Form IL444-2378B "Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (Snap)" - Illinois

What Is Form IL444-2378B?

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

Form Details:

  • Released on May 1, 2019;
  • The latest edition provided by the Illinois Department of Human 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 fillable version of Form IL444-2378B by clicking the link below or browse more documents and templates provided by the Illinois Department of Human Services.

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Download Form IL444-2378B "Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (Snap)" - Illinois

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State of Illinois
Department of Human Services
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
Last Name:
First Name:
MI:
Maiden Name:
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Present Address:
Apartment Number:
City:
State:
Zip Code:
County:
Birth Date:
Social Security Number:
Are you homeless?
Yes
No
Mailing Address (if different from above):
City:
State:
Zip Code:
County:
Telephone number(s) Home:
Work:
Other:
Daytime phone:
Best time to call you:
Signing here will start your application. You must sign Page 18 before we approve you for any benefits.
Signature:
Date:
Approved Representative
When you sign to have an approved representative it means you give permission for this person (1) to sign your application for
you, (2) to receive official information about this application, and (3) to act for you on all matters with this agency.
Do you want to name an approved representative?
No If yes, complete the following:
Yes
Address:
Name of approved representative:
Phone Number:
ID # if applicable:
Organization Name:
Signature of applicant:
Instructions to person(s) applying for Cash, Medical, and/or SNAP benefits
Cash -
Medical -
SNAP -
1.
Please print all of your answers on the application form so that we can read and understand your answers.
2.
You have the right to immediately file the application as long as the top of this page (Page 1) is completed with your name, address and signature.
The filing of this signed page (Page 1) starts the application processing timetable. Providing your date of birth and Social Security Number on this
signed page will help us with the application registration process.
3.
Read pages 14 & 15 to know your rights and responsibilities for SNAP benefits.
Read pages 16, 17 and 18 to know your rights and responsibilities for Cash and Medical benefits.
4.
Before you can get any benefits, you must sign page 18.
5.
If applying for SNAP benefits, a decision on your eligibility will be made within 30 days. If determined eligible, SNAP benefits will be issued from the
date the application is filed.
6.
You may be entitled to receive SNAP benefits right away if:
*
your gross nonexempt income and liquid assets are less than your monthly rent or mortgage payment and the appropriate utility standard:
or,
you have assets of $100 or less and
*
- your gross monthly income for the month of application is less than $150; or
- at least one person applying is a migrant who is "out of funds."
This application must be filed with your local Illinois Department of Human Services (IDHS) Family Community Resource Center (FCRC). You
7.
may complete this form at home and mail it, or bring it to your local FCRC. Another member of the household or an adult who knows you may
complete and return the form to us also. If someone else completes this form for the household, they are to answer the questions for the person(s)
they are applying for, not himself or herself. You have the right to choose the office where you apply. Use the IDHS Office Locator to find an
FCRC at www.dhs.state.il.us/page.aspx?module=12 or call the IDHS Helpline at 1-800-843-6154. Once you submit your application to an office it
will be processed by that office. You can also apply for benefits at ABE.Illinois.gov or by calling the IDHS Helpline at 1-800-843-6154.
8.
If you want to register to vote, fill out the enclosed Illinois Voter Registration Application (SBE R-19) and give it to your IDHS Family Community
Resource Center (FCRC) or your local election official. For help filling it out or for translation services, contact your IDHS Family Community
Resource Center (FCRC). You may also call the Helpline at 1-800-843-6154, or 1-866-324-5553 TTY/Nextalk, 711 TTY Relay. For information
online, see www.dhs.state.il.us or www.elections.il.gov/. Filling out the Voter Registration Application as part of this application is optional.
Registering to vote is your choice and will not affect the amount of benefits you get from this agency.
IL444-2378B (R-05-19) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Page 1 of 18
Printed by Authority of the State of Illinois
-0- Copies
State of Illinois
Department of Human Services
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
Last Name:
First Name:
MI:
Maiden Name:
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Present Address:
Apartment Number:
City:
State:
Zip Code:
County:
Birth Date:
Social Security Number:
Are you homeless?
