Form DWS-ESD61APP "Application for Snap, Financial Assistance, Child Care, and Medical Assistance" - Utah

What Is Form DWS-ESD61APP?

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

Form Details:

  • Released on June 1, 2019;
  • The latest edition provided by the Utah Department of Workforce 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 DWS-ESD61APP by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form DWS-ESD61APP "Application for Snap, Financial Assistance, Child Care, and Medical Assistance" - Utah

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DWS-ESD 61APP
State of Utah
Rev. 06/2019
Department of Workforce Services
APPLICATION FOR SNAP, FINANCIAL
ASSISTANCE, CHILD CARE, AND MEDICAL ASSISTANCE
Esta solicitud también se encuentra disponible en Español
For faster automated service, you can apply online at jobs.utah.gov
D12619700010134
Check The Services You Are Applying For:
SNAP (Food Stamps)
Cash/Financial Assistance
Child Care
Medical
Do you want help paying for medical bills from the last 3 months? .....................
Yes
No
If yes, for who? _______________________________
For which month(s)? _________________________________
1. Your Information:
Name:
First
Middle
Last
Home Address:
City:
Zip:
Mailing Address (If different from Home Address):
City:
Zip:
Phone #:
Other Phone #:
Birth Date:
Social Security #
(optional):
Do you speak English?
Yes
No
If no, what is your primary language?
Would you like to receive your notices in English or Spanish?
English
Spanish
Case #
Signature:
(optional):
2. Do you have a Utah Horizon Card (Financial and SNAP benefits)? ……..................................................
Yes
No
If you mark No, a new card will be mailed. Any other cards you have will no longer work.
3. Do ALL individuals who are applying for medical benefits have a Utah Medicaid medical card? ..............
Yes
No
If no, who needs a card? ____________________________________________________________________________
If you want to apply for unemployment benefits, log on to jobs.utah.gov.
Your Rights:
IF YOU NEED HELP FILLING OUT THIS APPLICATION, WE ARE HAPPY TO HELP.
YOU HAVE THE RIGHT TO AN INTERPRETER AT NO CHARGE.
Translation services are available if you require additional assistance during the application process.
SNAP and Medical:
You can turn in an incomplete application with only your name, address and signature; however, before we can
determine your eligibility for benefits, all questions will need to be answered. You can send in your application by:
fax: 877-313-4717, mail: PO Box 143245, SLC, UT 84114-3245 or drop off at your local office
o
We will issue your assistance based on the date we receive your application. If your application is received
outside business hours (Monday through Friday 8:00 a.m. to 5:00 p.m.) it will be effective the following
business day.
Financial and Child Care:
In order to file a Financial assistance application you must complete questions 1, 4 – 6, 8 – 30, the
o
Financial Section AND sign page 14.
In order to file a Child Care assistance application you must complete questions 1, 4 – 6, 8 – 10, 12 – 23,
o
30, the Child Care Section AND sign page 14.
o
If you do not complete all of the required questions for Financial or Child Care, the application for Financial
and/or Child Care will be considered incomplete and no action will be taken.
o
If eligible for Financial and/or Child Care, benefits are effective the date that we receive the completed
application with the exception of the General Assistance financial program where benefits will be effective
the first day of the month following the month an application is completed.
SNAP, Financial and Medicaid Information for Immigrants:
You can apply for and receive SNAP, Financial and Medicaid benefits for eligible family members, even if your
family includes other members who are not eligible because of immigration status. For example, immigrant parents
may apply for SNAP benefits for their U.S. citizen or qualified immigrant children, even though the parents may not
be eligible for benefits.
You do not have to provide immigration status information, Social Security numbers, or documents for any family
members who are not eligible for SNAP benefits because of immigrant status and who are not asking for SNAP
benefits. Family members who are not eligible for SNAP, Financial or Medicaid benefits will still need to answer
other questions about their name, relationship, income, assets, etc.
1
DWS-ESD 61APP
State of Utah
Rev. 06/2019
Department of Workforce Services
APPLICATION FOR SNAP, FINANCIAL
ASSISTANCE, CHILD CARE, AND MEDICAL ASSISTANCE
Esta solicitud también se encuentra disponible en Español
For faster automated service, you can apply online at jobs.utah.gov
D12619700010134
Check The Services You Are Applying For:
SNAP (Food Stamps)
Cash/Financial Assistance
Child Care
Medical
Do you want help paying for medical bills from the last 3 months? .....................
Yes
No
If yes, for who? _______________________________
For which month(s)? _________________________________
1. Your Information:
Name:
First
Middle
Last
Home Address:
City:
Zip:
Mailing Address (If different from Home Address):
City:
Zip:
Phone #:
Other Phone #:
Birth Date:
Social Security #
(optional):
Do you speak English?
