Form 100 "Application for Food Benefits, Cash, Medical, and Child Care Assistance" - Delaware

What Is Form 100?

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

Form Details:

  • Released on February 1, 2014;
  • The latest edition provided by the Delaware Health and Social Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 100 by clicking the link below or browse more documents and templates provided by the Delaware Health and Social Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 100 "Application for Food Benefits, Cash, Medical, and Child Care Assistance" - Delaware

435 times
Rate (4.5 / 5) 26 votes
D
H
S
S
(DHSS)
ELAWARE
EALTH AND
OCIAL
ERVICES
A
F
B
, C
,
PPLICATION FOR
OOD
ENEFITS
ASH
M
,
C
C
A
EDICAL
AND
HILD
ARE
SSISTANCE
Welcome to the State of Delaware Health and Social Services (DHSS)
Apply faster
Apply faster online at www.assist.dhss.delaware.gov
This includes anyone wishing to apply for Medical Assistance only.
online
Who can use this
Use this application to apply for anyone in your home including any tax
dependents who are out of the home.
application?
Apply even if you or your child already has health coverage. You could
be eligible for lower-cost or free coverage.
Families that include immigrants can apply. You can apply for your child
even if you aren’t eligible. Applying won’t affect your immigration status or
chances of becoming a permanent resident or citizen.
If someone is helping you fill out this application, you may need to
complete Appendix C.
If applying for Medical Assistance only, you may be able to use a short
form.
What you may
Social Security Numbers (or document numbers for any legal
immigrants)
need to apply
Employer and income information for everyone in your household (for
example, from paystubs, W-2 forms, or wage and tax statements)
Policy numbers for any current health insurance
Information about any job-related health insurance available to your
family. You may need to complete Appendix A.
Why do we ask for
We ask about income and other information to let you know what coverage you
qualify for and if you can get any help paying for it. We'll keep all the information
this information?
you provide private and secure, as required by law.
Please use the stamped self-addressed envelope to mail your signed application. If
What happens
you don’t have all the information we ask for, sign and submit your application
next?
anyway. We’ll follow-up with you. You’ll get instructions on the next steps. If you
don’t hear from us, call 1-800-372-2022.
Get help with this
Phone: Call our Customer Relations Unit at 1-800-372-2022.
application
In person: There may be social workers/case managers in your area who
can help.
En Español: Llame a nuestro centro de ayuda gratis al 1-866-843-7212.
In a language other than English: Call 1-866-843-7212.
TTY users: Call 711 or 1-800-232-5460.
Form 100 (Rev. 02/2014)
Document No. 350701-14-07-02
D
H
S
S
(DHSS)
ELAWARE
EALTH AND
OCIAL
ERVICES
A
F
B
, C
,
PPLICATION FOR
OOD
ENEFITS
ASH
M
,
C
C
A
EDICAL
AND
HILD
ARE
SSISTANCE
Welcome to the State of Delaware Health and Social Services (DHSS)
Apply faster
Apply faster online at www.assist.dhss.delaware.gov
This includes anyone wishing to apply for Medical Assistance only.
online
Who can use this
Use this application to apply for anyone in your home including any tax
dependents who are out of the home.
application?
Apply even if you or your child already has health coverage. You could
be eligible for lower-cost or free coverage.
Families that include immigrants can apply. You can apply for your child
even if you aren’t eligible. Applying won’t affect your immigration status or
chances of becoming a permanent resident or citizen.
If someone is helping you fill out this application, you may need to
complete Appendix C.
If applying for Medical Assistance only, you may be able to use a short
form.
What you may
Social Security Numbers (or document numbers for any legal
immigrants)
need to apply
Employer and income information for everyone in your household (for
example, from paystubs, W-2 forms, or wage and tax statements)
Policy numbers for any current health insurance
Information about any job-related health insurance available to your
family. You may need to complete Appendix A.
Why do we ask for
We ask about income and other information to let you know what coverage you
qualify for and if you can get any help paying for it. We'll keep all the information
this information?
you provide private and secure, as required by law.
Please use the stamped self-addressed envelope to mail your signed application. If
What happens
you don’t have all the information we ask for, sign and submit your application
next?
anyway. We’ll follow-up with you. You’ll get instructions on the next steps. If you
