INCOME: Proof of income may be required with this application including but not limited to pay-stubs, tax-returns, etc.
If you have reported no income, how do you pay your bills? (Do not leave blank if no income is reported.)
Net Monthly Income (After Taxes): Check type and fill in the amount on the lines.
Applicant Others in Household
Social Security
SSDI
SSI
Veteran’s Benefits
Employment Wages
FIP
Child Support
Rental Income
Dividends, Interest, etc.
Pension
Other
Total Monthly Income
HOUSEHOLD RESOURCES: Check type and fill in the amount and location on the lines.
Amount Bank, Trustee or Company
Cash
Checking Account
Savings Account
Certificate of Deposit (CD)
Trust Funds
Stocks and Bonds (cash value)
Burial Fund/Life Ins (cash value)
Retirement Funds (cash value)
Other
Total Resources
Motor Vehicles: Yes No Make & Year: Estimated value:
(include car, truck, motorcycle, Make & Year: Estimated value:
boat, recreational vehicle, etc.) Make & Year: Estimated value:
Do you, your spouse, or dependent children own or have interest in the following:
House (including the one you live in?)
Yes No Any other real estate or land? Yes No
If yes to any of the above, please explain:
Have you sold or given away any property in the last five (5) years? Yes No
If yes, what did you sell or give away?
Health Insurance (Check all that apply)
Primary Carrier (Pays 1
st
) Secondary Carrier (Pays 2
nd
)
Applicant Pays Medicaid Family Planning Only Applicant Pays Medicaid Family Planning Only
Medicare A, B, D Medically Needy MEPD Medicare A, B, D Medically Needy MEPD
No Insurance Private Insurance HAWK-I No Insurance Private Insurance HAWK-I
Company Name: Company Name:
Address: Address:
Policy Number: Policy Number:
(or Medicaid/Title 19 or Medicare Claim Number) (or Medicaid/Title 19 or Medicare Claim Number)
Start Date:
Any limits? Yes No Start Date: Any limits? Yes No
Spend Down: Deductible: Spend Down: Deductible:
