Fillable Medical, Cash and SNAP Redetermination Notice (Lake Land College)

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Medical, Cash and SNAP Redetermination Notice (Lake Land College)

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Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 1 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
Date:
ADDRESS:
ADDRESS:
CITY, ST. ZIP
Case Number:
Office Name:
Office Address:
Phone:
TTY:
Fax:
Tenemos este aviso en español. Para solicitar avisos
en español, por Internet vaya al sitio ABE-MMC o
llame al 1-800-843-6154, (TTY: 1-866-324-5553 TTY/
Nextalk, 711 TTY Relay).
You can manage your account online at abe.illinois.gov
Your Medical Cash SNAP
benefit period is ending
. If you do not complete a redetermination your
benefits will stop. To keep getting benefits without a break and to allow time for us to process your redetermination, please
complete it by , but, no later than
.
Use one of the 3 easy ways below:
1. Complete the electronic version of this form online in ABE Manage My Case at abe.illinois.gov; or
2. Fill out, sign, and send us this form and all verifications we ask for.
You may send the form by mail or fax.
* Mail to Central Processing Unit, P.O. Box 19138, Springfield, IL 62763; or
* Fax the form to 1-844-736-3563; or
3. Complete your redetermination in person. Bring this form and your verifications to the office listed above.
You must have an interview with a caseworker to reapply for SNAP and/or Cash.
Check one of the boxes below if you are returning this form to the Family Community Resource Center. Check one of the boxes
below so we can schedule your interview.
I am elderly, ill, disabled, employed, or have some other hardship and need to be interviewed by phone.
Enter Telephone Number Here:
I am able to come to the office for an interview.
We will schedule your interview when your application is returned to us. If you do not keep a scheduled interview, it is up to
you to ask for another one.
COMPLETE AND SEND
You have the right to immediately file this Redetermination Application as long as it contains your Name, Address, and Signature.
The filing of the signed form starts the application timetable.
Failure to complete the interview requirements may result in delay or denial of benefits.
An interview is not needed for Medical Benefits.
(and) Medical Benefits Renewal Form
(Interview Required)
SNAP and/or Cash Redetermination Form
NAME:
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 2 of 14
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If self-employed, attach your income and expense statement for the last 30 days. If someone got tips that are not on their pay
stubs, tell us Who?:
Yes No
Yes No
NoYes
Total Tips $
2. Are there other people living with you not listed above? If yes, list them here.
Full Name Birth Date Relationship Eats with you?
For additional persons, please attach a separate sheet.
3. Does anyone get paid for working?
If YES, enter their name below. Attach copies of the last 4 pay
stubs if paid weekly, last 2 pay stubs if paid every other week or twice a month, and the last pay stub if paid monthly.
and the total amount of tips received in the last 30 days.
4. Did you or anyone start a new job? If YES, complete the information above.
1. Do these people still live with you?
Individual Name Individual DOB
Yes No
NoYes
NoYes
NoYes
Attach a sheet of paper if you need more room to list your family's income.
COMPLETE AND SEND
Date:
Case Number:
No Yes
No Yes
No Yes
No Yes
No Yes
List the Name of
Everybody Who is Working
Name of Employer
If a person works more than
one job list all the employers.
Rate of Pay Hours Worked Weekly
How often is the person paid?
Weekly, every 2 weeks, twice a
month, monthly, other?
Attach a sheet of paper if you need
more room to list your family's income.
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 3 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
6. During the last 30 days did anyone receive any other income such as Child Support, Social Security, SSI, Unemployment,
VA, Worker's Compensation, Contributions, or any other money?
NoYes5. Did anyone stop working, or did their job end? If YES, enter name, reason and final pay date.
If YES, complete the box below. NoYes
COMPLETE AND SEND
Case Number:
Date:
Name Type of Income Amount How Often
$
$
Attach a sheet of paper if you need more room to list your family's income.
Note: If everyone in your SNAP case receives or plans to apply for SSI, you may apply for SNAP at your local Social Security
Administration (SSA) office.
You must do this by
. The SSA office will forward your application to us to process.
