Form W-1ER "Renewal of Eligibility" - Connecticut

What Is Form W-1ER?

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

Form Details:

  • Released on June 1, 2014;
  • The latest edition provided by the Connecticut State Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form W-1ER by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Social Services.

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Download Form W-1ER "Renewal of Eligibility" - Connecticut

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State Of Connecticut
Head Of Household
Department Of Social Services
Client ID Number
_______________________
Renewal Of Eligibility
W-1ER (Rev. 6/14)
This renewal form is only for current DSS clients who get one or more of the following:
Supplemental Nutritional Assistance Program (SNAP)
Cash Assistance (including boarding home payments)
Medical Insurance (HUSKY) only if you are:
(1) 65 years old or older;
(2) on Medicare;
(3) determined disabled by DSS and are working;
or
(4) receiving Long-Term Care
If you get HUSKY and you are not in one of these four groups then you cannot renew with this
form. You must renew online at www.CONNECT.ct.gov or by phone with our partner Access Health CT at
(855) 805-4325. You can also call (855) 805-4325 and ask for a paper form. Renewing online is fastest.
This form is only to renew eligibility for the benefits you get now or to add new members of your
household. You must fill out the form and sign and date page 6 for it to be complete.
Call us if you need help filling out this form or getting proof: (855) 626-6632. To apply for help that you do
not get now, apply online at www.CONNECT.ct.gov. You can also ask us to mail you a paper application.
Do you need a reasonable accommodation or extra help getting benefits because of a disability or
impairment?
Y
N. If yes, what kind of assistance do you need? _____________________________
______________________________________________________________________________________
Section 1: Head Of Household (you)
irst Name
Middle Name
Last Name
(Maiden Name)
Best Phone #
Other Phone #
F
Home Street Address
City
State
Zip Code
Mailing Address (If Different)
City
State
Zip Code
Section 2: Household Members
• List members of your household starting with you.
• If you want to add a person to your household, list them here and in Section 4.
Name
Date of
Gender
Marital
Renew or Add
How Related
Buy/cook food
(First, Middle, Last)
Birth
(M or F)
Status*
household member
to You
with you?
1 Myself
Self
Renew
Add
2
Y
N
Renew
Add
3
Y
N
Renew
Add
4
Y
N
Renew
Add
5
Y
N
Renew
Add
6
Y
N
Renew
Add
*Marital Status: N = never married M = married D = divorced S = separated W = widowed
W-1ER Page 1 of 8

