Form DHR/FIA CARES9701 "Application for Assistance" - Maryland

What Is Form DHR/FIA CARES9701?

This is a legal form that was released by the Maryland Department of Human Services - a government authority operating within Maryland. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2009;
  • The latest edition provided by the Maryland Department of Human Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form DHR/FIA CARES9701 by clicking the link below or browse more documents and templates provided by the Maryland Department of Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHR/FIA CARES9701 "Application for Assistance" - Maryland

144 times
Rate (4.3 / 5) 7 votes
FACTS YOU SHOULD KNOW ABOUT APPLYING FOR TEMPORARY CASH
ASSISTANCE, FOOD SUPPLEMENT PROGRAM (FORMERLY FOOD STAMPS)
AND MEDICAL ASSISTANCE
Social Security Numbers
You must give us a social security number for each family member who wants benefits.
If a person who wants benefits does not have a social security number, that person must apply for
a number. We can help applicants get their numbers.
If a family member has applied for a social security number, we will not delay your application
while you wait for the number.
We use social security numbers to prove income. We do not give numbers to other agencies like
Immigration and Naturalization.
Citizenship and Immigration Status
You must tell us about the citizenship and immigration status for each family member who wants
benefits.
Information
If a family member will not tell us about citizenship, immigration status or social security number,
that person will not get benefits.
They must still give us proof of income, expenses and other things.
The other family members who give us their information will get benefits if they meet the rules.
Emergency Medical Assistance
Immigrants who are not eligible for other kinds of medical assistance and apply only for
emergency medical assistance do not have to tell us their social security number, immigration or
citizenship status.
Time Limits
Temporary Cash Assistance has time limits.
The Food Supplement Program (formerly Food Stamps) and Medical Assistance do not have a
time limit.
When Temporary Cash Assistance ends because of time limits, earnings or other reasons, you
may still get Food Supplement benefits and Medical Assistance.
Interviews
You, a responsible family member or someone you choose to represent you must come into our
office for an interview.
If you have a serious problem, or if you are working, and you cannot come to our office for an
interview, we can interview you by telephone.
You must give or send us the proof we ask for at your interview.
If you need help
:
Applying for benefits, or
Have questions about information you must give us
Want to know what will happen to your benefits
Do not speak English and need free translation services
Call your case manager or call 1-800-332-6347
Si necesita ayuda para llenar el formulario favor de llamar al 1-800-332-6347.
DHR/FIA CARES 9701 Revised 9/09
FACTS YOU SHOULD KNOW ABOUT APPLYING FOR TEMPORARY CASH
ASSISTANCE, FOOD SUPPLEMENT PROGRAM (FORMERLY FOOD STAMPS)
AND MEDICAL ASSISTANCE
Social Security Numbers
You must give us a social security number for each family member who wants benefits.
If a person who wants benefits does not have a social security number, that person must apply for
a number. We can help applicants get their numbers.
If a family member has applied for a social security number, we will not delay your application
while you wait for the number.
We use social security numbers to prove income. We do not give numbers to other agencies like
Immigration and Naturalization.
Citizenship and Immigration Status
You must tell us about the citizenship and immigration status for each family member who wants
benefits.
Information
If a family member will not tell us about citizenship, immigration status or social security number,
that person will not get benefits.
They must still give us proof of income, expenses and other things.
The other family members who give us their information will get benefits if they meet the rules.
Emergency Medical Assistance
Immigrants who are not eligible for other kinds of medical assistance and apply only for
emergency medical assistance do not have to tell us their social security number, immigration or
citizenship status.
Time Limits
Temporary Cash Assistance has time limits.
The Food Supplement Program (formerly Food Stamps) and Medical Assistance do not have a
time limit.
When Temporary Cash Assistance ends because of time limits, earnings or other reasons, you
may still get Food Supplement benefits and Medical Assistance.
Interviews
You, a responsible family member or someone you choose to represent you must come into our
office for an interview.
If you have a serious problem, or if you are working, and you cannot come to our office for an
interview, we can interview you by telephone.
You must give or send us the proof we ask for at your interview.
If you need help
:
Applying for benefits, or
Have questions about information you must give us
Want to know what will happen to your benefits
Do not speak English and need free translation services
Call your case manager or call 1-800-332-6347
Si necesita ayuda para llenar el formulario favor de llamar al 1-800-332-6347.
DHR/FIA CARES 9701 Revised 9/09
Date Received
MARYLAND DEPARTMENT OF HUMAN RESOURCES
(Agency use only)
FAMILY INVESTMENT ADMINISTRATION
APPLICATION FOR ASSISTANCE
Your Name (Last, First, Middle)
Home Telephone
Work Telephone
Where do you live? (Number and Street)
Apt. #
City
State
Zip Code
Mailing Address (If different from home)
Cell Telephone
What language do you speak? □ English □ Spanish
□ Other ___________________________________
If you do not speak English and need free translation services, call your case manager or call 1-800-332-6347.
