with your name, address and signature.
The filing of this signed page (Page 1) starts the application processing timetable. Providing your date of birth and Social Security Number on this
signed page will help us with the application registration process.
3. Read pages 14 & 15 to know your rights and responsibilities for SNAP benefits.
Read pages 16, 17 and 18 to know your rights and responsibilities for Cash and Medical benefits.
4. Before you can get any benefits, you must sign page 18.
5. If applying for SNAP benefits, a decision on your eligibility will be made within 30 days. If determined eligible, SNAP benefits will be issued from the
date the application is filed.
6. You may be entitled to receive SNAP benefits right away if:
* your gross nonexempt income and liquid assets are less than your monthly rent or mortgage payment and the appropriate utility standard:
or,
* you have assets of $100 or less and
- your gross monthly income for the month of application is less than $150; or
- at least one person applying is a migrant who is "out of funds."
7. This application must be filed with the Illinois Department of Human Services (IDHS). You may complete this form at home and return it to your
local Family Community Resource Center (FCRC) in person or by mail. You have the right to choose the office where you apply. Use the IDHS
Office Locator to find an FCRC at www.dhs.state.il.us/page.aspx?module=12 or call the IDHS Helpline at 1-800-843-6154. You may also mail
this form to the Central Scan Unit (CSU), P.O. Box 19138, Springfield, IL 62763. You can also apply for benefits at ABE.illinois.gov or by
calling the IDHS Helpline at 1-800-843-6154. Another member of the household or an adult who knows you may complete and return the form
to us also. If someone else completes this form for the household, they are to answer the questions for the person(s) they are applying for, not
himself or herself.
8. If you want to register to vote, fill out the enclosed Illinois Voter Registration Application (SBE R-19) and give it to your IDHS Family Community
Resource Center (FCRC) or your local election official. For help filling it out or for translation services, contact your IDHS Family Community
Resource Center (FCRC). You may also call the Helpline at 1-800-843-6154, or 1-866-324-5553 TTY/Nextalk, 711 TTY Relay. For information
online, see www.dhs.state.il.us or www.elections.il.gov/. Filling out the Voter Registration Application as part of this application is optional.
Registering to vote is your choice and will not affect the amount of benefits you get from this agency.
Are you homeless? Yes No
Birth Date: Social Security Number:
click to sign
signature
click to edit
click to sign
signature
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Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 2 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
3. Does anyone have a physical, mental or emotional health condition that limits common activities (like bathing, dressing,
daily chores, etc)?
Citizenship/Immigration Status
If you or any other persons are not applying because you do not wish to provide information about your immigration status, you do
not have to give us that information. The failure to provide immigration information will not affect processing the application for the
remaining persons. However, any person who is applying for benefits for himself or herself has to provide information on their
immigration status.
Are all persons U.S. Citizens?
Yes No
Complete the following for any non-citizens who are applying for benefits. If you need more room, attach another sheet of paper.
Name Age Arrival Date in the United States Registration document/number
1.
2.
3.
4.
If there are persons who are not applying for SNAP and/or cash benefits because they do not wish to provide proof of their
immigration status, please list them below. We will only ask questions about their income & assets.
Name (Last) (First) (MI) Name (Last) (First) (MI)
1. 3.
2. 4.
General Household Questions
1. Are you or is anyone who lives with you blind?
Yes No
Disabled?
Yes No
2. Does anyone in the household receive Social Security Disability or Railroad Retirement benefits?
Yes
No
If yes, who: What is their SSN or RRB claim number?
Yes No
If yes, who:
4. Does anyone applying live in a nursing home facility, supportive living facility, or other facility or institution?
Yes No
If yes, who: Name of facility:
5. Does anyone in your household want help paying for medical bills from the last 3 months?
Yes No
6. Has anyone in your household been in foster care at age 18 or older?
Yes No
If yes, name of person:
7. Is anyone in your household age 18 or older a full time student? (college, or trade school)
Yes No
If yes, name of person:
Language Preference
Does the adult member of your household who will discuss your case with IDHS speak English fluently?
Yes No
If no, please list your preferred spoken language:
Does the adult member of your household who will usually receive mail or written information from IDHS read English fluently?
Yes No
If no, please list your preferred written language:
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 3 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Household Composition
How many people live with you (include yourself)?
Complete the following for everyone in the household. Include people who live with you who are not requesting assistance. You
must give us the Social Security Number for each person for whom you are requesting benefits. You do not have to give us the
number for any person for whom you are not requesting benefits, but if you do, it may speed up the application process.
1. Is this person Hispanic or Latino?
4. Will you be claimed as a dependent on someone else's tax return?
3. Do you have any dependents?
2. Will you file jointly with a spouse?
1. Do you plan to file a Federal Tax Return next year?
Person 1
Black or African AmericanAmerican Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander White
2. What is your race? (Select one or more)
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
If yes, list the name of the tax filer: How are you related to the tax filer?
Yes No
If yes, list name(s):
If yes, list name(s):
Yes No
If yes, answer 2-4 below
If this person is applying for Medical assistance answer question 1.
Social Security #
Gender
M
F
Marital Status Pregnant? If yes, due date How many babies expected?