State Of Connecticut
Head Of Household
Department Of Social Services
Client ID Number
_______________________
Renewal Of Eligibility
W-1ER (Rev. 6/14)
This renewal form is only for current DSS clients who get one or more of the following:
Supplemental Nutritional Assistance Program (SNAP)
Cash Assistance (including boarding home payments)
Medical Insurance (HUSKY) only if you are:
(1) 65 years old or older;
(2) on Medicare;
(3) determined disabled by DSS and are working;
or
(4) receiving Long-Term Care
If you get HUSKY and you are not in one of these four groups then you cannot renew with this
form. You must renew online at www.CONNECT.ct.gov or by phone with our partner Access Health CT at
(855) 805-4325. You can also call (855) 805-4325 and ask for a paper form. Renewing online is fastest.
This form is only to renew eligibility for the benefits you get now or to add new members of your
household. You must fill out the form and sign and date page 6 for it to be complete.
Call us if you need help filling out this form or getting proof: (855) 626-6632. To apply for help that you do
not get now, apply online at www.CONNECT.ct.gov. You can also ask us to mail you a paper application.
Do you need a reasonable accommodation or extra help getting benefits because of a disability or
impairment?
Y
N. If yes, what kind of assistance do you need? _____________________________
______________________________________________________________________________________
Section 1: Head Of Household (you)
irst Name
Middle Name
Last Name
(Maiden Name)
Best Phone #
Other Phone #
F
Home Street Address
City
State
Zip Code
Mailing Address (If Different)
City
State
Zip Code
Section 2: Household Members
• List members of your household starting with you.
• If you want to add a person to your household, list them here and in Section 4.
Name
Date of
Gender
Marital
Renew or Add
How Related
Buy/cook food
(First, Middle, Last)
Birth
(M or F)
Status*
household member
to You
with you?
1 Myself
Self
Renew
Add
2
Y
N
Renew
Add
3
Y
N
Renew
Add
4
Y
N
Renew
Add
5
Y
N
Renew
Add
6
Y
N
Renew
Add
*Marital Status: N = never married M = married D = divorced S = separated W = widowed
W-1ER Page 1 of 8
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Section 3: Other People Living With You
• List anyone else who lives with you but is not applying for help.
Name
Relationship
Total they
Does this person (check all that apply):
(First, Middle, Last)
to You
pay you
Share expenses
Pay for room and meals
$
Buy/cook food with you
Pay for room only
Share expenses
Pay for room and meals
$
Buy/cook food with you
Pay for room only
Section 4: New Household Members
• Use this section to add new members to your household.
• Providing optional race and ethnicity data will not affect eligibility or benefit amount – it will only be used to
make sure that everyone has the same access to benefits. Check all that apply.
First Name
Middle Name
Last Name
(Maiden Name)
Social Security #
1
U.S. citizen?
Y
N If no, date entered U.S.:
I-94 #
Member or spouse ever serve in armed forces?
Y
N
Last grade completed in school:
Racial Heritage (Optional):
White
Black or African American
American Indian or Alaska Native
Hispanic or Latino/a
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Samoan
Guamanian or Chamorro
Other Pacific Islander
Mexican
Mexican-American
Chicano/a
Cuban
Ethnicity if Hispanic or Latino/a (Optional):
Puerto Rican
Other Hispanic, Latino/a or Spanish
First Name
Middle Name
Last Name
(Maiden Name)
Social Security #
2
U.S. citizen?
Y
N If no, date entered U.S.:
I-94 #
Member or spouse ever serve in armed forces?
Y
N
Last grade completed in school:
Racial Heritage (Optional):
White
Black or African American
American Indian or Alaska Native
Hispanic or Latino/a
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Samoan
Guamanian or Chamorro
Other Pacific Islander
Mexican
Mexican-American
Chicano/a
Cuban
Ethnicity if Hispanic or Latino/a (Optional):
Puerto Rican
Other Hispanic, Latino/a or Spanish
First Name
Middle Name
Last Name
(Maiden Name)
Social Security #
3
U.S. citizen?
Y
N If no, date entered U.S.:
I-94 #
Member or spouse ever serve in armed forces?
Y
N
Last grade completed in school:
Racial Heritage (Optional):
White
Black or African American
American Indian or Alaska Native
Hispanic or Latino/a
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Samoan
Guamanian or Chamorro
Other Pacific Islander
Mexican
Mexican-American
Chicano/a
Cuban
Ethnicity if Hispanic or Latino/a (Optional):
Puerto Rican
Other Hispanic, Latino/a or Spanish
Section 5: Students In Your Household
• List everyone in your household who goes to school.
Part-time or
Graduation
Name of person in school
Name of school
Grade
Full-time
Date
W-1ER Page 2 of 8
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Section 6: Felon Status
• Tell us about anyone you listed who (1) has been convicted of a felony, (2) is fleeing authorities to avoid going
to court or jail for a felony crime, or (3) is violating a condition of parole or probation.
Name
If convicted, crime and date convicted:
Fleeing from authorities?
Y
N
Violating parole/probation?
Y
N
Fleeing from authorities?
Y
N
Name
If convicted, crime and date convicted:
Violating parole/probation?
Y
N
Section 7: Earned Income (Attach Proof)
• Tell us about money the people in your household made from working. Include wages, salaries, tips, and
commissions from jobs. Include self-employment income such as money you get from your own business or for
doing odd jobs or any other work you do for money. Include any income from job-training programs.
• List each job separately.
• If you have no earned income, list the last job held by each person since the last review.
• You must provide proof of your income. Examples of proof are your last 4 weeks of paystubs or, if self-
employed, your most recent business records.
Gross pay
If paid hourly, hours
Name of person working: ______________________________
(before deductions):
worked per week:
Is this job self-employment?
Y
N
$ ________ every:
________
If no, list place of work (name, address and phone #):
Hour
If you get tips, how