What type of assistance do you need now? (Check all that you need)
□ Cash Assistance
□ Child Care Services
□ Food Supplement Program (Food Stamps)
□ Medical Assistance - Do you have any unpaid medical bills from the past 3 months? □ Yes
□ No
Do you have any of these problems?
□ Utility shut off □ Eviction or foreclosure □ No place to stay □ No heat □ No food □ Cannot afford child care □ other:_____________
Are you or anyone in your household pregnant? □ Yes □ No If yes, who?________________________ Due Date___________
Are you or anyone in your household disabled? □ Yes □ No If yes, who? ________________________ Disability?___________
What type of assistance do you or any household members receive now
or in the past? (Check Now if you are currently receiving this assistance)
Under what name?
Now
1.
1.
Now
2.
2.
Now
3.
3.
If you are applying for the Food Supplement Program (FSP) you can complete all of the form and give it to us now. You may also
fill in your name, address, sign this page and give the page to us. You can then finish the rest of the application at home and bring or
mail it back to the office. You will not get any benefits until we receive the entire form and interview you.
Your Food Supplement benefit is based on the date you sign this application and give it to the department of social services.
You may get Food Supplement benefits right away if you meet one of the following conditions:
Your household’s monthly rent or mortgage and utilities are more than your household’s income and resources.
Your household’s gross monthly income is less than $150, and your resources, such as bank accounts, are $100 or less.
Your household is a migrant or seasonal farm worker household.
If you qualify to get Food Supplement benefits right away, you will receive them within 7 days from the date you sign the form;
however, you will not get expedited Food Supplement benefits, if eligible, until we get a completed application form and interview you.
YOUR SIGNATURE
DATE
Go to page 2
FOR AGENCY USE ONLY
LDSS Office
Programs applied for or receiving
AU ID #s
Case Manager’s Name
Application/Redetermination Date
MA #s
EXPEDITED SERVICE FOR FSP BENEFITS (CUSTOMERS SHOULD NOT WRITE IN THIS AREA – FOR AGENCY USE ONLY)
Applicants who meet the standards below are eligible to receive Food Supplement benefits within 7 days. The customer must be
interviewed, either in person or by telephone, in order to determine eligibility for expedited service. The application must be complete,
signed, and identity verified before expedited benefits can be issued.
1. Is the total household income this month, before deductions, less than $150 AND household cash/savings $100 or less? □ Yes □ No
Estimated self-reported income for this month = $__________ Household’s monthly rent or mortgage amount = $___________
Household cash and savings for all members = $__________ Appropriate utility standard (SUA, LUA or actual) = $___________
A. Total income and liquid resources = $__________
B. Total shelter costs = $___________
2. Is the total amount for B. (Total shelter costs) greater than the total for A. (Total income and liquid resources)? □ Yes
□ No
3. Are the household members destitute migrant or seasonal farm workers whose cash and savings are $100 or less? □ Yes
□ No
If the answer to any of the above questions is yes, this household is potentially eligible for Expedited FSP.
4. If there is another reason why this household should NOT be expedited, list it here: _______________________________________
I certify that I screened this applicant for expedited Food Supplement benefits and determined that the household □ was □ was not
eligible for expedited issuance at this time.
Signature of Case Manager
Date
DHR/FIA CARES 9701 Revised 9/09
1
A. HOUSEHOLD MEMBERS
Fill in the blanks for everyone that lives with you. List your own name first. Social
Only Answer the questions
Security number and Citizenship are optional for members not applying for benefits.
below for each person
Use the codes below to complete the Citizenship, Race and Ethnicity columns. Enter
who
wants benefits
each code that applies, using at least one code for each person.
Ethnicity Codes: 1= Hispanic or Latino, 2=Not Hispanic/Latino
Race Codes: you can choose one or more race code - 1=American Indian/Alaskan Native,
2=Asian, 3=Black/African American, 4=Native Hawaiian/Pacific Islander, 5=White
Citizenship/Immigration Code: 1=United States Citizen, 2=Permanent Resident, 3=Asylee,
4=Alien granted conditional entry, 5=Parolee 1 year or more, 6=Alien whose deportation is
withheld, 7=Refugee, 8=Battered alien spouse, child, or parent of child(ren)
Note: You do not have to give information about your race or ethnicity. If you do, it will
help show how we obey the Federal Civil Rights Law. We will not use this information to
decide if you are eligible. If you do not give us your race, it will not affect your
application. The case manager will enter a race code for statistical purposes only. Title
VI of the Civil Rights Act of 1964 allows us to ask for this information.
