Fillable MEDICAL ASSISTANCE FOOD STAMPS Combined Application for DC (LawHelp.org)

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MEDICAL ASSISTANCE FOOD STAMPS Combined Application for DC (LawHelp.org)

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Combined Application for DC
MEDICAL ASSISTANCE
FOOD STAMPS
CASH ASSISTANCE*
* for the Disabled and Families with Children
If you live in D.C., you
can use this form to apply
for benefits. If you need help with this form, just
ask your worker or another IMA employee. You
can also call (202) 724-5506. Free interpreters
are available.
Please bring this form to your area Service
Center. To find out which Center is closest to
you, call (202) 724-5506. You may also mail this
form to 645 H St., NE, Washington, DC 20002.
Sí, hablo ESPAÑOL (SPANISH)
For Agency Use Only
Case Name
Date Rec'd
Date Disp.
Case #
Prog. Approved
Prog. Denied
Si usted vive en D.C., puede usar este
formulario para solicitar beneficios. Si necesita
ayuda con este formulario, pídale ayuda a su
trabajador u otro empleado de IMA. También
puede llamar al (202) 724-5506. Intérpretes
gratis están disponibles.
Por favor, lleve este formulario al Centro de
Servicio de su área. Para saber cuál Centro le
queda más cerca, llame al (202) 724-5506.
También puede enviar este formulario por
correo a 645 H St., NE, Washington, DC 20002.
Application Recertification
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HUMAN SERVICES
INCOME MAINTENANCE ADMINISTRATION
GOVERNMENT OF THE DI STRICT OF COLUMBI A
DEPARTMENT OF HUMAN SERVICES
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S
Anacostia Service Center
2100 Martin Luther King Avenue, SE
Washington, DC 20020
Phone: (202) 645-4614
Fax: (202) 727-3527
Congress Heights Service Center
4001 South Capitol Street, SW
Washington, DC 20032
Phone: (202) 645-4546
Fax: (202) 645-4524
H Street Service Center
645 H Street, NE
Washington, DC 20002
Phone: (202) 698-4350
Fax: (202) 724-8964
Fort Davis Service Center
3851 Alabama Ave., SE
Washington, DC 20020
Phone: (202) 645-4500
Fax: (202) 645-6205
Taylor Street Service Center
1207 Taylor Street, NW
Washington, DC 20011
Phone: (202) 576-8000
Fax: (202) 576-8740
Customers may call IMA at (202) 724-5506
to learn which Service Center serves their address.
Your Information
Last Name First Name Middle Name Date of Birth
Telephone
Current Address
Apt.
Mailing Address (if different)
City State
Zip Code
City State
Zip Code
I am applying for:
Medical Assistance
Food Stamps IDA (Interim Disability Assistance)
TANF/GC (Temporary Assistance for Needy Families / General Assistance for Children)
Note: Your Food Stamp benefits start on the day that you apply. You can apply right away. Make sure to write down your name
and address above and then sign at the bottom of this page.
Expedited Food Stamps
You might be able to get Food Stamps in less than a week! To see if you qualify, please tell us:
1. Will your household income be more than $150 this month?
2. Do you have more than $100 in cash or in the bank?
3. Is your income this month more than your housing costs (rent and utilities)?
Yes No
Yes No
Yes No
If you answered NO to the questions above, then you may be eligible. Please tell us:
(b) What did you pay for housing (rent and utilities) this month?
(a) What will be your total income this month?
$
$
Authorized Representation
Do you want someone else to act for or represent you?
Yes No If YES, please tell us:
Name of Your Authorized Representative: Address of Rep.: Telephone of Rep.:
What do you want them to do?
Signature
By signing below, I give my permission to DHS to get information about me. DHS can get this from my employer, landlord,
bank, and utility company. I give all of these people my permission to give information about me to DHS. I believe that all of
my information on this entire six-page form is correct. I know that if I give any false information, I may be breaking the
law. I know that state and federal officials will check this information. I agree to help with their investigations.
I agree to follow the rules for DHS benefits. I have received a copy of these rules. I know that I will have to recertify for my
benefits. I also understand that my child may get free health care through "HealthCheck."