NoYes
When do you expect this change to happen?
NoYes8. Is the address at the top of the first page your correct mailing address?
If NO, tell us the correct mailing address:
7. Do you expect any changes in anyone's income or employment?
If YES, what is the change?
Is this correct?
NoYes
If NO, tell us the correct address where you live:
Our records show that you live at:
Rent? $ Lot Rent? $ Mortgage? $
Enter any taxes and homeowner's insurance paid separately: $
Yes No
If YES, tell us who and how much:
Are any of these paid by someone else?
9. How much is your:
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 4 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
14. Does someone in your unit who is 60 or older or is blind or disabled have monthly medical expenses of $36 or more that are
paid by you and not reimbursed or paid by someone else?
Has any person who is receiving Cash Assistance from DHS been convicted of a felony involving drugs?
Answering YES will not reduce your benefits. If NO, do you pay for or are you billed separately from your rent or mortgage
for heat or air conditioning, or excess cost for heat or air conditioning?
10. Did you receive an energy assistance 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)?
Case Number:
Date:
Yes No
Yes No
Yes No
If NO, do you pay any other utilities?
If YES, what utilities?
Note: Air conditioning is a window air or central air conditioning unit.
NoYes
Yes No
If YES, who is the care for, who provides the care, how much do you pay for the care, and how often?
12. Does anyone in your household pay for the care of a child or disabled adult living in your home so someone can work, attend
training, or school to prepare for a job?
11. Does anyone in your household pay child support? If YES, who makes the payments,
how much and how often?
13. Does anyone who is age 18 or over attend a school, other than a high school, half-time or more?
If YES, who?
Yes No
Yes No
Yes No
For your ( Cash and) Medical benefits, please answer the following questions.
Are you or is anyone who lives with you pregnant?
If YES, name? Due date: Expected number of babies:
Policy NumberIf YES, name of insurance plan:
Do you or anyone living with you have health insurance? NoYes
Who is covered by this health insurance?
Name of insurance plan:
Who is covered by this health insurance?
COMPLETE AND SEND
Answer the following questions if the box is checked.
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 5 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
Will you or anyone who lives with you be claimed as a dependent on anyone's tax return for this year?
NoYes
Will you or anyone who lives with you file a federal income tax return next year to report income earned this year?
If YES, name of person(s) filing tax return:
If this person will file jointly with a spouse, write name of spouse:
If this person will claim dependents on the tax return, write name(s) of dependents:
Case Number:
Date:
NoYes
If YES, name of dependent:
Tax filer's name and relationship to dependent:
Do you or anyone living with you pay any expense that can be deducted on your federal income tax return?
No
Yes
If YES, list the expense: How much?
How often?
COMPLETE AND SEND
Do you or anyone living with you pay any of these expenses? Check all that apply.
Spousal support paid to someone else
How much? How often?
How often?How much?
Student loan interest paid
How often?How much?
Employment expenses (lunches/meals,
tools, uniforms, union dues)
How often?How much?
Child Support
How often?How much?
Child care expenses
How often?How much?
Other:
Answer the following questions if the box is checked.
Answer the following questions if the box is checked.
(Continued)
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 6 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
COMPLETE AND SEND
Case Number:
Date:
Do you or anyone living with you own other resources (assets)? Check all that apply.
Cash and bank accounts
What is the value? $
What is the value? $
Life insurance (cash value)
What is the value? $
Nursing home residence account
Burial funds
What is the value? $
What is the value? $
Certificate of deposit
What is the value? $
Annuities
Trust funds
What is the value? $
What is the value? $
Oil, coal, gas, mineral rights
What is the value? $
Car, truck or motor vehicle
Mutual funds, stocks, bonds
What is the value? $
What is the value? $
401(k), IRA or Keough accounts
What is the value? $
Loan (Money that is owed to you)
Inheritance
What is the value? $
What is the value? $
Other property or land
What is the value? $
Other:
Attach proof showing who owns these resources and the current value.
You do not need to attach proof of the value of the vehicle or your home.
Do you own or pay on a house or mobile home?