don’t hear from us, call 1-800-372-2022.
Get help with this
Phone: Call our Customer Relations Unit at 1-800-372-2022.
application
In person: There may be social workers/case managers in your area who
can help.
En Español: Llame a nuestro centro de ayuda gratis al 1-866-843-7212.
In a language other than English: Call 1-866-843-7212.
TTY users: Call 711 or 1-800-232-5460.
Form 100 (Rev. 02/2014)
Document No. 350701-14-07-02
D
H
S
S
(DHSS)
ELAWARE
EALTH AND
OCIAL
ERVICES
A
F
B
, C
,
PPLICATION FOR
OOD
ENEFITS
ASH
M
,
C
C
A
EDICAL
AND
HILD
ARE
SSISTANCE
Welcome to the State of Delaware Health and Social Services (DHSS)
We help Delawareans in need by providing food benefits, medical, child care, and cash assistance. We can provide
information about other helpful services in your community. You can answer only the questions related to the program(s)
you are applying for. If you answer ALL the questions on the Assistance Application, we can see if you are eligible for all
programs. A friend or relative, or anyone that you wish, may help you complete this application.
Your application is not complete until you sign the last page. Return the application to us.
At your interview, you will need to show us:
Proof of who you are
Proof of child care costs (only for cash assistance)
Proof of your address
Proof of money you have received in the last 30 days
STEP 1
Tell us about yourself.
(We need one adult in the household to be the contact person for your application.)
 Cash Assistance
 Food Benefits
For which program(s) are you applying?
 Medical Assistance
 Child Care
First Name, Middle Name, Last Name, & Suffix
Home Address
City
State
Zip Code
Mailing Address (if different from Home Address)
City
State
Zip Code
Primary Telephone
Secondary Telephone
Preferred Methods of Contact
I want to receive information about this application and future communication by:
Email Address
U.S. Mail
E-Mail Address:________________________________________________________________________________________________
Preferred spoken or written language (if not English)
If you wish to have someone else manage your case and act as your representative, please complete Appendix C.
For Food Benefits, the day we get this first page of the application with your name, address, and signature sets
the date benefits may start if you sign and return the completed application to DHSS within 30 days.
__________________________________________________
__________________________
Applicant’s Signature (Required)
Date
__________________________________________________
_________________________
Authorized Representative’s Signature
Date
Form 100 (Rev. 02/2014)
1
D
H
S
S
(DHSS)
ELAWARE
EALTH AND
OCIAL
ERVICES
A
F
B
, C
,
PPLICATION FOR
OOD
ENEFITS
ASH
M
,
C
C
A
EDICAL
AND
HILD
ARE
SSISTANCE
Delaware’s Emergency Food Benefit
If your household has little or no income right now, you may be able to receive emergency food benefits within 7 days from
the day we receive your completed application.
You may be able to get emergency food benefits in seven days if:
Your household expects to receive less than $150 in income this month
Your household does not have more than $100 in cash or bank accounts
Your household is a migrant or seasonal farm worker household
Your household’s rent, mortgage, and utilities are more than your household’s gross monthly income and liquid
resources combined
Delaware’s Food First Electronic Benefits Transfer (EBT) Card
We issue food benefits on an EBT card. To use your food benefits, you must have an EBT card and a Personal
Identification Number (PIN). When we approve your benefits, our EBT vendor will mail your card to you if you
never had one before. You can also go to a card issuance site to get your card.
In each of the headings in this application, you will see program symbols. These symbols will help you to identify
the questions you must answer for the program(s) you are requesting.
Symbols
Programs
Terms
Definition
Medical Assistance Programs
Alien:
A person who is not a U.S. citizen
(doctors, hospitals, prescriptions, labs,
and x-rays)
- free or low-cost insurance from
Medicaid or the Children’s Health
Insurance Program (CHIP)
- affordable, private health insurance
plans through the Marketplace
- a new tax credit that can immediately
help pay your premiums for health
coverage
Child Care Assistance
EBT card:
Electronic Benefit Transfer—a plastic card
(help with the cost of child care)
that you use at a store to buy food.
Cash Assistance - Temporary
Eligible:
Meeting all of the guidelines to get benefits.
Assistance for Needy Families
(TANF) - General Assistance (GA) –
Refugee Cash Assistance (RCA)
A person or a group of people who live
Household:
Food Supplement Program
together and buy food and fix meals
(help with monthly food expenses)
together.