Authorized Representatives: If the applicant cannot sign this form, you may sign it for them. By signing, you certify that this
person wants to apply for benefits and agrees to the conditions above.
Signature X
Date
Complete Interviews Report Changes Use EBT Card
Who Lives With You?
(Please list everyone in the household, even if you are not applying for them.)
Last Name First Name
Middle
Name
Applying for
this
Person?
(Yes/No)
Sex
(M/F)
Date of
Birth
Age
Social Security
Number*
Relation
to you
(child, aunt,
friend, etc.)
Do you eat
together?
(Yes/No)
U.S.
Citizen?
(Yes/ No)**
* You can leave
this blank if this person does not want benefits for him/herself. However, you may still have to provide information about this person’s income and assets.
** Many immigrants are eligible for benefits. To see if you may qualify, please fill out all of page 6. *** Attach another sheet if more than seven people live in your house.
General Questions
1. Are you:
2. Is anyone pregnant
3. How much do you pay for
child-care or elder-care (day care, babysitter, etc.)?
4. Are
you in a long-term care facility (nursing home, ICF-MR, CRF, etc.)?
5. Have you gotten benefits from
another State in the last three (3) months?
6. Does anyone age 16 or older go
to school or a job-training program?
(Not needed for food stamps)
(Not needed for food stamps)
If YES, who?
When is the baby due?
Single Married Divorced Separated Widowed
Yes No
$
How often do
you pay this?
1.
2.
3.
4.
5.
6.
7.***
7. In the last two (2) months, did anyone stop working or cut back on their hours?
Reason?
What was their last day at work?
Date of final paycheck:
If YES,
who?Yes No
Name of school or program?
If YES, who?Yes No
How many hours per week?
If YES, where?
Yes No
If YES, where?
Yes No
(self)
(n/a)
Income
Income from Work (before taxes or other deductions: gross, not net amount)
Person who is
working
How often do
you get paid?
(weekly, biweekly,
monthly, etc.)
How much
is each paycheck?
(before taxes)
Start Date
Employer's
Name/Telephone
$
Other Income
Do you or anyone else get any other income? Please check any that apply and list each payment below.
SSI
Social Security (not SSI)
Veterans benefits
Unemployment/Workers Comp.
Pensions and retirement
Foster care/adoption subsidy
(GROSS)
$
(GROSS)
Child support
Help with expenses
Other
Type of Payment
How often do you
get paid? (weekly,
biweekly, monthly, etc.)
How much
is each payment?
(before taxes and deductions?)
Who gets this?
$
(GROSS)
$
(GROSS)
$
(GROSS)
Does anyone pay your family for meals or to rent a room (for example, a roommate or boarder)?
Yes
No If YES, who pays? How much do they pay each month? $
Assets
Cash
Bank Accounts
Life Insurance
Real Property
Other
Transfers
Does anyone have more than $1,000 in cash?
If YES, how much?
Yes No
Yes No
Does anyone have more than $1,000 in the bank?
If YES, please attach your most recent bank statement(s).
Does anyone have life insurance that they can cash in?
If YES, how much money would you get if you cashed it in today?
$
Yes No
Does anyone own property other than the home you live in?
(For example: boats, rental property, real estate)
Yes* No
Yes* No
Does anyone have any stock, bonds, etc.?
Did anyone sell, trade, or give away anything worth more
than $1,000 during the last three (3) years?
Yes* No
* If YES, please attach a description to this form.
For the Blind and Disabled
(Medical Assistance and IDA Only)
Is anyone in your house blind or severely disabled?
If YES, who?
Yes
No
To get Medical Assistance and Interim Disability Assistance (IDA), you may need to show that you are
blind or disabled. Please get a Medical Form and have a doctor fill it out. If you do not have a doctor,
then call the Alliance on (202) 842-2810. They will help you find a doctor. The Alliance doctor will fill
out the Medical Form for you. DHS will treat all of your information as confidential.
Note: You do not need to fill out a Medical Form (856) if you are age 65 or older or if a child under
19 lives with you. Also, you may not need to fill out the form if you get Social Security. If you have
questions, please ask your worker or call (202) 724-5506.