NoYes
If YES:
a. Do you regard the property as your home and intend to return to it?
b. Does your spouse, minor child, disabled child, or your dependent brother or sister
live in the property?
c. Is the property vacant?
d. Does the property produce income?
e. Is the property listed for sale?
NoYes
No
Yes
NoYes
NoYes
NoYes
Answer the following questions if the box is checked.
(Continued)
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 7 of 14
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Do you own or pay on any other land or buildings?
If YES:
a. Is the property listed for sale?
b. Does the property produce income?
No
Yes
NoYes
NoYes
Case Number:
Date:
COMPLETE AND SEND
Do you have life insurance?
Name of Company
Policy Number Face Value $
Face Value $Policy Number
Name of Company
Do you have health insurance?
Name of Company Policy Number
Premium Amount $
Does it cover long term care?
How Often Paid
Do you have other insurance?
Name of Company Policy Number
Premium Amount $
Does it cover long term care?
How Often Paid
NoYes
NoYes
NoYes
NoYes
NoYes
(Continued)
Answer the following questions if the box is checked.
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 8 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
Transfer of Resources
During the past year, have you:
* Sold or given away any resources such as cash, house, land, insurance, stocks, certificates of
deposit, etc.?
* Closed any savings, checking or other financial institution accounts?
* Changed the way any resource is held? This includes, but is not limited to, adding a name to a
house or deed or creating a trust.
If YES to any of the above, enter the following information about each transfer:
Description of resources:
Date transferred: Value Amount Received
Action taken (check only one):
Resources Sold Resources Given Away Change in Ownership
If ownership changed, describe the change in the way the resource is held:
Reason for Transfer:
Description of resources:
Date transferred: Value Amount Received
Action taken (check only one):
Resources Sold Resources Given Away Change in Ownership
If ownership changed, describe the change in the way the resource is held:
Reason for Transfer:
If more transfers were made, please attach an additional page.
During the past year, have you spoken with a financial planner or an attorney?
1. Person who Transferred the resources:
2. Person who Transferred the resources:
NoYes
NoYes
NoYes
NoYes
Case Number:
Date:
COMPLETE AND SEND
(Continued)
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 9 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
COMPLETE AND SEND
Case Number:
Date:
Income Diversion
This section does not affect your eligibility for medical assistance. It will affect the amount you must pay the facility
where you live.
Are you giving a part of your monthly income, like Social Security or a pension, to your spouse in the community,
your children or other dependent family members living with your spouse in the community, or children under age
21 not living with your spouse?
1. If the answer is NO, do you want to start giving part of your income to these family members?
2. If the answer is YES, do you want to continue to give a part of your income to these family
members?
3. If the answer is YES to #2, after we complete a current calculation, do you want to increase the
amount diverted to your family if more is available to do so?
If the answer to 1, 2 or 3 is "YES", please provide the information below about your spouse or other dependent family members in
the community.
You must give us verification of the income of the person(s) you name above if you want to start or increase the amount
of your income you give them.
No
Yes
NoYes
No
Yes
No
Yes
Name of Person Amount You Want To Give
If you are working and pay any of the following expenses, show the amounts you pay:
Day Care: $
Transportation To and From Work Car: pool or public transportation $
per week.
If you drive your own car, the number of miles you drive:
per week.
Answer the following questions if the box is checked.
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 10 of 14
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SHELTER
1. Please show the amount your household is billed for each of the following:
Rent or Mortgage Payment $
Property Taxes (if not included in the Mortgage): $
Insurance on Home (if not included in the Mortgage): $
AMOUNT How often is each payment due
Case Number:
Date:
2. Please show which of the following you pay in addition to your rent or mortgage:
Electricity:
Water:
Sewer Charges:
Heating:
Cooking Fuel:
Garbage Disposal:
Yes No
No Yes
No Yes
No Yes
No Yes
No Yes
3. If you pay heating expenses, please check which type of heating you have:
Electric:
Metered Gas:
Bottled Gas:
Fuel Oil:
Coal:
4. Do you have telephone service in your name?
No Yes
If YES, what is the name of your telephone company?