First M.I. Last Suffix Former Name, if any
Relationship to you
SELF
Mark the box for the program this person is applying for: SNAP Medical Cash
Birth Date
Yes No
Yes No
Yes No
Person 2
Black or African AmericanAmerican Indian/Alaskan Native Asian
Native Hawaiian or Other Pacific Islander
White
2. What is his/her race? (Select one or more)
1. Is this person Hispanic or Latino?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
If yes, list the name of the tax filer: How is this person related to the tax filer?
4. Is this person claimed as a dependent on someone else's tax return? Yes No
3. Does this person have any dependents?
If yes, list name(s):
2. Will this person file jointly with a spouse?
If yes, list name(s):
1. Does this person plan to file a Federal Tax Return next year?
Yes No
If yes, answer 2-4 below
If this person is applying for Medical assistance answer question 1.
Social Security #
Gender
M
F
Birth Date Marital Status Pregnant? If yes, due date How many babies expected?
First M.I. Last Suffix Former Name, if any Relationship to you
Mark the box for the program this person is applying for: SNAP Medical Cash
Yes No
Yes No
Yes No
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 4 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Household Composition (Continued)
Person 3
Black or African AmericanAmerican Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander White
2. What is his/her race? (Select one or more)
1. Is this person Hispanic or Latino?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
If yes, list the name of the tax filer: How is this person related to the tax filer?
4. Is this person claimed as a dependent on someone else's tax return? Yes No
3. Does this person have any dependents?
If yes, list name(s):
2. Will this person file jointly with a spouse?
If yes, list name(s):
1. Does this person plan to file a Federal Tax Return next year?
If yes, answer 2-4 below
If this person is applying for Medical assistance answer question 1.
Social Security #
Gender
M
F
Birth Date Marital Status Pregnant? If yes, due date How many babies expected?
First M.I. Last Suffix Former Name, if any Relationship to you
Mark the box for the program this person is applying for: SNAP Medical Cash
Yes No
Yes No
Yes No
Yes No
Person 4
Black or African AmericanAmerican Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander White
2. What is his/her race? (Select one or more)
1. Is this person Hispanic or Latino?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
If yes, list the name of the tax filer: How is this person related to the tax filer?
4. Is this person claimed as a dependent on someone else's tax return? Yes No
3. Does this person have any dependents?
If yes, list name(s):
2. Will this person file jointly with a spouse?
If yes, list name(s):
1. Does this person plan to file a Federal Tax Return next year?
If yes, answer 2-4 below
If this person is applying for Medical assistance answer question 1.
Social Security #
Gender
M
F
Birth Date Marital Status Pregnant? If yes, due date How many babies expected?
First M.I. Last Suffix Former Name, if any Relationship to you
Mark the box for the program this person is applying for: SNAP Medical Cash
Yes No
Yes No
Yes No
Yes No
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 5 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Household Composition (Continued)
Person 5
Black or African AmericanAmerican Indian/Alaskan Native Asian Native Hawaiian or Other Pacific Islander White
2. What is his/her race? (Select one or more)
1. Is this person Hispanic or Latino?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
If yes, list the name of the tax filer: How is this person related to the tax filer?
4. Is this person claimed as a dependent on someone else's tax return? Yes No
3. Does this person have any dependents?
If yes, list name(s):
2. Will this person file jointly with a spouse?
If yes, list name(s):
1. Does this person plan to file a Federal Tax Return next year?
If yes, answer 2-4 below
If this person is applying for Medical assistance answer question 1.
Social Security #
Gender
M
F
Birth Date Marital Status Pregnant? If yes, due date How many babies expected?
First
M.I.
Last Suffix Former Name, if any Relationship to you
Mark the box for the program this person is applying for: SNAP Medical Cash
Yes No
Yes No
Yes No
Yes No
Person 6
Black or African American
American Indian/Alaskan Native
Asian Native Hawaiian or Other Pacific Islander White
2. What is his/her race? (Select one or more)
1. Is this person Hispanic or Latino?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
If yes, list the name of the tax filer: How is this person related to the tax filer?
4. Is this person claimed as a dependent on someone else's tax return? Yes No
3. Does this person have any dependents?
If yes, list name(s):
2. Will this person file jointly with a spouse?
If yes, list name(s):
1. Does this person plan to file a Federal Tax Return next year?
If yes, answer 2-4 below
If this person is applying for Medical assistance answer question 1.
Social Security #
Gender
M
F
Birth Date Marital Status Pregnant? If yes, due date How many babies expected?
First M.I. Last Suffix Former Name, if any Relationship to you
Mark the box for the program this person is applying for: SNAP Medical Cash
Yes No
Yes No
Yes No
Yes No
If needed, please list extra
household members on an
additional piece of paper.
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 6 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
If you are applying for SNAP benefits complete this page.
How much money do you or anyone who lives with you have in cash, checking, and/or savings? $
What is the monthly gross income (income of all sources before any deductions)
for you and everyone who lives with you? $
How much money have you or anyone who lives with you received or expect to receive from any source in the month of
application?
$ When?
Who:
Source:
(For mortgage include property taxes and insurance.)
Do you share this expense with anyone?
Shelter Costs
1. How much are you charged each month for your rent or mortgage? $
Yes No
2. Did you receive a payment of $21 or more this month or in any of the last 12 months from the Low Income Home
Energy Assistance Program (LIHEAP), (in Chicago paid through CEDA)?