Housing, Utilities, & Other Bills
(Food Stamps Only)
Your Food Stamps amount may depend on your housing, utility, and medical bills. Please tell us the current
amount of these bills. Do not include any past due amount. To qualify for more Food Stamps, you must
provide proof of these bills. If you do not, we will assume that you do not want this deduction.
Rent or Mortgage
Other
(describe below)
Monthly
Property
Taxes*
MortgageRent
Homeowner's
Insurance*
Condo Fee*
How Much?
Who Pays?
$ $ $ $ $ $
Do you pay for heating or air-conditioning separately from your rent?
Utility Bills (if separate from rent/mortgage)
Other
(describe below)
Fuel Oil*
Gas Bill*
Electic
Bill*
Phone Bill
(including cell)
Water Bill*
How Much?
Who Pays?
$ $ $ $ $ $
* Leave this blank if it is part of your rent or mortgage.
Yes No
Other Bills
1. Is there anyone who is disabled or age 60 or older who pays medical bills?
2. Does anyone in your home pay child support?
Yes No If YES, who pays? How much do they pay each month? $
Yes No If YES, who pays? How much do they pay each month? $
Health Insurance and Medical Bills
(Medical Assistance Only)
You may still get Medical Assistance even if you have other health insurance. We can also pay your
Medicare premiums for you. Please tell us about your health insurance.
Medicare
Health Insurance
Retro Medicaid/
Medical Bills
Yes No
Does anyone have Medicare (a red, white and blue card)?
If YES, who has Medicare?
Yes No
Does anyone have any other insurance?
If YES, please give us a copy of the insurance card.
Yes No
Did anyone have any medical bills in the last three months?
If you get Medical Assistance, you can get paid back for some bills that
you have paid. We can also pay some unpaid bills. Call (202) 698-2009.
Were your address, income, and assets the same as now
during the last three months?
Yes No
Parents Not Living in the Home
(TANF and Medical Assistance Only)
We can help you get child support. Please tell us about any absent parents (any parents not living with
their child). However, you could have a good reason for not telling us about an absent parent. If you
are afraid that an absent parent might hurt you or someone in your family, then you have a good
reason. If you have a good reason, then you do not have to give any information now.
Do you have a good reason for not telling us about an absent parent?
Yes No
If NO, then you need to fill in the information below. Please give as much information as you can.
Child's Name
Absent Parent's
Name
Absent Parent's
SSN
Monthly Support
Received
Reason for
Absence*
1.
2.
3.
4.
* Reasons for absence: never married, separated/divorced, in jail/prison, deceased, living somewhere else, etc.
Do you want to get this help with child support right away?
Yes No
Voluntary Questions
Your Ethnicity:
Hispanic/Latino Not Hispanic/Latino
Black/African American Asian American Indian or Alaskan Native
Your Race:
White Native Hawaiian or Other Pacific Islander
Note: You may check more than one race. Also, you do not have to provide this information. None of this
information will affect your benefits. We only ask for this information to make sure that we do not discriminate.
For Immigrants (Non-Citizens) Applying for Benefits
Many immigrants are eligible for benefits. For any non-citizen applying for benefits, please provide the immigration information below.
We keep this information confidential. If your status is "OTHER," then we will not ask you for any more information about your
immigration status.
If you are only applying for your child, you do not have to give details about your immigration status. Instead, you can just give your
child's immigration information. If you just want benefits for your child, you can mark "OTHER" for your own immigration status.
Please use these categories for "Current Status" in the table below:
• Lawful permanent resident (LPR)
• Refugee or Asylee
• Cuban or Haitian Entrant
• Person who has been granted withholding of deportation
(removal)
• Parolee admitted for at least one year
• Alien who has been present before April 1, 1980, as a “Conditional
Entrant"
• Person on active duty in U.S. Armed Forces (or veteran)
• Spouse, widow or dependent of American soldier or veteran
• A victim of domestic violence
• A victim of a severe form of trafficking in human persons
• Native American/Inuit born outside of the U.S.
• Hmong/Laotian
• Amerasians who came to the U.S. due to the Vietnam War
• OTHER: status does NOT match one of those listed here.
Name
Alien ID#
("A" Number)
Current Status
Date You Moved to
the U.S.
