MISSISSIPPI APPLICATION FOR HEALTH BENEFITS
(MEDICAID, CHIP, HELP PAYING COSTS FOR HEALTH INSURANCE
COVERAGE)
This application is used to apply for health coverage for:
Medicaid
CHIP (Children’s Health Insurance Program)
The new tax credit that can help pay your health insurance premiums
Private health insurance plans through a federal Health Insurance
Marketplace
Use this application to apply for children, pregnant women, low-income parents of children
under age 18 and anyone in your family that needs to apply for health coverage. If you need
assistance in completing this application, need this application in a language other than
English, or if you are hearing or visually impaired and need special assistance, contact 1-800-
421-2408.
You do not have to fill out this application on paper. If you choose, you can apply on-line at
www.medicaid.ms.gov or www.HealthCare.gov.
What you will need to apply:
Social Security Numbers or document numbers for legal immigrants who need insurance,
Birth dates,
Employer and income information for each person in your family with income. Use
income from paystubs or W-2 forms or any document that shows exactly what each
person receives as income,
Policy numbers for any current health insurance,
Information about any job-related health insurance available to your family.
We will keep all the information you provide private, as required by law.
Complete and sign this application and send it to the address below. If you have questions,
call 1-800-421-2408 for assistance.
REGIONAL MEDICAID OFFICE ADDRESS & PHONE NUMBER
Cover Sheetrevised 01/01/2015
PART I HEAD OF HOUSEHOLD – This is the primary adult contact for this application. We will
contact you for any additional questions we may have. You do not have to apply for health coverage to
be the primary contact.
Full Name
Home Address
City State Zip County
Mailing Address
City State Zip County
Phone Numbers – (home) (cell)
(work) (message #)
Do you want to get information about this application by email? Yes No
If yes, provide email address: ___________________________________________________________
Preferred spoken or written language (if not English)
PART 2 – AUTHORIZED REPRESENTATIVE (Optional) – You can name a person you trust to act
as your authorized representative. This means you are giving this person permission to see your
application and to act for you on matters relating to this application, including providing information
needed to complete this application. You must complete and sign this portion of the application to name
someone to act for you. If someone is legally appointed to act for you, submit proof with this application.
Name of Representative
Address (include Apt or Lot #)
City State Zip Phone #
Relationship to Head of Household
Organization Name ID# (if applicable)
By signing, you allow this person to sign your application, get official information about this
application and act for you in all future matters related to the health coverage of the ones applying:
Signature of Head of Household Date
Part 1 & Part 2 - revised 01/01/2015
click to sign
signature
click to edit
PART 3 HOUSEHOLD MEMBERS – Include everyone who lives with you, even if not applying. If you file a
federal tax return, include everyone that you include on your federal tax return, even if they do not live with you.
Person 1 is the head of household for this application.
Name
Social Security
Number*
Date Of
Birth
Sex:
Male
Female
How is this person
related to you?
applying?
1
SELF
2
3
4
5
6
7
8
9
10
*Social Security Numbers (SSN) – We need SSNs for everyone who has one and is applying for health coverage.
You are not required to provide an SSN for household members not applying but it will speed up the application
process if you do give us SSNs of everyone. We use SSNs to check income and other information to see who is
eligible for help with health coverage. If you need help getting an SSN, contact Social Security at 1-800-772-1213.
TTY users call 1-800-325-0778. Or visit www.socialsecurity.gov.
PART 4 – RETROACTIVE MEDICAID COVERAGE (not available to children qualifying for CHIP) If
determined eligible for Medicaid, does any household member applying need Medicaid to cover services received
within the last 3 months? Yes No If yes, complete the following:
Name of household members/months needed:
PART 5 – HEALTH INSURANCE INFORMATION If anyone applying for health coverage currently has
health insurance, tell us about it. This includes Medicaid, CHIP, Medicare, and coverage through VA health
programs, private coverage, work, a retiree health plan or any type of health insurance.
Name of Person
Type of Coverage
Name of Health Plan
Policy Number
Part 3, Part 4 & Part 5 - revised 01/01/2015
PART 6 – INFORMATION NEEDED ON HOUSEHOLD MEMBERS – please complete the following
information on all household members listed in Part 3.