Yes
No
If no, what is your primary language?
Would you like to receive your notices in English or Spanish?
English
Spanish
Case #
Signature:
(optional):
2. Do you have a Utah Horizon Card (Financial and SNAP benefits)? ……..................................................
Yes
No
If you mark No, a new card will be mailed. Any other cards you have will no longer work.
3. Do ALL individuals who are applying for medical benefits have a Utah Medicaid medical card? ..............
Yes
No
If no, who needs a card? ____________________________________________________________________________
If you want to apply for unemployment benefits, log on to jobs.utah.gov.
Your Rights:
IF YOU NEED HELP FILLING OUT THIS APPLICATION, WE ARE HAPPY TO HELP.
YOU HAVE THE RIGHT TO AN INTERPRETER AT NO CHARGE.
Translation services are available if you require additional assistance during the application process.
SNAP and Medical:
You can turn in an incomplete application with only your name, address and signature; however, before we can
determine your eligibility for benefits, all questions will need to be answered. You can send in your application by:
fax: 877-313-4717, mail: PO Box 143245, SLC, UT 84114-3245 or drop off at your local office
o
We will issue your assistance based on the date we receive your application. If your application is received
outside business hours (Monday through Friday 8:00 a.m. to 5:00 p.m.) it will be effective the following
business day.
Financial and Child Care:
In order to file a Financial assistance application you must complete questions 1, 4 – 6, 8 – 30, the
o
Financial Section AND sign page 14.
In order to file a Child Care assistance application you must complete questions 1, 4 – 6, 8 – 10, 12 – 23,
o
30, the Child Care Section AND sign page 14.
o
If you do not complete all of the required questions for Financial or Child Care, the application for Financial
and/or Child Care will be considered incomplete and no action will be taken.
o
If eligible for Financial and/or Child Care, benefits are effective the date that we receive the completed
application with the exception of the General Assistance financial program where benefits will be effective
the first day of the month following the month an application is completed.
SNAP, Financial and Medicaid Information for Immigrants:
You can apply for and receive SNAP, Financial and Medicaid benefits for eligible family members, even if your
family includes other members who are not eligible because of immigration status. For example, immigrant parents
may apply for SNAP benefits for their U.S. citizen or qualified immigrant children, even though the parents may not
be eligible for benefits.
You do not have to provide immigration status information, Social Security numbers, or documents for any family
members who are not eligible for SNAP benefits because of immigrant status and who are not asking for SNAP
benefits. Family members who are not eligible for SNAP, Financial or Medicaid benefits will still need to answer
other questions about their name, relationship, income, assets, etc.
1
Using SNAP, Medicaid and Financial benefits will not affect your immigration status or the
immigration status of your family. Immigration information is private and confidential.
In order to determine your eligibility for SNAP, complete questions 1, 4 – 6, 9 – 25, 27 – 33,
54 – 74 and sign page 14.
Use of Medical benefits by you or your family members should not affect your ability to
apply or permanent resident status unless you use Medicaid to pay for long-term care
(nursing home or other institutionalized care). Use of Medicaid benefits will not affect your
ability to apply for citizenship unless you committed fraud in getting those services.
D12619700010234
Medical Only Information
Who do you need to include on this application?
o
Tell us about all the family members who live with you. If you file taxes, we need to know about everyone
on your tax return. (You don’t need to file taxes to get health coverage). The amount of assistance or type
of program you qualify for depends on the number of people in your family and their incomes. This
information helps us make sure everyone gets the best coverage they can.
Affordable Private Health Insurance and Advanced Premium Tax Credits (APTC)
o
Information obtained from this application could also be used to determine your eligibility for affordable
private health insurance plans and APTC, which could immediately help you pay your premiums for health
coverage.
Assets and Expenses (Questions 24 – 33)
o
You are only required to answer these questions if there is anyone in your household who is applying for
Aged (65+), Blind or Disabled Medicaid, Spenddown Medicaid, Nursing Home, Waiver, Medicare Cost
Sharing, and/or Refugee Medical.
Expedited SNAP Information
The following households are entitled to expedited services:
Households whose combined monthly gross income and liquid resources are less than the household’s monthly
utilities and rent or mortgage.
Households with less than $150 in monthly gross income and whose liquid resources (cash, savings, checking
accounts, etc.) are no more than $100.
Some migrant and seasonal farm worker households.
Let us know if you disagree with the decision made on your case about Expedited SNAP and a meeting will be scheduled
for you within two (2) working days.