Ever a
Refugee/
Asylee
Cuban/
Haitian?
1.
2.
3.
4.
5.
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Important: Did anyone above move to the United States before August 22, 1996?
Yes No
Note: Some immigrants who moved to the U.S. after August 22,
1996 do not have to wait five years before getting benefits.
If YES, who?
For Lawful Permanent Residents (LPRs) only:
1. Do you have a sponsor?
2. Have you, your parents, your spouse, and/or your sponsor ever worked in the U.S.?
Yes No
Yes No
This Is Your Receipt
The date stamp at the right shows that DHS got your application. If you have any
questions, you can call your worker or (202) 724-5506.
Your worker will give you a "checklist." This checklist tells you which documents
that you need to bring back to DHS. You can also mail copies to your Service
Center or to DHS/IMA, 3rd Floor, 645 H St., NE, Washington, DC 20002. If you
mail them, please write your name and your date of birth on each document.
IMA DATE STAMP
Case Name
IMA Contact
Tel.
Service Center address
Documents That You May Need to Bring to DHS
Proof of: Examples
Income
Recent paystubs; statement showing retirement income, disability income, or
Worker’s Compensation; pension statement; etc.
Assets
Recent bank and checking account statements, etc.
D.C. residency
DC driver’s license, lease, rent receipt, written statement for your landlord, utility or
telephone bill, etc.
Social Security number
Social Security card; tax or payroll documents with your SSN on it; etc.
Medical Exam Report/Disability
Recent medical report (or Form 856) and any supporting materials from your doctor.
Immigration Information
Employment Authorization card, I-94, visa, passport, or other documents from the
INS.
Rent/mortgage (Food Stamps only)
Lease, rent receipt, cancelled check, mortgage statement, etc.
Utility bills (Food Stamps only)
Recent bills for electric, gas, fuel, phone, water, telephone, etc. (if you pay these
separately from your rent).
Relationship (TANF only)
Birth certificate (full copy) for your child(ren) or official records from a school,
court, hospital, etc.
“Living with” (TANF only)
Statements from two non-relatives or school records.
Also bring your Medicare card or other health insurance card, if you have one.
Referrals
HealthCheck provides free check-ups for children on Medicaid. It also pays for other services that a child needs.
HealthCheck can also get you free rides to the doctor. To find out more, call 1-888-557-1116.
WIC is a program for children under five. With WIC, you can save up to $140 each month on food. Also, WIC staff can
talk with you about breast-feeding. To find out more, call (202) 645-5663.
If you are eligible for Medical Assistance, you can get money back for recent medical bills that you have paid. To find
out more, call (202) 698-2009.
The District has a special program for seniors and the disabled who need in-home nursing and other home care. This
program has a higher income limit than regular Medical Assistance. To find out more, call (202) 442-9055.
•
•
•
•
HIV/AIDS testing and services (202) 671-4900 Medicare 1-800-633-4227
Alcohol and drugs 1-888-7WE-HELP Social Security Administration 1-800-772-1213
Depression and mental health 1-888-7WE-HELP Energy Assistance (202) 673-6700
Breast/cervical cancer screening (202) 442-5900 Public Housing and Section 8 (202) 673-6700
Free Legal Help
Neighborhood Legal Services
1213 Good Hope Rd., SE
(202) 678-2000
Legal Clinic for the Homeless
1200 U St., NW
Washington, D.C. 20009
(202) 328-5500
Bread for the City Legal Clinic
1640 Good Hope Rd., SE
(202) 561-8587
Legal Aid Society
Suite 800
666 11th St., NW
(202) 628-1161
Bread for the City Legal Clinic
1525 Seventh St., NW
(202) 265-2400
Legal Counsel for the Elderly
(for people age 60 and older)
601 E St., NW
Building A, 4th Floor
(202) 434-2120
Your Rights and the Program Rules
Recertification
We will send you a recertification notice in the mail. If you
get Medical Assistance, just complete the form and send
it back to DHS. If you get Food Stamps or cash assistance
(TANF, GC or IDA), then you will need to come to DHS for
an interview. If you do not recertify, then you will lose your
benefits.
If you move, please let us know. Just call (202) 727-5355.