No Yes5. Do you have to pay to do your laundry?
No Yes
6. Do you share household expenses (including food
and shelter) with any of the people who live with you?
If YES, who?
COMPLETE AND SEND
Answer the following questions if the box is checked.
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 11 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
The following two questions are voluntary. Answering these questions will not affect your eligibility or level of benefits. The
reason for this information is to assure that program benefits are distributed without regard to race, color or national origin.
(Please, answer for the questions for each member of your household. Attach additional pages as needed.)
Case Number:
Date:
COMPLETE AND SEND
Do you have a pending asylum application? No Yes
No YesHas the immigration status for you or your family members changed?
If yes, attach a current letter of confirmation from your attorney or legal representative.
If no, attach proof of your current immigration status.
No YesAre you receiving federally funded torture treatment services?
If yes, attach a current letter of confirmation from the torture treatment center.
Do you have an asylum appeal pending? No Yes
If yes, attach a Form EOIR-26 Notice of Appeal with Filing Receipt for Appeal or Petition for Review of a Board
of Immigration Appeals Decision stamped by the U.S. Court of Appeals of the Seventh Circuit.
Answer the following questions if the box is checked.
Name (Last, First MI) Are you Hispanic or Latino? What is your race? (Select one or more)
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
No Yes
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander White
This information is requested solely for the purpose of determining the State's compliance with Federal civil rights laws, and your
response will not affect consideration of your application, and may be protected by the Privacy Act. By providing this information,
you will assist us in assuring that this program is administered in a nondiscriminatory manner.
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 12 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
CERTIFICATION AND CONSENT TO RELEASE GENERAL INFORMATION
Signature This application must be signed below.
By signing below; I swear or affirm, under penalty of perjury, the answers on this application are true and correct to the best of
my knowledge.
Signature Daytime or Cell Phone Number Date
CERTIFICATION AND CONSENT TO RELEASE GENERAL INFORMATION
I agree that the information I have provided may be shared with other state departments and agencies or community providers
who are funded by the Department of Human Services if they are asked to provide services to me. Any information I give will be
held confidential and will be used only when necessary to determine my eligibility for services and/or to provide services to me. If
information is shared with other state agencies or community providers who are funded by the Department of Human Services,
that provider or agency must also maintain the confidentiality of the information.
TANF: I assign and give all my rights, title and interest of child support and medical support to the Illinois Department of
Healthcare and Family Services for as long as I receive TANF cash and/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 Illinois Department of Healthcare and Family Services as long as I receive TANF cash.
* I understand that officials in charge of my health benefits may check all information on this form.
* I understand they may check my information electronically. If they ask for my help checking information, I must
cooperate.
* I understand that anyone who knowingly lies or provides untrue information, or arranges for someone to knowingly lie
or provide untrue information, or intentionally misuses the health benefits card issued by the State of Illinois, may be
committing a crime which can be prosecuted or punished under federal law, state law, or both.
* If the Illinois Department of Healthcare and Family Services pays medical bills for me, the State of Illinois may collect
my medical support payments instead of me.
Signature This application must be signed below.
By signing below; I swear or affirm, under penalty of perjury, the answers on this application are true and correct to the best of
my knowledge.
NOTE: If release of medical, mental health, drug or alcohol, school, or vocational rehabilitation information is sought, a Specific
Release for that information must be obtained. This form does not apply to the release of such information.
DateDaytime or Cell Phone NumberSignature
Case Number:
Date:
COMPLETE AND SEND
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 13 of 14
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
USDA Nondiscrimination Statement
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.
This is an equal opportunity employer.
Additional Illinois Nondiscrimination Information
You may also write the Department of Human Services (IDHS) at 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 Relay.
DHS, 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.
Medical, Cash and SNAP
Redetermination Notice
State of Illinois
Department of Human Services
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination
Printed by Authority of the State of Illinois -0- Copies
Page 14 of 14
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Page Intentionally Left Blank
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.
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
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Medical, Cash and SNAP Redetermination Notice (Lake Land College)

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Completed 22 June 2021

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