HOUSEHOLD AND GENERAL INFORMATION
4. List everyone who is living in your household and applying for benefits:
U.S. Citizen/
Utah
Utah
Eligible
Gender
Marital
Resident
1
3, 6
4, 6
First and Last Name
Social Security #
Birth Date
Relationship
Resident
Race
Ethnicity
5
2
Status
Non-Citizen
M / F
Since
Yes/No
Yes/No
(ex: 1/1/2013)
Self
1
Social Security number and Citizenship information are only needed for the people applying for benefits. If someone wants help getting a Social Security number, call 800-772-
1213 or visit socialsecurity.gov. TTY users should call 800-325-0778. Social Security number is not required for Child Care.
2
Utah Resident is optional for all programs
3
Race (optional):
AI = American Indian or Alaska Native (For medical applicants only, complete Attachment A)
GC = Guamanian or Chamorro
ASI = Asian Indian
CH = Chinese
JA = Japanese
KO = Korean
OPI = Other Pacific Islander
FI = Filipino
VI = Vietnamese
AS = Asian
OA = Other Asian
BL = Black or African American
SA = Samoan
NH = Native Hawaiian
OT = Other
WH = White
4
Ethnicity (optional):
N = Not Hispanic , Latino or Spanish Origin
M = Mexican
MA = Mexican American
CH = Chicano/a
PR = Puerto Rican
CU = Cuban
AH = Another Hispanic, Latino or Spanish Origin
OT = Other
5
Marital Status is not required for SNAP
6
For SNAP: You do not have to give us racial/ethnic information. If you do not want to give us this information, it will have no effect on your case.
2
5. Is there anyone living with you who is not applying for benefits? ...................
Yes
No
If yes, list below:
Do you purchase and prepare
Name
Relationship to you
food with this person?
(
to SNAP only)
applicable
Yes
No
Yes
No
D12619700010334
Yes
No
6. Has anyone moved into your home in the past three months? .......................
Yes
No
Name: ___________________________
Date entered the home: _____________
Name: ___________________________
Date entered the home: _____________
7. Answering this question is only required for medical assistance:
Do you plan to file a federal income tax return next year or will you be claimed as a dependent on someone’s tax return
next year? ...........................................................................................................................................
Yes
No
If yes, complete all columns below (if you are claiming more than 6 dependents, please make a copy of this page
and attach it to your application). In addition to the questions below, please complete Attachment B of this
application for all dependents that are NOT living with you but are claimed on your tax return.
Filing Jointly with Spouse
Dependents listed on your Tax Return
st
1
Tax Filer -or-
Tax Dependent
(applicable to Tax Filers only)
(applicable to Tax Filers only)
Name: ___________________________
First & Last Name: ____________________
Are you filing jointly with
Living with tax filer:
Yes
No
your spouse?
Will you be claimed as a dependent on
Name: ___________________________
someone’s tax return? …
Yes
No
Yes
No
Living with tax filer:
Yes
No
If yes, list name of tax filer and your
If yes, name of spouse:
Name: ___________________________
relationship to the tax filer:
Living with tax filer:
Yes
No
Name:______________________________
_______________________
Name: ___________________________
Living with tax filer:
Yes
No
Name: ___________________________
Relationship:_________________________
Living with tax filer:
Yes
No
Name: ___________________________
Living with tax filer:
Yes
No
Filing Jointly with Spouse
Dependents listed on your Tax Return
nd
2
Tax Filer -or-
Tax Dependent
(applicable to Tax Filers only)
(applicable to Tax Filers only)
Name: ___________________________
First & Last Name: ____________________
Are you filing jointly with
Living with tax filer:
Yes
No
your spouse?
Will you be claimed as a dependent on
Name: ___________________________
someone’s tax return? …
Yes
No
Yes
No
Living with tax filer:
Yes
No
If yes, list name of tax filer and your
If yes, name of spouse:
Name: ___________________________
relationship to the tax filer:
Living with tax filer:
Yes
No
Name:______________________________
_______________________
Name: ___________________________
Living with tax filer:
Yes
No
Relationship:_________________________
Name: ___________________________
Living with tax filer:
Yes
No
Name: ___________________________
Living with tax filer:
Yes
No
3
8. This question is not required for SNAP:
Is anyone who is applying for benefits currently pregnant or has anyone been pregnant in the
last 3 months? …...........................................................................................
Yes
No
If yes, who? ____________________________________________________________
Due date (if still pregnant):_________________________________________________
How many babies are expected during this pregnancy? __________________________
D12619700010434
Has she smoked or used tobacco in the past 6 months? ......................
Yes
No
(Information about tobacco use among pregnant women is needed only to determine potential eligibility for
tobacco programs. Response to this question is optional.)