Person 1 This is the person named as Head of Household
Name
(first) (middle/maiden) (last) (suffix)
What is your marital status? ____________________________
Are you pregnant? Yes No If yes, what is the expected date of delivery?
How many babies are expected?
Do you plan to file a federal income tax return next year? Yes No If yes, select your filing status:
Married Filing Jointly Married Filing Separately Individual Head of Household Qualifying
Widow(er) If filing jointly with spouse, name of spouse
Will you claim any dependents on your tax return? Yes No If yes, name of dependents claimed:
Will you be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax filer:
How are you related to tax filer?
Do you need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
D
o you have a physical, mental or emotional health condition that limits common activities like bathing, dressing,
daily chores, etc. or do you live in a medical facility or nursing home? Yes No If you are disabled, would
you like to apply for Medicaid as a disabled person? Yes No If yes, you will be asked to complete
additional forms to determine if you qualify for Medicaid as a disabled individual.
Are you a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number _
Have you lived in the U.S. since 1996 Yes No Are you or your spouse or parent a veteran or an active-
duty member of U.S. military? Yes No
Do you live with at least one child under the age of 18 and are you the main person taking care of this child?
Yes No If yes, name of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, you will be asked to
cooperate with child support services to collect medical support from the absent parent unless child support
services determines you have good cause not to cooperate.
Were you in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 1 - revised 10/01//2019
Person 1 continued
Cu
rrent Job & Income Information: Are you currently:
Employed – How many jobs? ____ Self-employed – How many jobs? _ Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment __________
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will you get from this self-employment?
$ How often is this income received?
In the past year, did you: Change jobs Stop Working Start Working Fewer Hours Other
Explain:
Other Income – Tell us about other income that you receive that is not the result of your current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement,
Interest, Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If you are eligible for certain benefits, such as Unemployment Compensation, you must apply in order to be
eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if you get these income types to support your family.
Check here if you get any of these income types:
Deductions from income certain deductions allowable on a federal tax return are allowed to be deducted from
your reported income (unless already deducted from income shown above). If you pay alimony, student loan
interest or have other allowable deductions, tell us what they are: Type
Amount Paid $ How Often?
Yearly Income complete if your income changes from month to month: What is your total income for this
calendar year? $ Next year (if different) $
Part 6 / Person 1 continued - revised 01/01/2015
Person 2 – give us information on person #2 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
Name
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?_______________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, give names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 2 - revised 10/01/2019
Person 2 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment_
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward household income, but it helps us to know if this person gets these income types to help support the family.
Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this persons total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 2 continued - revised 01/01/2015
Person 3 – give us information on person #3 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 3 - revised 10/01/2019
Person 3 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this persons total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 3 continued - revised 01/01/2015
Person 4 – give us information on person #4 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
Name
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ______________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No If
yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, name of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 4 - revised 10/01/2019
Person 4 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $ How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 4 continued - revised 01/01/2015
Person 5 – give us information on person #2 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
Name
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, give names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 5 - revised 10/01/2019
Person 5 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employedHow many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment_
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward household income, but it helps us to know if this person gets these income types to help support the family.
Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this persons total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 5 continued - revised 01/01/2015
Person 6 – give us information on person #3 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Does this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 6 - revised 10/01/2019
Person 6 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employedHow many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this persons total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 6 continued - revised 01/01/2015
Person 7 – give us information on person #4 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ___________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No If
yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, name of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 7 - revised 10/01/2019
Person 7 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed How many jobs? _ Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $ How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 7 continued - revised 01/01/2015
Person 8 – give us information on person #2 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, give names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 8 - revised 10/01/2019
Person 8 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employedHow many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment_
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward household income, but it helps us to know if this person gets these income types to help support the family.
Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this persons total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 8 continued - revised 01/01/2015
Person 9 – give us information on person #3 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native
Chinese Asian Indian Filipino J apanese Korean Vietnamese Other Asian Native
Hawaiian Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 9 - revised 10/01/2019
Person 9 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employedHow many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veteranspayments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this persons total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 9 continued - revised 01/01/2015