Yes
No
Mailing Address (if different from above):
City:
State:
Zip Code:
County:
Telephone number(s) Home:
Work:
Other:
Daytime phone:
Best time to call you:
Signing here will start your application. You must sign Page 18 before we approve you for any benefits.
Signature:
Date:
Approved Representative
When you sign to have an approved representative it means you give permission for this person (1) to sign your application for
you, (2) to receive official information about this application, and (3) to act for you on all matters with this agency.
Do you want to name an approved representative?
No If yes, complete the following:
Yes
Address:
Name of approved representative:
Phone Number:
ID # if applicable:
Organization Name:
Signature of applicant:
Instructions to person(s) applying for Cash, Medical, and/or SNAP benefits
Cash -
Medical -
SNAP -
1.
Please print all of your answers on the application form so that we can read and understand your answers.
2.
You have the right to immediately file the application as long as the top of this page (Page 1) is completed with your name, address and signature.
The filing of this signed page (Page 1) starts the application processing timetable. Providing your date of birth and Social Security Number on this
signed page will help us with the application registration process.
3.
Read pages 14 & 15 to know your rights and responsibilities for SNAP benefits.
Read pages 16, 17 and 18 to know your rights and responsibilities for Cash and Medical benefits.
4.
Before you can get any benefits, you must sign page 18.
5.
If applying for SNAP benefits, a decision on your eligibility will be made within 30 days. If determined eligible, SNAP benefits will be issued from the
date the application is filed.
6.
You may be entitled to receive SNAP benefits right away if:
*
your gross nonexempt income and liquid assets are less than your monthly rent or mortgage payment and the appropriate utility standard:
or,
you have assets of $100 or less and
*
- your gross monthly income for the month of application is less than $150; or
- at least one person applying is a migrant who is "out of funds."
This application must be filed with your local Illinois Department of Human Services (IDHS) Family Community Resource Center (FCRC). You
7.
may complete this form at home and mail it, or bring it to your local FCRC. Another member of the household or an adult who knows you may
complete and return the form to us also. If someone else completes this form for the household, they are to answer the questions for the person(s)
they are applying for, not himself or herself. You have the right to choose the office where you apply. Use the IDHS Office Locator to find an
FCRC at www.dhs.state.il.us/page.aspx?module=12 or call the IDHS Helpline at 1-800-843-6154. Once you submit your application to an office it
will be processed by that office. You can also apply for benefits at ABE.Illinois.gov or by calling the IDHS Helpline at 1-800-843-6154.
8.
If you want to register to vote, fill out the enclosed Illinois Voter Registration Application (SBE R-19) and give it to your IDHS Family Community
Resource Center (FCRC) or your local election official. For help filling it out or for translation services, contact your IDHS Family Community
Resource Center (FCRC). You may also call the Helpline at 1-800-843-6154, or 1-866-324-5553 TTY/Nextalk, 711 TTY Relay. For information
online, see www.dhs.state.il.us or www.elections.il.gov/. Filling out the Voter Registration Application as part of this application is optional.
Registering to vote is your choice and will not affect the amount of benefits you get from this agency.
IL444-2378B (R-05-19) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Page 1 of 18
Printed by Authority of the State of Illinois
-0- Copies
State of Illinois
Department of Human Services
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
Citizenship/Immigration Status
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
If you or any other persons are not applying because you do not wish to provide information about your immigration status, you do
not have to give us that information. The failure to provide immigration information will not affect processing the application for the
remaining persons. However, any person who is applying for benefits for himself or herself has to provide information on their
immigration status.
Are all persons U.S. Citizens?
Yes
No
Complete the following for any non-citizens who are applying for benefits. If you need more room, attach another sheet of paper.
Name
Age
Arrival Date in the United States
Registration document/number
1.
2.
3.
4.