Yes No
3. If No, are you billed separately from rent or mortgage for:
NOTE: Air conditioning is a window air or central air conditioning unit.
A. Heat or air conditioning?
Yes No
B. Excess cost for heat or air conditioning?
Yes No
C. Does anyone outside of your SNAP household pay or help pay for your housing costs?
Yes No
D. Does anyone outside of your SNAP household pay your utility expenses?
Yes No
If yes, please list the bills and the amounts paid:
Please complete the following information if you answered No, to question 2 or 3 and are not billed for heat or air conditioning
separately
Expenses Amount How Often Due Amount You Pay Paid By Others
Electricity
Water and/or Sewerage
Garbage
Cooking Fuel
Basic Phone Service (including cell phone)
Septic Tank Installation Maintenance
Well Installation /Maintenance
A Fee for Starting Utility Service
A Flat Amount for Utilities
Explain:
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 7 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Are you or is anyone who lives with you expecting to receive more than $25 in income from a new source within the next 10
days?
If yes, did the income recently stop?
Is this a SNAP household of migrant or seasonal farm workers?
Yes No
Yes No
Migrant or Seasonal Farmworker Questions
If yes, date the income stopped?
Are liquid assets of household $100 or less AND does the household have a destitute migrant or seasonal farmworker?
NoYes
Yes No
Yes NoDid the household have income prior to the date of application?
Benefit Information
Has the primary applicant received SNAP benefits in any state in the month of application?
Is the applicant a resident of a domestic violence shelter?
NoYes
Yes No
Medical Deduction for Persons Disabled or Age 60 or Older
If a SNAP household member is disabled or age 60 or older your SNAP household may be entitled to a Standard Medical
Deduction. To get the Standard Medical Deduction, you have to prove you pay out of pocket monthly medical expenses of $36
or more.
*If you do not live in a group home the Standard Medical Deduction is $200.
*If you live in a group home the Standard Medical Deduction is $485.
Can you prove that you pay $36 or more monthly in medical expenses?
Yes No
If yes and you give us proof, we will allow the Standard Medical Deduction that applies to your household. If your monthly
medical expenses that you pay are more than $200/$485 and you give us proof, we will allow your actual medical expenses.
I am able to come to an office interview.
We will interview you within 14 days, or right away if you qualify for an expedited SNAP interview.
Please complete the following:
Application Interview - Cash and SNAP
I can be reached by phone Monday - Friday between 8:30 and 5:00 at:
Problems with health, transportation, caring for a child or disabled adult,
ongoing severe weather or educational activities conflict with work hours.
Hours of work or educational activities conflict with office hours.
I am applying for cash assistance
Problems with health, transportation, caring for a child or disabled adult,
ongoing severe weather or educational activities conflict with work hours.
And someone in my household is employed.
I am applying for SNAP
I must be interviewed by phone because:
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 8 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Income - Benefits - Expenses
Is anyone in your household currently employed?
Yes No
If yes, complete the following:
Name of Person:
Employer Address:
Number of hours worked weekly:
Employer:
Employer Phone:
Amount Paid (including tips) before taxes $
How often paid:
Weekly Every two weeks Twice a month Monthly
Name of Person:
Weekly Every two weeks Twice a month Monthly
How often paid:
Amount Paid (including tips) before taxes $Number of hours worked weekly:
Employer Address: Employer Phone:
Employer:
What kind of work do they do?
Is anyone in your household self-employed?
Yes No
How much will they make this month, once they pay business expenses? $
If yes, name of person:
Complete only if your income changes from month to month. If you don't expect changes, skip this section.
What is the total income for each person for this year? If you anticipate a change, what will it be next year?
Total income this year: $
Total income next year: $Total income this year: $Person:
Person: Total income this year: $ Total income next year: $
Total income next year: $Person:
Does anyone named on this form RECEIVE money from any source other than employment (such as Social Security, educational
benefits, child support, spousal support, rental property, unemployment benefits, pensions, retirement, trusts)?
If yes, complete the following:
NoYes
Source:
Name of Person:
Name of Person:
Source: Monthly Amount $
Monthly Amount $
Monthly Amount $Source:Name of Person:
(Include additional pages, if needed.)
If this income is from rental property, is this person receiving the income also the property manager?
In the past year, has anyone in your household changed jobs, stopped working or started working fewer hours?
NoYes
Yes No
If yes, name of Person:
Does anyone in your household pay any of the following expenses?
Alimony paid: $
Weekly Every two weeks Twice a month Monthly
Weekly Every two weeks Twice a month Monthly
Weekly Every two weeks Twice a month Monthly
Weekly Every two weeks Twice a month Monthly
How often?
How often?
How often?
How often?
Child Support paid : $
Day-care: $
Student loan interest: $
Other deductions (Do not include any expenses you have already reported)
How often?
Weekly Every two weeks Twice a month Monthly
$Type of expense:
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 9 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
American Indian or Alaska Native Family Member (AI/AN)
If No, skip to next section.
If yes, tribe name:
Are you or anyone in your family American Indian or Alaska Native (AI/AN)?
NoYes
NoYes
Are you or anyone in your household a member of a federally-recognized tribe?
List any family members who received services from the Indian Health Service, a tribal health program, or urban Indian health
program. If nobody received these services, is anyone qualified to receive them?