9. Is anyone who is applying for benefits living in an institution? …….……........
Yes
No
If yes, check which applies:
Hospital/Medical Facility
Shelter
Drug/Rehab Center
Group Home
Nursing Home
Jail - If yes, on work release? .........
Yes
No
Who?
Name of Institution:
Date entered the institution:
Anticipated release date (if known):
10. Does anyone who is applying for benefits have a disability (a physical, mental or emotional health condition that causes
limitations in activities like bathing, dressing, daily chores, etc.)? ......................................................
Yes
No
If yes, who?
Start date of disability:
Is the disability permanent or temporary?
If temporary, how long is it expected to last?
Disability/Incapacity determined by:
SSA Disability Recipient
SSI Recipient
(VA) Veterans Affairs
Medical Statement
Railroad Retirement Board
State Medical Disability Office
Other: ____________________________
If the disabled person is the parent(s), is he/she able to care for their children? ..........................
Yes
No
Is the disabled person a child? ...................................................................................................
..
Yes
No
.
11. This question is not required for Medical assistance or Child Care:
Has anyone in your household ever applied for or received SNAP, Financial or Medical benefits in Utah or any other
state? …………………………………....................................................................................................
Yes
No
Name
Type of Assistance
Where?
When?
Date Ended
(list all states)
12. Answer the following question only for individuals who are applying for benefits:
If anyone in your household has an eligible immigration status and is applying for benefits, complete the chart below:
Alien Registration or
Immigration
Have you lived in the
Document ID Number
Name
I-94 Number
Document Type
U.S. since 1996?
(if different from A#)
Yes
No
Yes
No
Yes
No
If applying for Medical Assistance and you are an American Indian or Alaska Native, please complete Attachment A
as this can help you receive better benefits.
This question is not required for SNAP or Child Care:
Is anyone listed in question #12 a Veteran, an active-duty member of the U.S. Military or has a spouse or parent
who is a Veteran or an active-duty member of the U.S. Military?..................................................
Yes
No
If yes, who? __________________________________________________________________
13. Is anyone in your household attending school? ....................................................................................
Yes
No
If yes, complete all columns:
Expected Graduation Date
Name of Student
School Name / Type
Full Time / Part Time
(if over 16 years old)
4
14. Has anyone in your household applied for, received, or been denied Social Security Income,
Veterans Benefits, Unemployment or Workers’ Compensation?.................
Yes
No
If yes, who? ______________________ Benefit type: ___________________________
15. This question is not required for medical assistance:
Is anyone in your household a fleeing felon? (Hiding or running from the law to avoid
prosecution, being taken into custody, or going to jail, for a felony crime or attempted
felony crime) ..........................................................................................
Yes
No
D12619700010534
If yes, who? _____________________________________________________________
16. This question is not required for medical assistance:
Is anyone in your household violating a condition of parole or probation for a felony or
misdemeanor?...................................................................................…….....
Yes
No
If yes, who? _____________________________________________________________
INCOME
17. Does anyone in your household have earned income? .......................................................................
Yes
No
If yes, complete all columns:
Additional
How Often
Hours
Hourly Rate or
Employed
Employer
Date of
Income
Paid?
Worked
Monthly Salary
Person
Name
Hire
(ex: Tips, Bonus,
(ex: weekly,
Weekly
(ex: $900/mo, $8/hr)
Commission)
monthly)
$
$
$
This question is only for Child Care assistance:
If your job began in the last 30 days, what is the date and amount you expect to receive on your first check? _________
18. Is anyone in your household self-employed? .......................................................................................
Yes
No
If yes, complete all columns:
Hours
Type of Business
Business
Gross Monthly
Self - Employed Person
Company Name
% Owned
Worked
(ex: LLC, S-Corp,
Start Date
Income
1099, etc.)
Monthly
$
$
Are there any self-employment expenses? ....................................................................................
Yes
No
This question is only required for medical and Child Care assistance:
If yes, how much net income (profits once business expenses are paid) will you get from this self-employment this
month? $______________
19. Does anyone in your household expect any changes in earnings or in the number of hours worked?
Yes
No
If yes, who? ___________________ Explain change(s):________________________________________________
20. Has anyone in your household left a job or reduced work hours in the last 30 days? ..........................
Yes
No
If yes, complete the following information:
If left a job:
Name:
Name of employer:
Last day worked:
Date of last pay check:
Reason the job ended:
If reduced work hours:
Name:
Name of employer:
Hours reduced from:
to:
Date of first pay check with reduced hours:
Reason hours reduced:
21. In the past year, did anyone in your household change jobs, stop working
or start working fewer hours? ………………………………………………………………………………….
Yes
No
If yes, who? ________________ Explain change(s): ___________________________________________________
5