If you do not tell us your new address, then we cannot
send you the recertification form.
Fair Hearings
If you think that DHS has made a mistake, then you can
get a Fair Hearing. Call (202) 698-4650 to find out more.
You can also call (202) 727-8280. At a Fair Hearing, you
can ask someone else to speak for you. This could be an
attorney, a friend, a relative, or someone else. You can
also bring witnesses. We will pay for transportation to the
Fair Hearing for you and your witnesses. We may also
pay for some of your other costs. You can also get free
legal help for a Fair Hearing. Call one of the agencies
above to talk to a lawyer or counselor.
General Rules
You must give true and complete information. If you lie or
give false information, you may lose your benefits. You
could also be fined and go to prison.
We may verify your information to make sure it is correct.
We may check on your income, your Social Security
information, and your immigration information. We verify
this information through computer matching programs.
We may also interview you and do a home visit.
Your case may be chosen for a Quality Control review.
This is a detailed review of all of your information. It may
include some personal interviews and a review of your
medical records. By applying, you agree to cooperate
with the state or federal reviewers. If you refuse to
cooperate, you may lose all or part of your benefits.
If you are under investigation or are fleeing to avoid the
law, we may share your information with federal and local
agencies. We may also share your Food Stamps
information with private debt collectors.
Under federal and District law, you must provide your
Social Security Number (see 42 CFR 435.910, 7 CFR
273.6, DC Code §4-204.07, §4-205.05a, and §4-217.07)
if you are in the assistance unit for Medical Assistance,
IDA, Food Stamps, or TANF. Your SSN will be used to
verify your identity, prevent receipt of duplicate benefits,
and make required program changes. The DHS computer
system uses your SSN to verify your income by using
records from the Internal Revenue Service, the Social
Security Administration, and the DC Child Support
Services Division (CSSD).
Medical Assistance Rules
After you apply, you will get a decision about your Medical
Assistance within 45 days (or 90 days if DHS must
determine if you are disabled). If you do not get a notice
within this period, please call your IMA worker or (202)
724-5506. To get free legal help with Medicaid, call
Terris, Pravlik, and Millian on (202) 682-0578 or write to
them at 1121 12th Street, NW, Washington, DC 20005.
If you get Medical Assistance, then you must recertify
each year when we send you a recertification notice.
There is no time limit for getting Medical Assistance. Also,
if you lose TANF, you may still get Medical Assistance.
Child Support: You agree to cooperate fully with the DC
Child Support Services Division (CSSD) in establishing
paternity and getting child and medical support as
required by law. You can apply for an exception to this if
you have a good reason. However, you can lose your
benefits if you do not cooperate without a good reason.
Estate Recovery: The District will seek recovery for the
bills we pay if you are in a nursing home or other medical
institution. Also, if you are age 55 or older, the District will
seek recovery for services that you get. This means that
we may put a lien or claim on your property or estate. If
you have questions, call (202) 442-9075.
Lawsuits: If you sue or enter into settlement negotiations
with a third party for a medical claim or injury, you must
provide within 20 calendar days, written notice of the
action (either by personal service or certified mail) to the
Medical Assistance Administration, Third Party Liability
Section, 825 N. Capitol St., NE, 4th Floor, Washington,
DC 20002. If you have questions, call (202) 442-9075.
TANF Rules
After you apply, you will get a decision about your TANF
within 45 days. If you do not get a notice within 45 days,
you can get a Fair Hearing. Also, if you think your benefit
amount is incorrect, then you can get a Fair Hearing.
If you do not follow all of the program rules, then you may
lose part or all of your benefits. You would lose these
benefits until you comply or longer. Also, if you fail to
cooperate with CSSD, then you would lose 25% of your
TANF benefit.
• Go to treatment programs, as required.
If you do not follow the rules, then you may lose part or
all of your IDA benefits. Also, DHS will take out the
amount of IDA that you got from your first "lump sum" SSI
check; DHS will send the rest of your first SSI check to
you.
Food Stamp Rules
You may file an application for Food Stamps separately
from other benefits. You will get Expedited Food Stamps
within seven (7) days if you are eligible. After you apply,
you will get a decision about your Food Stamps within 30
days. If you do not get a notice within this period you can
get a Fair Hearing. Also, if you do not think your benefit
amount is correct, then you can get a Fair Hearing.