Indian Health Services
List the names of anyone who received services:
List the names of anyone who qualifies for services:
Money from selling things that have cultural significance?
Tribal Related Income
Does the income you listed on Page 7 include money from any of the following:
Payments from a tribe that come from natural resources, usage rights, leases or royalties?
NoYes
Payments from natural resources, farming, ranching, fishing, leases or royalties from land designated as Indian trust land by the
Department of the Interior (including reservations and former reservations)?
NoYes
NoYes
If yes, amount: $
If yes, amount: $
If yes, amount: $
SNAP and Cash Applicants:
Have you or any other person applying for Cash been convicted of a felony involving drugs on or after 08/22/96?
NoYes
If yes, Name of Person:
If yes, who
If yes, who
If yes, who
If the drug-related felony conviction was NOT Class X or Class I, did the felony take place more than 2 years ago, or has the
person completed a drug treatment program, or is the person in a drug treatment program now?
NoYes
Has any person been convicted in state or federal court of misrepresenting an address to receive assistance in two or more
states at the same time?
NoYes
Is any person in violation of their parole or probation?
NoYes
Is anyone fleeing from felony prosecution, an outstanding felony warrant or jail?
NoYes
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 10 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Your Family's Health Coverage
Medicaid
CHIP
Medicare
Tricare (Don't check if you have
Direct Care or a Line of Duty)
Veteran's Health Insurance Program
Peace Corps Health Insurance
Employer Insurance
Other
Name of Insurance
Policy Number
Is this a retiree health plan?
Is this COBRA coverage?
Is this a limited-benefit plan (such as a school accident policy)?
Is anyone listed on this application offered health coverage from a job?
Tell us about the job that offers coverage:
Can you get coverage now or sometime in the next 3 months?
Yes No
Yes No
Yes No
Yes No
Check YES even if the coverage is from someone else's job, such as a parent's or spouse's.
If YES, complete Page 11.
Employer Name:
Employer Address:
Employer Phone Number:
Employer Identification Number (EIN):
Who can we contact about employee health coverage at this job?
Phone Number: E-Mail address:
Yes No
If yes, when?:
List the name of anyone who can get coverage from this job:
Is anyone enrolled in health coverage now from any of the following? If YES, check the type of coverage and
write their names next to the coverage they have.
Complete this page if you are applying for cash or medical benefits.
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 11 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Your Family's Health Coverage
Does the employer offer a health plan that pays at least 60% of the total costs of benefits? (The minimum value standard for
health plans)
Yes No
Yes No
Yes No
For the lowest-cost minimum value plan offered to the employee ONLY (don't include family plans):
Does the employer offer wellness programs?
If yes, what premium would the employee pay if he or she got
the maximum discount for a tobacco cessation program? $
a. How much would the employee have to pay in premiums for this plan? $
b. How often?
Weekly Every two weeks Twice a month Quarterly Yearly
What changes will the employer make for the new plan year, if you know?
Employer won't offer health coverage.
Employer will start offering health coverage to employees.
Employer will change the premium for the lowest-cost plan minimum value plan available to the employee only.
a. How much would the employee have to pay in premiums for this plan? $
a. Name of household member:
b. When did the insurance end?
c. Reason insurance ended:
If yes, enter the person's name:
If yes, enter the person's name and relationship to the Veteran:
b. How often?
Weekly Every two weeks Twice a month Quarterly Yearly
You must answer for all household members age 19 or younger:
Did anyone lose health insurance from a job within the past three months?
Does anyone applying receive services through Department on Aging's Community Care Program or has anyone applied
Is anyone applying a Veteran or the spouse, child, widow(er) or parent of a Veteran?
If yes, answer the questions below:
General Medical Questions
Complete this page if you are applying for cash or medical benefits and anyone listed on this application is offered health
coverage from a job.
for these services?
Yes
No
or
or
Yes No
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 12 of 18
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Complete only for persons who are blind, have a disability or are age 65 or older. If married and living with spouse, also
enter any resources the spouse owns. If yes to any of the following, enter the details below. Attach proof. Attach additional
sheet(s) if needed.
Does anyone own any property (ies) such as a home, vacation home, time share, building or land?
Yes No
Owner Address Type Value Amount Owed
$ $
$ $
Does anyone own a car, truck, motorcycle, boat, trailer or other vehicle?
Does anyone own any life insurance?
Yes No
Owner Type Make/Model/Year Value Amount Owed
$ $
$ $
Yes No
Owner Insurance Company Policy Number Face Value Cash Value
$ $
$ $
RESOURCE INFORMATION
Does anyone have an insurance policy that pays when he or she is in a nursing home?
Yes No
If yes, list the following:
Policy Number:
Name of Company:
List, If other:
Does anyone own any of the following resources? Check all that apply:
Business
Money Market Account
Government Bonds
Reverse Mortgage
Inheritance
Deferred Comp
Stocks, Bonds
Life Estate
Trust Funds
Certificates of Deposit
Promissory Note/Loan
Other
Mutual Funds
IRA/401 K
Nursing Home Account
Funeral/Burial Plans
Savings Checking Account
Annuity
Burial Plots Mineral/Oil Rights
Owner(s) Type of Resource Account/Policy No. Value Name of Bank, Company, etc.
$
$
Do you have resources that are held jointly with another person?
Yes No
(Jointly held resources are those held in two or more names; for example, in your name and in the name of another person(s).