If there are persons who are not applying for SNAP and/or cash benefits because they do not wish to provide proof of their
immigration status, please list them below. We will only ask questions about their income & assets.
Name (Last)
(First)
(MI)
Name (Last)
(First)
(MI)
1.
3.
2.
4.
General Household Questions
1. Are you or is anyone who lives with you blind?
Yes
No Disabled?
Yes
No
2. Does anyone in the household receive Social Security Disability or Railroad Retirement benefits?
Yes
No
If yes, who:
What is their SSN or RRB claim number?
3. Does anyone have a physical, mental or emotional health condition that limits common activities (like bathing, dressing,
Yes
No
daily chores, etc)?
If yes, who:
4. Does anyone applying live in a nursing home facility, supportive living facility, or other facility or institution?
Yes
No
If yes, who:
Name of facility:
5. Does anyone in your household want help paying for medical bills from the last 3 months?
Yes
No
6. Has anyone in your household been in foster care at age 18 or older?
Yes
No
If yes, name of person:
7. Is anyone in your household age 18 or older a full time student? (college, or trade school)
Yes
No
If yes, name of person:
Language Preference
Does the adult member of your household who will discuss your case with IDHS speak English fluently?
Yes
No
If no, please list your preferred spoken language:
Does the adult member of your household who will usually receive mail or written information from IDHS read English fluently?
Yes
No
If no, please list your preferred written language:
IL444-2378B (R-05-19) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Page 2 of 18
Printed by Authority of the State of Illinois
-0- Copies
State of Illinois
Department of Human Services
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
Household Composition
How many people live with you (include yourself)?
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Complete the following for everyone in the household. Include people who live with you who are not requesting assistance. You
must give us the Social Security Number for each person for whom you are requesting benefits. You do not have to give us the
number for any person for whom you are not requesting benefits, but if you do, it may speed up the application process.
Person 1
Mark the box for the program this person is applying for:
SNAP
Medical
Cash
First
M.I. Last
Suffix
Former Name, if any
Relationship to you
SELF
Gender
Social Security #
Birth Date
Marital Status
Pregnant? If yes, due date
How many babies expected?
M
F
If this person is applying for Medical assistance answer question 1.
1. Do you plan to file a Federal Tax Return next year?
Yes
No
If yes, answer 2-4 below
2. Will you file jointly with a spouse?
Yes
No
If yes, list name(s):
3. Do you have any dependents?
Yes
No
If yes, list name(s):
4. Will you be claimed as a dependent on someone else's tax return?
Yes
No
If yes, list the name of the tax filer:
How are you related to the tax filer?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
1. Is this person Hispanic or Latino?
Yes
No
2. What is your race? (Select one or more)
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Person 2
Mark the box for the program this person is applying for:
SNAP
Medical
Cash
First
M.I. Last
Suffix
Former Name, if any
Relationship to you
Gender
Social Security #
Birth Date
Marital Status
Pregnant? If yes, due date
How many babies expected?
M
F
If this person is applying for Medical assistance answer question 1.
1. Does this person plan to file a Federal Tax Return next year?
Yes
No
If yes, answer 2-4 below
2. Will this person file jointly with a spouse?
Yes
No
If yes, list name(s):
3. Does this person have any dependents?
Yes
No
If yes, list name(s):
4. Is this person claimed as a dependent on someone else's tax return?
Yes
No
If yes, list the name of the tax filer:
How is this person related to the tax filer?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
1. Is this person Hispanic or Latino?
Yes
No
2. What is his/her race? (Select one or more)
Native Hawaiian or Other Pacific Islander
American Indian/Alaskan Native
Asian
Black or African American
White
IL444-2378B (R-05-19) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Page 3 of 18
Printed by Authority of the State of Illinois
-0- Copies
State of Illinois
Department of Human Services
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
Household Composition (Continued)
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Person 3
Mark the box for the program this person is applying for:
SNAP
Medical
Cash
First
M.I. Last
Suffix
Former Name, if any
Relationship to you
Gender
Social Security #
Birth Date
Marital Status
Pregnant? If yes, due date
How many babies expected?
