Fillable Case Number: __ (Montgomery County Maryland)

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Case Number: __ (Montgomery County Maryland)

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The Case Number: __ (Montgomery County Maryland) form is 2 pages long and contains:

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  • 37 check-boxes
  • 99 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Montgomery County Maryland

BROWSE MONTGOMERY COUNTY MARYLAND (MD) FORMS

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Head of Household Name (Last, First, Middle)
Home Telephone
Work Telephone
Cell Telephone
Where Do You Live? (Number and Street)
Apt. #
City
State
Zip Code
Mailing Address (If different from home address)
What language do you speak? ☐ English ☐ Spanish ☐ Other __________________________________________________________________
Are you or anyone in your household pregnant?
☐
Yes
☐
No If yes, who? ________________________ Due Date _________________________________________
Have you ever received a County health program benefit program?
Yes
No
Under what name?
____________________________________________________________
SECTION A. HOUSEHOLD MEMBERS
Fill in the blanks for all the people in your household. Check YES for each person you are applying for. Check NO for each person you are
not applying for. Check services you are requesting.
Please complete for
each person who has a
Social Security number
APPLYING FOR
☐ MONTGOMERY CARES
☐ CARE FOR KIDS
☐ MATERNITY PARTNERSHIP
☐ SENIOR DENTAL
NAME
(Last, First, Middle)
RELATION
TO YOU:
DATE
OF
BIRTH
MM/DD/YY
GENDER
M =Male
F= Female
MARITAL
STATUS
M = Married
S = Single
D = Divorced
P = Separated
W = Widowed
*RACE
(Indicate below for
each person)
A = Asian
B = Black/African
American
C = White
N = Amer-Indian or
Alaska Native
P = Native Hawaiian
or Pacific Islander
(You may select
more than one code)
*ETHNICITY
H/L = Hispanic/
Latino
N/L = Non-
Hispanic/
Non-Latino
SOCIAL SECURITY NUMBER
(SSN)
☐
Yes ☐ No
SELF
☐
H/L ☐ N/L
☐
Yes ☐ No
☐
H/L
☐
N/L
☐ Yes ☐ No
☐ H/L ☐ N/L
☐ Yes ☐ No
☐ H/L ☐ N/L
☐
Yes
☐
No
☐
H/L
☐
N/L
*You do not have to give information about your race/ethnicity. We will not use this information to decide if you are eligible. If you do not give us your race, it will not affect your application. The
case manager will enter codes for statistical purposes only. Title VI of the Civil Rights Act of 1964 allows us to ask for this information.
MONTGOMERY COUNTY SAFETY-NET PROGRAMS
APPLICATION
COUNTY OFFICIAL USE ONLY:
eICM Contact ID:_____________________________
Case Number: __
_____________________________
Name (Last, First, Middle)
Country of Birth
Do you have Health insurance ☐ Yes ☐ No
If yes, is it: ☐ Private-Payer ☐ Employer-Based
Name (Last, First, Middle)
Country of Birth
Do you have Health insurance ☐ Yes ☐ No
If yes, is it: ☐ Private-Payer ☐ Employer-Based
Name (Last, First, Middle)
Country of Birth
Do you have Health insurance
☐
Yes
☐
No
If yes, is it: ☐ Private-Payer ☐ Employer-Based
Name (Last, First, Middle)
Country of Birth
Do you have Health insurance ☐ Yes ☐ No
If yes, is it: ☐ Private-Payer ☐ Employer-Based
NAME
(Last, First, Middle)
EMPLOYER
RATE
OF PAY
(HOURLY)
NUMBER
OF
HOURS
WORKED
GROSS
AMOUNT
PER PAY
PERIOD
HOW OFTEN
RECEIVED
WE = Weekly
BW = Bi-weekly
MO = Monthly
JOB START
DATE
(MM/DD/YY)
JOB END
DATE
(MM/DD/YY)
STUDENT
STATUS
(Full or Part-time)
PERSON RECEIVING INCOME
TYPE (For benefits, Include Claimant ID#)
GROSS AMOUNT RECEIVED
HOW MANY TIMES A YEAR?
I certify that the information I have provided above is true to the best of my knowledge and I give permission for Montgomery County to make any
necessary contacts to check my statements. I have read and agree to the rights and responsibilities in this application packet. I know that I can be
penalized if I knowingly give false information, and I declare under penalty of perjury that the facts I state in this application are true, correct, and
complete to the best of my ability, belief, and knowledge.
Signature of Applicant/Recipient
Print (Name)
Date
SECTION B. ADDITIONAL INFORMATION
SECTION C. EARNED INCOME
Does anyone in your household receive any income from employment?
☐
Yes
☐
No If yes, list all gross income (from full or part-time employment, self-employment,
babysitting, odd jobs, day work, roomer/boarder payments)
SECTION D. UNEARNED AND OTHER INCOME
List any other income received such as alimony, child support, pension, Social Security, income received from renting property to others, and benefits (retirement, strike
benefits, unemployment, veterans, workers compensation). Include out-of-state benefits.
SIGNATURE SECTION
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Case Number: __ (Montgomery County Maryland)

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Completed 6 May 2021

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