This includes resources that may be held by you and your spouse, son or daughter, brother or sister, grandchild, friend,
companion, etc.)
Resource: Value: Name and relationship of Other Person(s) Holding the Resource:
Property in Illinois: $
Property in another state: $
Checking/Savings account: $
Certificate of Deposit: $
Stocks/Mutual Funds: $
Other: $
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 13 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Complete only for employed persons who are blind, have a disability or are age 65 or older. Also enter the employment
expenses for an employed spouse or parent of a child under age 18 if they live together.
Employment and Employment Related Expenses
Employed person's name: (1)
Amount received before deductions (gross amount): $
Federal, State and City taxes withheld: $
If yes, enter the items bought, how often, and cost. Attach proof.
Social Security tax withheld: $
How often paid:
Buy Lunch Bring Lunch
Weekly
Every two weeks Bi-Monthly Monthly
Does this person buy or bring lunch to work?
Does this person buy uniforms or special tools?
How does this person get to and from work?
Yes No
Own car Bus Other
Please list. if other:
If this person uses his/her own car, how many miles to and from work?
If this person person takes the bus, what is the fare to and from work? $
If other transportation is used, enter type and cost. Attach proof.
Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan
withholding as a condition of employment?
Yes No
Monthly amount: $
Must this person pay union dues, group life insurance premiums, group health insurance premiums, or retirement plan
withholding as a condition of employment?
Monthly amount: $
Yes No
If other transportation is used, enter type and cost. Attach proof.
If this person person takes the bus, what is the fare to and from work? $
If this person uses his/her own car, how many miles to and from work?
Please list. if other:
OtherBusOwn car
Yes No
How does this person get to and from work?
Does this person buy uniforms or special tools?
Does this person buy or bring lunch to work?
Weekly
Every two weeks Bi-Monthly Monthly
Bring LunchBuy Lunch
How often paid:
Social Security tax withheld: $
If yes, enter the items bought, how often, and cost. Attach proof.
Federal, State and City taxes withheld: $
Amount received before deductions (gross amount): $
Employed person's name: (2)
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 14 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Read carefully before signing this application on page 18. Ask your caseworker to explain anything you do not understand.
Because the SNAP program requires a Social Security Number (SSN) for every member of your household who is applying for SNAP benefits,
we are explaining how your SSN is used by IDHS.
What does IDHS do with your Social Security Number?
The SSN will be used in the administration of the SNAP program to check the identity of household members, prevent duplicate participation,
and to facilitate making mass changes. If you or any member of your household wants to apply for SNAP benefits, but does not have a SSN, we
can help you apply for one. The SSN (or any other information in this application) may be used in computer matching and program reviews or
audits and to make sure the household is eligible for SNAP benefits, other Federal assistance programs, and Federally assisted state programs,
such as school lunch, TANF, and Medicaid. This may result in criminal or civil action or administrative claims against persons fraudulently
participating in the SNAP program. We do not require a Social Security Number for any member of your household who is not eligible for the
SNAP program or who does not wish to apply.
Why does IDHS collect your Social Security Number?
IDHS secures and uses information about all clients through the income and eligibility verification system. This includes such information as
receipt of social security benefits, unemployment insurance, unearned income and wages from employment. When information does not match,
we may contact a third party, such as employers, claims representatives, or financial institutions to verify the information. This information may
affect your eligibility for assistance and the amount of assistance provided.
Right to appeal.
A fair hearing may be requested either orally, in writing, by using the ABE Appeals Portal, facsimile (fax), mail or in person at the Bureau of
Hearings or at any FCRC if there is a disagreement with any action taken on this case. The SNAP unit's case may be presented at the hearing
by any person chosen by the SNAP unit.
Non-Discrimination.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its
Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on
race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any
program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American
Sign Language, etc.), should contact the Agency (State of Illinois Department of Human Services) where they applied for benefits. Individuals
who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://
www.ascr.usda.gov/complaint_filing_cust.html , and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the
information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA
by:
(1) Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) Fax: (202) 690-7442; or
(3) Email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Additional Illinois Nondiscrimination Information
You may also write the Illinois Department of Human Services (IDHS) at Illinois Department of Human Services, Bureau of Civil Affairs, 401
South Clinton St., 6
th
Floor, Chicago, Illinois, 60607 or call the IDHS Helpline Number at 1-800-843-6154 or 866-324-5553 TTY/Nextalk or 711
TTY Relay.
IDHS, HHS, and USDA are equal opportunity providers and employers.
The State of Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with
Disabilities Act of 1990
SNAP - CLIENT RIGHTS AND RESPONSIBILITIES
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 15 of 18
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SNAP - CLIENT RIGHTS AND RESPONSIBILITIES continued
Declaration Regarding Citizenship/Alien Status
I declare, under penalty of perjury, that the statements I have made regarding the citizenship or alien status of each person
requesting assistance are true and correct. I understand that the alien status of each person requesting assistance who is not a
citizen of the United States will be verified with the United States Citizenship and Immigration Services (USCIS). This will require
the disclosure to USCIS of certain identifying information which I have provided. The information received from USCIS may affect
eligibility for assistance and the benefit level.
I understand that documents may have to be provided to prove what I have said. I agree to do this. If documents are not available,
I agree to give the name of the person or organization the IDHS Family Community Resource Center (FCRC) may contact to
obtain the necessary proof. The information on this form is subject to verification by Federal, State, and Local Officials. If
any information is found to be inaccurate, I may be denied SNAP benefits, and/or be subject to criminal prosecution for
knowingly providing false information.
I understand that a change that happens after the eligibility interview and before the notice of decision must be reported within 10
calendar days unless otherwise notified. If I have any doubt about whether to report a change, I will ask my Human Services
caseworker.
I understand that if I am approved for SNAP benefits and I receive more benefits than I am entitled to, whether an error on my part
or an agency error, the amount of overpaid benefits may be subtracted from my monthly benefit amount.
AT THE APPLICATION
You Must Report You must report and verify:
Child care expenses Medical expenses
Rent or mortgage payment, property taxes and insurance and
utility expenses.
Child support paid to a non-SNAP Unit member
Failure to report or verify above expenses will be seen as a statement by your SNAP Unit that you do not want to receive
a deduction for the unreported expenses.
Child support payments are subject to verification by computer matching with the records of the Division of Child Support
Enforcement.
Penalty Warning - What are the SNAP Program Penalties?
If you........... Then you will lose SNAP benefits
* Hide or give wrong information on purpose to get SNAP benefits
* Trade, steal or sell SNAP benefits, or resell food bought with SNAP
benefits
* Use SNAP benefits to buy non-food items like alcohol or tobacco.
* Use someone else's SNAP benefits for yourself or someone else.
* Throw away beverages purchased with SNAP benefits just to get
money back from a container deposit.
* 12 months first time
* 24 months the second time
* Permanently the third time
Trade SNAP benefits for controlled substance, such as drugs.
* 24 months first time
* Permanently the second time
Trade SNAP benefits for firearms, ammunition or explosives. * Permanently
Buy, sell, steal or trade SNAP benefits of more than $500.00 * Permanently
* Give false information about who you are and where you live so you can
get extra SNAP benefits.
* 10 years
You can also be fined up to $250,000 and put in prison up to 20 years or both. In addition, you may be barred from SNAP for an additional 18
months if court ordered. You can also be charged under other Federal Laws. Persons who are fleeing felons or probation/parole violators are
ineligible for SNAP benefits.
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 16 of 18
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Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES
Read carefully before signing this application on page 18. Ask your caseworker to explain anything that you do not
understand.
To receive benefits, a person must have a valid Social Security Number (SSN) or proof that he or she has applied for one, unless
exempt. If you or any member of your household wants to apply for assistance, but do not have a SSN, we can help you to apply
for one. State law requires us to explain how your SSN is used by the State of Illinois.
ü Your Social Security Number (SSN) will be used in the administration of the cash and/or medical program to check
the identity of household members, prevent duplicate participation, and to facilitate making mass changes to the cash
and/or medical program.
• The SSN (or any other information in this application) may be used in computer matching and program reviews
or audits and to make sure the household is eligible for assistance, other federal assistance programs, and
federally assisted state programs, such as school lunch, TANF, and Medicaid.
• IDHS secures and uses information about all clients through the income and eligibility verification system. This
includes such information as receipt of social security benefits, unemployment insurance, unearned income and
wages from employment.
• Any information obtained will be used in determining eligibility for assistance and the amount of assistance
provided for all programs.
• When discrepancies are found, verification of this information may be obtained through contacts with a third
party, such as employers, claims representatives, or financial institutions. This information may affect your
eligibility for assistance and the amount of assistance provided.
• IDHS will only use your SSN for the purpose for which it was collected.
• IDHS will not: sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly
display your SSN; print your SSN on any card required for you to access our services; require you to transmit
your SSN over the Internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any
materials that are mailed to you, unless State or Federal law requires that number be on documents mailed to
you, or unless we are confirming the accuracy of your SSN.
ü When an application for cash or medical assistance is filed, a determination of eligibility under all of the programs
administered by IDHS will be made unless I do not want to be considered for a particular program(s). If I do not want to
be considered for a particular program, IDHS will not consider my eligibility for that program(s).
ü The information provided on this form will be subject to verification by Federal, State, and Local officials. If any
information is found to be inaccurate, I may be denied cash benefits and/or medical assistance. I understand that
anyone who knowingly misuses the medical card issued by the State of Illinois may be committing a crime.
ü All information related to the establishment of paternity and child support enforcement has been provided to the best
of my knowledge.
ü If my application is approved, I give the State of Illinois the right to recover under the terms of any private or public
health care coverage any amount for which I or a member of my family may be eligible.
ü I also authorize staff of the IDHS to obtain information from my records or copy my records from the Social Security
Administration (SSA). I authorize release of my records from SSA to the staff of IDHS with respect to any claims for
disability benefits and all related appeals. I certify that I understand that the materials requested may be protected
under the Privacy Act. I authorize release of any material protected under the Privacy Act to the staff of IDHS.
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 17 of 18
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ü I understand that the State of Illinois will release information concerning medical services that I have received for any
reason authorized by law.
ü I understand that if the children I am applying for are approved for "All Kids Share or All Kids Premium", then I am
responsible for paying the premiums and copayment amounts.
ü If I am approved for TANF Cash and/or medical benefits for myself and my children, and the State of Illinois pays medical
bills for me, I give my right to collect medical support payments to the State of Illinois. I understand I must help to obtain
medical support payments for members of my family unless I have a good reason not to. My children can get health
insurance even if I do not help when the Department asks me to.