NAME
DATE
SOCIAL SECURITY NUMBER
(Last, First, Middle)
OF
BIRTH
Self
Are any of the household members a roomer or boarder? □ Yes □ No
If yes, who?_____________________________________
B. CITIZENSHIP/ IMMIGRATION STATUS
If anyone for whom you are applying is not a United States citizen, fill in this section. ONLY ANSWER THESE
QUESTIONS FOR EACH PERSON WHO WANTS BENEFITS. If you are not eligible for other kinds of Medical
Assistance and you are applying only for Emergency Medicaid, you do not have to fill-in this section.
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
DHR/FIA CARES 9701 Revised 9/09
2
C. AUTHORIZED REPRESENTATIVE:
You may choose a person to apply for you. You may also choose a person to get your benefits through your
Independence Card. This person can use your benefits the same way you do. If you choose someone to help you, give
us the following information about the person and check what you want this person to do.
Name (Last, First , Middle)
Relationship
Telephone Number
Number, Street
City
State
Zip Code
Check what you want the representative to do:
□ Complete interview for you
□ Use your Independence Card (cash)
□ Receive your notices
□ Sign your application
□ Use your Food Supplement benefits
□ Receive your Medical Assistance card
D. STUDENTS
Are any household members between ages 18-50 attending a school for higher education (college, vocational or technical
school)?
□ Yes □ No
Name of student _______________________________________________
School__________________________________
Is the student employed? □ Yes □ No
Is the student getting educational grants, scholarships, or loans? □ Yes □ No
Amount $__________________
Amount of tuition $_________________ Books $_______________ Fees $________________ Transportation
$______________
E. RESOURCES/ASSETS
Does anyone in your household have any resources or assets such as a checking or savings account, stocks, bonds, cash
on hand, property other than where you live, prepaid burial plan, trust fund, IRA or KEOGH account? □ Yes □ No If yes,
list below:
NAME OF OWNER
LOCATION
(Specify if self-employed)
TYPE OF RESOURCE/ASSET
BALANCE/VALUE
(Name of Bank, at home, etc.)
F. TRANSFER OF ASSETS
Has anyone in your household sold, traded or given away any property, stocks, bonds, cash or other assets in the past 36
months? (60 months if a trust is involved)
Former Owner
Transfer
Who Received the Asset?
Type of asset
Date
Fair Market Value
Amount Received
Reason for Transfer
$
$
G. EARNED INCOME
Dose anyone in your household receive any income from employment? □ Yes □ No If yes, list all gross income before
deductions (such as full or part-time employment, self-employment, baby-sitting, odd jobs, day work, roomer/boarder
payments, etc.)
NAME OF EMPLOYER
RATE OF PAY
NUMBER OF
AMOUNT
HOW
NAME
(INCLUDE ADDRESS AND PHONE
HOURS
PER PAY
OFTEN
NUMBER)
WORKED
PERIOD
RECEIVED
DHR/FIA CARES 9701 Revised 9/09
3
H. DEPENDENT CARE
If anyone in your household pays someone to care for a child or disabled adult, fill in this section:
Name of Care Provider
Telephone
Name of Care Provider
Telephone
Number
Street
Number
Street
City
State
Zip code
City
State
Zip code
Household Member Receiving Care
Under 2 years
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
old? □ Yes □ No
Who Pays?
Cost
Who Pays?
Cost
$
$
Household Member Receiving Care
Under 2 years
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
old? □ Yes □ No
Who Pays?
Cost
Who Pays?
Cost
$
$
I. CHILD SUPPORT/ALIMONY EXPENSE
Does any household member pay court ordered child support to a NON-HOUSEHOLD member? □ Yes □ No If yes, who?
(Includes current payments, arrearages, health insurance)
PERSON OR AGENCY
HOW OFTEN
DEPENDENT’S NAME, ADDRESS AND PHONE NUMBER
AMOUNT PAID
PAID
PAID
J. OTHER INCOME AND BENEFITS
If anyone in your household receives, applied for or was denied any benefit listed below, place a check in the box next to
the benefit
□ Alimony
□ Child Support
□ Social Security
□ SSI
□ Railroad Retirement
□ Veteran’s Pension/Benefit
□ Unemployment Benefits
□ Education Grants or Loans
□ Worker’s Compensation
□ Pension or Retirement
□ Union Benefits
□ Disability, Sick or Maternity Benefits
□ Military Allotment
□ Money from Rental Income
□ Black Lung Benefits
□ Money from Friends or Relatives
□ Lump Sum Cash Amounts □ Civil Service Annuity
□ Temporary Cash Assistance
□ TDAP
□ Social Security Disability
□ Interest Dividends from Stocks, Bonds, Savings or Other Investments
□ Other ______________________________________
Do you agree to apply for all benefits you may be entitled to receive? □ Yes □ No
If you checked yes to receiving, applying for or being denied any benefits, fill in below:
HOUSEHOLD MEMBER
TYPE OF BENEFIT
Applied
CLAIM NUMBER
Received
Amount
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
DHR/FIA CARES 9701 Revised 9/09
4