You must have an interview with DHS to get Food Stamps.
If you need to do an interview by telephone, please let
your worker know. We can do phone interviews if you
cannot come to DHS because of work. We can also do
phone interviews if you are sick or have a sick relative for
whom you are caring.
You will have to come to DHS to recertify when we send
you a notice. Note: some elderly and disabled customers
only have to recertify every two years. However, there is
no time limit for getting Food Stamps. In fact, even if you
lose TANF, you may still get Food Stamps.
If you get Food Stamps, you must follow these rules.
• Do not lie or hide information to get Food Stamps.
• Do not trade or sell your Food Stamps;
• Do not use someone else’s Food Stamps; and
• Do not buy alcohol or tobacco with your Food
Stamps.
If you break the rules, then you could be fined and go
to prison for up to 20 years. You may also lose your
benefits for one year for the first violation, two years
for the second violation, and permanently for the third
violation. If you lie about living in the District or your
identity, then you cannot get Food Stamps for 10
years. If you sell or trade your Food Stamps for any
purpose (e.g., to get drugs, firearms, ammunition, or
explosives) or traffic in $500 or more in benefits, then
you may lose your benefits permanently.
Rights of Support
You must turn over to the District Government any
payments
that you get from an insurance company for
medical care. You must turn over part or all of your child
support to the DC Child Support Services Division
(CSSD) after you get your first TANF payment. If you do
not agree to these conditions, then you cannot get
Medicaid or TANF. Once you are off TANF, then you can
keep any current child support payments. If you use a
Medicaid card or the TANF benefit, then you are telling
us that you agree to these conditions.
IDA Rules
After you apply, you will get a decision about your IDA
within 60 days. If you do not get a notice within 60 days,
you can get a Fair Hearing.
Also, if you do not think your
benefit amount is correct, then you can get a Fair
Hearing.
If you get IDA, then you must cooperate with your IDA
case manager. This means:
• Give us medical reports and other materials;
• Keep your appointments with the doctor and with the
Social Security Administration;
• Keep your appointments with your case manager; and
Confidentiality
By applying, you give DHS permission to talk
with your
employer, your landlord, your bank, your doctor, and
other people who have information about you. You
also give these people your permission to give
information about you to DHS. In addition, you also
give DHS permission to look at your motor vehicle
records, wage data, tax information, and other
government records. Of course, DHS keeps all of your
information confidential. DHS does not release your
records without your permission (except when required
by law).
Equality and Non-Discrimination
In accordance with Federal law and U.S. Department of
Agriculture (USDA) and U.S. Department of Health and
Human Services (HHS) policy, this institution is
prohibited from discriminating on the basis of race,
color, national origin, sex, age, or disability. Under the
Food Stamp Act and USDA policy, discrimination is
prohibited also on the basis of religion or political beliefs
To file a complaint of discrimination, write USDA, Director,
Office of Civil Rights, Room 326-W, Whitten Building,
1400 Independence Avenue, SW, Washington, DC,
20250-9410 or call (202) 720-5964 (voice and TDD).
Write HHS, Director, Office for Civil Rights, Room 506-F,
200 Independence Ave., SW, Washington, DC 20201 or
call (202) 619-0403 (voice) or (202) 619-3257 (TDD).
USDA and HHS are equal opportunity providers and
employers.
In accordance with the D.C. Human Rights Act of 1977,
as amended, D.C. Official Code § 2-1401.01 et seq.,
(Act) the District of Columbia does not discriminate on
the basis of actual or perceived: race, color, religion,
national origin, sex, age, marital status, personal
appearance, sexual orientation, familial status, family
responsibilities,matriculation, political affiliation,
disability, source of income, and place of residence or
business. Sexual harassment is a form of sex
discrimination, which is prohibited by the Act. In
addition, harassment based on any of the above
protected categories is prohibited by the Act.
Discrimination in violation of the Act will not be
tolerated. Violators will be subject to disciplinary action.
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MEDICAL ASSISTANCE FOOD STAMPS Combined Application for DC (LawHelp.org)

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Completed 13 June 2021

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