ü As a condition of eligibility, if I am approved for TANF Cash and/or medical assistance for myself and my children, I
understand that I may be required to cooperate with child support enforcement.
• Cooperation includes establishment of paternity and/or support enforcement and modification of child
support orders.
• I assign and give all my rights, title and interest of child support and medical support to Healthcare and
Family Services (HFS) as long as I receive TANF Cash/or medical assistance.
• I understand and agree that any child support payments paid through the clerk of the circuit court and
through the State Disbursement Unit (SDU) may be forwarded to the HFS as long as I receive TANF
Cash.
• I understand that if I apply for TANF Cash and/or medical assistance for my children only, I am not
required to cooperate with child support enforcement, but I may request services.
ü I declare under penalty of perjury, that the statements I have made regarding the citizenship or immigration status of each
person requesting assistance are true and correct.
ü I understand the Department will not share any information about immigration or any persons who do not have an Alien
Registration Number.
ü The Department will verify the immigration status of any person for whom I give an Alien Registration Number. To do that,
the Department will check the number with the U.S. Citizenship and Immigration Service (USCIS). The Department may
send other information to USCIS, such as copies of proof that I give of an Alien Registration Number and the person's
Social Security Number, if they have one.
ü If I am approved for Aid to the Aged, Blind, or Disabled (AABD) for cash and/or medical assistance, I understand that
IDHS may have the right to place a lien on my home or other real property I own. The amount of the lien is the amount of
assistance IDHS has provided to me.
ü I agree to inform the agency within 10 days of any change in my household's size, income, property, living arrangements,
school attendance, or address.
ü I understand that if approved for cash benefits, and I receive more benefits than I am entitled to, whether it be an error on
my part or an agency error, the amount of overpaid benefits are subject to recoupment/recovery.
Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued
ü I understand that a person convicted of a Class X or Class I felony or a comparable federal law, for acts that occurred on
or after 08/22/96 involving possession, use, or distribution of a controlled substance is ineligible to receive Cash
assistance. I understand that a person convicted of drug-related felony, other than a Class X or Class I, under Illinois or
any comparable federal law an act that occurred on or after 08/22/96, is ineligible for Cash assistance for 2 years
following the date of the conviction, unless they are in drug treatment or aftercare, or successfully participated in and
completed drug treatment and/or aftercare subsequent to their conviction.
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
State of Illinois
Department of Human Services
IL444-2378B (R-07-21) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Printed by Authority of the State of Illinois -0- Copies
Page 18 of 18
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
ü Right to Appeal I understand that if I am not satisfied with the action taken on my application that I have the right to
a fair hearing. I understand that I can ask for a fair hearing by getting in touch with the office where I applied or by writing to:
Illinois Department of Human Services, Bureau of Assistance Hearings, 401 South Clinton Street, 6th Floor, Chicago, Illinois
60607, or by calling 1-800-435-0774.
ü I understand that if I am mentally and physically unable to apply and I want someone else to apply for cash and/or
medical benefits for me, I must attach a written statement that gives the person permission. The statement must include the
person's name, address, and phone number. The statement must say that I am still responsible for the information provided
by the person
ü I understand that if I or anyone I have applied for is not eligible for Medicaid or All Kids, the state will send the
information from the application to the Health Insurance Marketplace. The Health Insurance Marketplace needs detailed
information about health coverage that my employer may offer even if I do not take it. The information requested on Pages
10 and 11 may be required if the state sends my application to the Health Insurance Marketplace.
ü I understand that by signing this application form, I consent to any investigation made by the Department to verify or
confirm the information I have given or any other investigation made by them in connection with my request for public
assistance. I understand that I must cooperate in these efforts to verify information.
Cash/Medical Assistance - CLIENT RIGHTS AND RESPONSIBILITIES continued
I declare under penalties of perjury that I have examined this form and all accompanying statements or documents pertaining to
the income and resources of myself (the applicant) or any member of my family (the applicant's family) included in this application
for aid, or pertaining to any other matter having bearing upon my (the applicant's) eligibility for aid, and to the best of my
knowledge and belief the information supplied is true, correct, and complete.
I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution,
criminal, civil or both. I certify under the penalty of perjury that the information I have provided on this application form is the truth
to the best of my knowledge.
Applicant Signature
Signature: Applicant Makes a Mark (X)
Applicant:
Spouse:
Signature of Witness:
Date
Date
Date
If you have made your mark (X) instead of signing your name, one witness must sign here:
Signature of Witness:
Signature of Witness: Date
Date
Applications based on blindness must be attested to by two witnesses.
Signature: Applicant Blind
Home Address:
Signature of Approved Representative:
APPROVED REPRESENTATIVE SIGNATURE
If the application is initiated by someone else for the applicant, they must sign below. If an approved representative completes
and signs this application, written authorization from the applicant is required.
I understand that if I have given false information or intentionally failed to disclose information, I may be subject to prosecution,
criminal, civil or both. I certify under the penalty of perjury that the information I have provided on this application form is the truth
to the best of my knowledge.