Able Bodied Adult Without Dependents—An
ABAWD:
Signature Required
adult aged 18 through 50 years old, without
dependents, and physically able to work.
Form 100 (Rev. 02/2014)
2
STEP 2
Tell us about yourself and the people in your household.
Are you?  Single  Married  Divorced  Civil Union  Separated  Widowed  Unmarried Partnership
Instructions
Fill in the blocks for all of the people who live with you. If you are applying for medical assistance and file taxes, we need to
know about everyone on your tax return.
Race:
B = Black/African American
W=White
Ethnic Group:
H=Hispanic/Latino
PI = Native Hawaiian/Pacific Islander
A=Asian
N=Non-Hispanic/Latino
I = American Indian/Alaskan Native (If anyone in your household is American Indian/Alaskan Native, also complete Appendix B.)
U.S.
Are you
Race/
Citizen?
applying
Birth
Ethnic
Answer for
First Name,
Relation
for this
Sex
Date
Social Security
Group
applicants
Last Name
Middle Name
to you
person?
M/F
mm/dd/yyyy
Number*
(optional)
only. **
 Yes
 M
 Yes
Self
 No
 F
 No
 Yes
 M
 Yes
 No
 F
 No
 Yes
 M
 Yes
 No
 F
 No
 Yes
 M
 Yes
 No
 F
 No
 Yes
 M
 Yes
 No
 F
 No
 Yes
 M
 Yes
 No
 F
 No
 Yes
 M
 Yes
 No
 F
 No
*We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too
since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with
health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit
socialsecurity.gov.
TTY users should call 1-800-325-0778.
**Applies to applicants for health coverage only.
Complete this section for legal alien applicants only.
 Yes. Complete the section below.
1. Do applicants have eligible immigration status?
Have you lived
Are you or your spouse or parent
Immigration
Document ID
in the U.S.
a veteran or an active-duty
Name
Document Type
number
since 1996?
member of the U.S. military?
 Yes  No
2. Has anyone ever received cash, food, or child care assistance in another state?
What benefits? _______________
Name of state? ________________ Month/Year ________________________
 Yes  No
3. Has anyone ever been disqualified for cash or food assistance in another state?
What benefits? ______________ _ Name of state? __________________ Month/Year ________________________
Form 100 (Rev. 02/2014)
3
 Yes  No
4. Is anyone in your household in violation of probation or parole or fleeing prosecution?
(Applies to TANF, food benefits, and general assistance.)
 Yes  No
5. Has anyone been convicted of a drug felony after August 22, 1996?
(Applies to TANF and general assistance.)
6. Have you or any member of your household been convicted of trading food benefits for drugs after September 22, 1996?
 Yes  No
(Applies to food benefits.)
7. Have you or any member of your household been convicted of buying or selling food benefits over $500 after September
 Yes  No
22, 1996?
(Applies to food benefits.)
8. Have you or any member of your household been convicted of fraudulently receiving duplicate food benefits in any state
 Yes  No
after September 22, 1996?
(Applies to food benefits.)
9. Have you or any member of your household been convicted of trading food benefits for guns, ammunitions, or explosives
 Yes  No
after September 22, 1996?
(Applies to food benefits.)
10. Answer the questions below if a parent(s) of any child under 18 does not live in your household.
Absent
Absent
Absent
Parent’s
Parent’s
Absent
Absent
Child’s
Parent’s
Date of
Social Security
Parent’s
Parent’s
Name
Name
Birth
Number
Address
Employer
 Yes  No
11. Are there any children under the age 19 living in the household?
If yes, fill in below.
Parent or Caregiver’s Name
Child’s Name
STEP 3
Tell us about your health care.
Is anyone in your household offered health coverage from a job (even if the coverage is from someone
else’s job, such as a parent or spouse)? If yes, you’ll need to complete Appendix A.  Yes  No
 Yes  No
Is this a state employee benefit plan?
Other than Medicaid does anyone in your household have
 Yes  No
health insurance or Medicare?
If yes, provide the following information:
Name of Policy
Name of
Who is
Holder
Insurance
Covered
Circle what is Covered
Policy Number
·
·
·
Doctor
Hospital
Lab Tests
X-rays
·
·
·
Doctor
Hospital
Lab Tests
X-rays
·
·
·
Doctor
Hospital
Lab Tests
X-rays
12. Name anyone in your household who is pregnant
due date ___________________
How many babies are expected during this pregnancy? __________
13. Name anyone who has a physical, mental, or emotional health condition that causes limitations in activities (like bathing,
dressing, daily chores, working, etc.) or live in a medical facility or nursing home _______________________________ .
14. Name anyone who was injured in the last 2 years (car accident, work related injury, medical malpractice,
etc.). __________________________________________________________________________________________
Form 100 (Rev. 02/2014)
4
Page of 19