Week
1
much each week:
Two Weeks
$________
Start date ___/___/___
End date ___/___/___
Twice a month
Month
If left job: 1. Explain why:__________________________________
2. Did you apply for Unemployment Benefits?
Y
N
Gross pay
If paid hourly, hours
Name of person working: ______________________________
(before deductions):
worked per week:
Is this job self-employment?
Y
N
$ ________ every:
________
If no, list place of work (name, address and phone #):
Hour
If you get tips, how
Week
2
much each week:
Two Weeks
$________
Start date ___/___/___
End date ___/___/___
Twice a month
Month
If left job: 1. Explain why:__________________________________
2. Did you apply for Unemployment Benefits?
Y
N
Gross pay
If paid hourly, hours
Name of person working: ______________________________
(before deductions):
worked per week:
Is this job self-employment?
Y
N
$ ________ every:
________
If no, list place of work (name, address and phone #):
Hour
If you get tips, how
Week
3
much each week:
Two Weeks
$________
Start date ___/___/___
End date ___/___/___
Twice a month
Month
If left job: 1. Explain why:__________________________________
2. Did you apply for Unemployment Benefits?
Y
N
Has anyone in your household quit a job in the last 90 days?
Y
N If yes, who?_____________________
Why did that person quit? ____________________________
Date of last check ___________________
W-1ER Page 3 of 8
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Section 8: Other Income (Attach Proof)
• List any money that people in your household get from places other than work.
• Examples of non-work money (also called unearned income): child support, alimony, Social Security benefits,
SSI, unemployment compensation, educational loans and grants, VA benefits, pensions, workers
compensation, stocks, bonds, annuities, rental property, roomers, boarders, money from friends or relatives,
any other source.
Gross Monthly Amount
Type of Income
Who Gets the Income?
(before any deductions)
$
$
$
$
$
Section 9: Assets (Attach Proof)
• List any assets or resources that people in your household own.
• Assets are things you own or are buying that can be sold, traded, or converted to cash held by others. An
asset does not include personal property such as furniture or clothing. Examples of assets:
-Cash
-Trusts / trust funds
-Prepaid funeral contracts
-Life estate / Life use
-Bank accounts
-Stocks / mutual funds
-Houses / Condos / Buildings
-Motor vehicles
-Life insurance
-Bonds / US savings bonds
-Land (including out-of-state)
-Boats / Campers
-Death benefits
-Money market accounts / CDs
-Real estate / property
-Motorcycles
-Annuities
-Retirement accounts
-Limited partnerships
-Other assets
Asset
Who Owns
Location or Account/Policy #
Value
$
$
$
$
$
$
Section 10: Asset Transfers
Has anyone in your household (1) sold, traded, given away, or transferred ownership of any assets since your last
review, or (2) had assets transferred through the probate court or surrogate court in any state since your last review?
Yes
No If yes to either question, list below.
Asset Transferred
Transferred To Whom?
Date of Transfer
Value Received
$
$
Section 11: Medical Insurance
• Tell us if anyone in your household is covered by medical insurance other than HUSKY.
Include information about medical insurance provided to a child by an absent parent.
Policy or
Insurance
Premium
Insurance Type
Covered Members
Claim #
Company
Amount
Medicare A (Hospital)
Medicare B (Medical)
Other Hospital / Medical Coverage (such as
Tricare, Blue Cross/Blue Shield, union coverage)
Long-Term Care (pays for nursing home care,
adult day care, assisted living care, and is
separate from hospital/medical coverage)
W-1ER Page 4 of 8
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Section 12: Community Spouse (Attach proof of income and expenses)
• Complete this section if you are married and (1) you get long-term care at home but your spouse does not, or
(2) if you get long-term care in a facility and your spouse lives in the community.
What is your spouse’s gross monthly income (before taxes or deductions)? $ ________ per month
List your spouse’s monthly shelter expenses below:
Rent
Mortgage
Condo Fees
Homeowner’s Ins.
Fire/Hazard Ins.
Property Tax
Other Fees
$
$
$
$
$
$
$
Section 13: Special Eating Arrangement
• Complete this section only if someone in your household is blind, disabled, or over age 65,
and renewing State Supplement cash or HUSKY C medical benefits.
Does anyone in your household eat at least one meal a day at a restaurant?
Yes
No
Does anyone in your household have a special diet?
Yes
No If yes, why?_______________________
Section 14: Lawsuits
• List household members who are suing others.
Person With Lawsuit
Attorney’s Name And Address
Section 15: Inheritance
• List household members who received an inheritance since your last review.
Name of Recipient
Date of Inheritance
Amount of Inheritance
Section 16: Child Support
• List household members who pay court-ordered child support for children who are not household members.
Person Who Pays
M onthly Payment Owed
Monthly Amount Paid
Person Who Pays
Monthly Payment Owed
Monthly Amount Paid
Section 17: Dependent Care
• Tell us about household costs for day care for a child or adult with a disability.
Person Who Gets Daycare
Amount Household Pays
Amount Paid by State or Other Source
$
per week
$___________ per week
1
Provider Name, Address And Phone #
Amount Household Pays
Amount Paid By State Or Other Source
Person Who Gets Daycare
$
per week
$
per week
2
Provider Name, Address And Phone #
Person Who Gets Daycare
Amount Household Pays
Amount Paid By State Or Other Source
$
per week
$
per week
3
Provider Name, Address And Phone #
Section 18: Medical Expenses (Attach proof)
• Complete this section if anyone in your household is 60 years old or older, or is a person with an SSI/SSD
disability, and has medical expenses such as medical insurance (premiums, deductibles and co-pays),
transportation cost for medical appointments or dental bills.
Person With Expense
Type Of Expense
Amount Of Expense
$
$
$
W-1ER Page 5 of 8
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