Form 08MP004E (FSS-BR-1) "Renew My Benefits" - Oklahoma

What Is Form 08MP004E (FSS-BR-1)?

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

Form Details:

  • Released on September 13, 2021;
  • The latest edition provided by the Oklahoma 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 08MP004E (FSS-BR-1) by clicking the link below or browse more documents and templates provided by the Oklahoma Department of Human Services.

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Download Form 08MP004E (FSS-BR-1) "Renew My Benefits" - Oklahoma

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Renew My Benefits
Date:
Case name:
Case number:
County number:
Supervisor/worker #:
Case Information
Case name
Social Security number
Oklahoma Human Services (OKDHS) staff uses the information you report on this form to see if your
household can still get help with food, SoonerCare (Medicaid), or child care subsidy benefits. Please
fill out, sign, and return this form to the OKDHS office shown above. Attach additional sheets of
paper to this form if you need more space to answer questions. Return this form by
or your benefits will stop on
.
If you need help filling out this form, call your OKDHS office. [Nota Importante: Si usted no puede
leer esta forma, póngase en contacto con su trabajador social, llamando al número de teléfono que
se menciona arriba.]
If you want help filling out a voter registration application form, call 1-855-880-8003 for assistance.
Tell Us About Where You Live
Mailing address
City
State
ZIP code
Street address
City
State
ZIP code
Home phone
Work phone
Cell phone
Message phone
Email address
Finding directions to your home
08MP004E
9/13/2021
Page 1 of 11
Renew My Benefits
Date:
Case name:
Case number:
County number:
Supervisor/worker #:
Case Information
Case name
Social Security number
Oklahoma Human Services (OKDHS) staff uses the information you report on this form to see if your
household can still get help with food, SoonerCare (Medicaid), or child care subsidy benefits. Please
fill out, sign, and return this form to the OKDHS office shown above. Attach additional sheets of
paper to this form if you need more space to answer questions. Return this form by
or your benefits will stop on
.
If you need help filling out this form, call your OKDHS office. [Nota Importante: Si usted no puede
leer esta forma, póngase en contacto con su trabajador social, llamando al número de teléfono que
se menciona arriba.]
If you want help filling out a voter registration application form, call 1-855-880-8003 for assistance.
Tell Us About Where You Live
Mailing address
City
State
ZIP code
Street address
City
State
ZIP code
Home phone
Work phone
Cell phone
Message phone
Email address
Finding directions to your home
08MP004E
9/13/2021
Page 1 of 11
People Getting Benefits Now
List the people getting benefits in your case:
Yes
No
Still live with you?
Name:
Military status, check one:
active duty military
former military
National Guard/Military Reserve
none
Yes
No
Still live with you?
Name:
Military status, check one:
active duty military
former military
National Guard/Military Reserve
none
Yes
No
Still live with you?
Name:
Military status, check one:
active duty military
former military
National Guard/Military Reserve
none
Yes
No
Still live with you?
Name:
Military status, check one:
active duty military
former military
National Guard/Military Reserve
none
Yes
No
Still live with you?
Name:
Military status, check one:
active duty military
former military
National Guard/Military Reserve
none
Tell Us About Other People Living in Your Home
Please fill out the information below for everyone else living in your home that is not already shown
above. If you want benefits for him or her, you must check the United States (U.S.) citizen block and
fill in the Social Security number for each person. OKDHS staff will contact you. Providing race and
ethnic background information is voluntary and does not affect your eligibility or benefit amount. This
information is used to assure that program benefits are distributed without regard to race, color or
national origin. The U.S. Department of Agriculture (USDA) requires us to answer these questions
for you if you do not provide this information.
Name
Date of birth
Relationship to you
Gender
U.S. Citizen?
Hispanic or Latino?
Social Security number
M
F
Yes
No
Yes
No
Race - check all that apply:
American Indian or Alaska Native; when checked, tribe:
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Name
Date of birth
Relationship to you
Gender
U.S. Citizen?
Hispanic or Latino?
Social Security number
M
F
Yes
No
Yes
No
Race - check all that apply:
American Indian or Alaska Native; when checked, tribe:
08MP004E
9/13/2021
Page 2 of 11
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Name
Date of birth
Relationship to you
Gender
U.S. Citizen?
Hispanic or Latino?
Social Security number
M
F
Yes
No
Yes
No
Race - check all that apply:
American Indian or Alaska Native; when checked, tribe:
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White
Tell Us About Your Household's Income
Income is all the money you and the people living with you get each month. Types of income include
money earned from working for someone else, working for yourself, and any unearned income.
Some types of unearned income are: child support, Social Security, Supplemental Security Income
(SSI), State Supplemental Payment (SSP), Temporary Assistance for Needy Families (TANF), Tribal
TANF, veteran's benefits (including a pension, disability compensation, retirement, Aid and
Attendance, and/or veteran's benefits for dependents, or a deceased family member's benefit),
unemployment benefits, military allotments, alimony, gambling or lottery winnings, Workers’
Compensation, contributions, student income, interest, dividends, pension or retirement income from
any source, rental income, foster care or adoption subsidy payments, and income from mineral
rights or oil and gas leases, and personal loans.
Tell us about your household's income for the month of
.
If income stopped, fill out the information below:
Name
Income type
Final amount Date of final amount
If you have income, fill out the information below:
Name of person getting income
Amount before taxes
How often received
Income type
Self-employment gross income last year
Employer
Employer phone number
Employer address
Name of person getting income
Amount before taxes
How often received
Income type
Self-employment gross income last year
08MP004E
9/13/2021
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Employer
Employer phone number
Employer address
Name of person getting income
Amount before taxes
How often received
Income type
Self-employment gross income last year
Employer
Employer phone number
Employer address
If anyone 16 years of age or older is a student, please fill out the information below:
Student name
Full or part time?
School name
Tell Us About Your Bills and Expenses
Please fill out the information below about your bills and expenses:
Child care expense
How much do you pay each month for child care?
Adult day care expense
How much do you pay each month for day care for an elderly or disabled
person who lives with you?
Medical expense
Tell us the medical costs not paid by insurance for everyone who is disabled or age 60 and older.
These could be doctor or hospital bills, medicine, transportation, health insurance premiums, or
other medical services.
Name
Expense type
Monthly expense
08MP004E
9/13/2021
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Child support expense
Does anyone in your household pay court-ordered child support?
Yes
No
If yes, please fill out the information below:
Who pays support?
How much?
How often?
Who gets support?
Phone number of person receiving support
Housing expenses
Do you get help to pay for housing?
Yes
No
When yes,
Who pays?
To whom?
How much?
Do you or anyone in your household pay for housing?
Yes
No
How much do you pay for housing?
Amount
per
Amount
per
Homeowner insurance, if separate:
Property tax, if separate:
Amount
per
Person or company you pay rent/mortgage to:
What is his or her phone number?
Do you expect to pay the same amount for housing next month?
Yes
No
If you consider yourself homeless, do you have any shelter costs associated
Yes
No
with being homeless such as living in a car and having a car payment, giving
a friend money to sleep in their home, paying camping fees, or hotel/motel
charges?
If yes, how much do you spend for these expenses?
Utility expenses
Are you responsible for paying heating or cooling expenses?
Yes
No
What utility expenses do you pay:
Electric
Garbage/water
Gas/butane/propane
Phone
Wood
Other
Do you get help to pay for utility costs such as a utility allowance, tribal assistance,
Yes
No
or help from a friend or relative?
If yes, who pays?
To whom?
How much?
Enter utility account information if your heating or cooling cost is not included in your rent.
Natural gas
Company name
Account number
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