M
F
If this person is applying for Medical assistance answer question 1.
Yes
No
1. Does this person plan to file a Federal Tax Return next year?
If yes, answer 2-4 below
2. Will this person file jointly with a spouse?
Yes
No
If yes, list name(s):
3. Does this person have any dependents?
Yes
No
If yes, list name(s):
4. Is this person claimed as a dependent on someone else's tax return?
Yes
No
If yes, list the name of the tax filer:
How is this person related to the tax filer?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
1. Is this person Hispanic or Latino?
Yes
No
2. What is his/her race? (Select one or more)
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Person 4
Mark the box for the program this person is applying for:
SNAP
Medical
Cash
First
M.I. Last
Suffix
Former Name, if any
Relationship to you
Gender
Social Security #
Birth Date
Marital Status
Pregnant? If yes, due date
How many babies expected?
M
F
If this person is applying for Medical assistance answer question 1.
Yes
No
1. Does this person plan to file a Federal Tax Return next year?
If yes, answer 2-4 below
2. Will this person file jointly with a spouse?
Yes
No
If yes, list name(s):
3. Does this person have any dependents?
Yes
No
If yes, list name(s):
4. Is this person claimed as a dependent on someone else's tax return?
Yes
No
If yes, list the name of the tax filer:
How is this person related to the tax filer?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
1. Is this person Hispanic or Latino?
Yes
No
2. What is his/her race? (Select one or more)
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
IL444-2378B (R-05-19) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Page 4 of 18
Printed by Authority of the State of Illinois
-0- Copies
State of Illinois
Department of Human Services
Request for Cash Assistance - Medical Assistance -
Supplemental Nutrition Assistance Program (SNAP)
Household Composition (Continued)
2aabfaa2-d3e7-47d2-8547-1ab9b3cfbd4c
Person 5
Mark the box for the program this person is applying for:
SNAP
Medical
Cash
First
M.I. Last
Suffix
Former Name, if any
Relationship to you
Gender
Social Security #
Birth Date
Marital Status
Pregnant? If yes, due date
How many babies expected?
M
F
If this person is applying for Medical assistance answer question 1.
1. Does this person plan to file a Federal Tax Return next year?
Yes
No
If yes, answer 2-4 below
2. Will this person file jointly with a spouse?
Yes
No
If yes, list name(s):
3. Does this person have any dependents?
Yes
No
If yes, list name(s):
4. Is this person claimed as a dependent on someone else's tax return?
Yes
No
If yes, list the name of the tax filer:
How is this person related to the tax filer?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
1. Is this person Hispanic or Latino?
Yes
No
2. What is his/her race? (Select one or more)
American Indian/Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Person 6
Mark the box for the program this person is applying for:
SNAP
Medical
Cash
First
M.I. Last
Suffix
Former Name, if any
Relationship to you
Gender
Social Security #
Birth Date
Marital Status
Pregnant? If yes, due date
How many babies expected?
M
F
If this person is applying for Medical assistance answer question 1.
Yes
No
If yes, answer 2-4 below
1. Does this person plan to file a Federal Tax Return next year?
2. Will this person file jointly with a spouse?
Yes
No
If yes, list name(s):
3. Does this person have any dependents?
Yes
No
If yes, list name(s):
4. Is this person claimed as a dependent on someone else's tax return?
Yes
No
If yes, list the name of the tax filer:
How is this person related to the tax filer?
The following two questions are optional. Answering these questions will not affect your eligibility or benefit amount.
This information is to assure that program benefits are distributed without regard to race, color or national origin.
1. Is this person Hispanic or Latino?
Yes
No
2. What is his/her race? (Select one or more)
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
American Indian/Alaskan Native
If needed, please list extra
household members on an
additional piece of paper.
IL444-2378B (R-05-19) Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program
Page 5 of 18
Printed by Authority of the State of Illinois
-0- Copies