Apt. Number:
Relationship:
Phone Number:
You can mail or bring this form to an Illinois Department of Human Services, Family Community Resource Center (FCRC). Use the IDHS Office
Locator to find an FCRC at www.dhs.state.il.us/page.aspx?module=12 or call the IDHS Helpline at 1-800-843-6154. You can also apply for benefits
at ABE.Illinois.gov or by calling the Helpline at 1-800-843-6154.
ILLINOIS VOTER REGISTRATION APPLICATION
FOR ILLINOIS RESIDENTS ONLY (September 2017)
TO VOTE YOU MUST: TO COMPLETE THIS FORM:
TO VOTE IN THE NEXT ELECTION:
IMPORTANT INFORMATION:
IF YOU HAVE NO STREET ADDRESS,
below describe your home: list the name of subdivision; cross streets;
roads; landmarks; mileage and/or neighbors’ names.
N
W E
S
If you have questions about completing this form, please call the State Board of Elections at (217) 782-4141 or (312) 814-6440
(or webmaster@elections.il.gov).
TYPE OR PRINT CLEARLY IN BLACK OR BLUE INK
This is my signature or mark in the space below.
12. If you cannot sign your name, ask the person who helped you fill in this form to print their name, address and telephone number.
Today's date: / /
Box 1-If you do not have a middle name, leave blank.
Box 3-If mailing address is same as Box 2, write "same".
Box 4-By providing an email address you agree to receiveelection related
notices via email.
Box 5-If you have never registered before, leave blank. If you do not remember
your former address; provide as muchinformation as possible.
Box 6-If you have not changed your name, leave blank.
Box 10-If you have an Illinois Driver's License or Secretary of State ID, check
the first box and fill in the number. If you do not have a Driver's License or SOS
ID, check the second box and fill in the last four digits of your Social Security
Number. If you do not have a SSN, check the third box and send a copy of the
appropriate document (as described in the "Important Information" section)
along with this form.
Box 11-Read, date and personally sign your name or make your mark in the
box.
Name of person assisting. Full Address Telephone No.
- Be a United States citizen
- Be at least 18 years old (some 17 year olds may vote in the
General Primary Consolidate Primary or Caucus.)
- Live in your election precinct at least 30 days
- Not be convicted and incarcerated.
- Not claim the right to vote anywhere else
- Mail or deliver this application to your County Clerk or
Boardof Election Commissioners no later than 28 days before
the next election. (click here for County Clerk/Election Boardlistings
)
or go to http://www.elections.il.gov
− If you do not have a driver's license, State Identification Card or social
security number, and this form is submitted by mail, and you have never
registered to vote in the jurisdiction you are now registering in, then you must
send, with this application, either (i)a copy of a current and valid photo
identification, or (ii) a copy of a current utility bill, bank statement,
government check, paycheck,or other government document that shows the
name and address of the voter. If you do not provide the information required
above,then you will be required to provide election officials with either (i)or
(ii) described above the first time you vote in person or prior to voting by
mail.
- If you change your name you must re-register.
- If you register at a public service agency, any information regarding the
agency that assisted you will remain confidential as will any decision not to
register.
- If you do not receive a Notice within 2 weeks of mailing or delivering this
application, call your County Clerk or Board of Election Commissioners.
Are you a citizen of the United States of America? (check one)
Will you be 18 years of age on or before the next election day OR are you currently 17 and
will be 18 by the day of the next General or Consolidated Election? (check one)
If you checked "no" in response to either of these questions, then do not complete this form.
You can use this form to: (Check One)
apply to register to vote in Illinois change your address change your name
Yes No
Yes No
Suffix (Circle One)
Jr. Sr. II III IV
Middle Name or InitialFirst Name1. Last Name
TownshipCountyZip CodeCity/Village/Town
2. Address where you live (House No., Street Name, Apt. No.)
Office Use
4. Email (optional)Zip CodeCity/Village/Town
3. Mailing address (P.O. Box)
5. Former Registration address: (include City and State and Zip Code) Former County 6. Former Name: (if changed)
10. ID Number - check the applicable box and provide the appropriate number
IL Driver's License or, if none, Sec. of State ID, ot
Last 4 digits of Social Security Number
I have none of the above identification numbers
9. Home telephone number, including
area code (optional)
-)(
8. Sex (circle one)
M F
7. Date of Birth: MM/DD/YY
11.Voter Affidavit - Read all statements and sign within the box to the right.
I swear or affirm that:
- I am a citizen of the United States;
- I will be at least 18 years old on or before the next election (or the next
General or Consolidated Election);
- I will have lived in the State of Illinois and in my election precinct at least 30
days as of the date of the next election;
- The information I have provided is true to the best of my knowledge under
penalty of perjury. If I have provided false information, then I may be fined,
imprisoned, or if I am not a U.S. citizen, deported from or refused entry into
the United States.
SBE-R19
YOUR ADDRESS
PUT
FIRST
CLASS
STAMP
HERE
CHANGE OF ADDRESS
PCT WARD CODE ADDRESS CITY ZIP COUNTY DATE CLERK
SUSPENSION, CANCELLATION AND REINSTATEMENT
DATE EXPLAIN CLERK DATE EXPLAIN CLERK
To Election Judges
MAIL TO:
Voting Record 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Primary
General
NonPartisan
Special
For Primary, mark
D for Democrat
R for Republican
for all other
elections mark V
Back of SBE No. R-19
SBE-R19
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