Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application Instructions
This form contains 255 fields organized into 54 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Ability to Speak for Applicant | ||
| Can Speak for Applicant - No | Checkbox |
Check this box if the person cannot speak for the applicant.
|
| Can Speak for Applicant - Yes | Checkbox |
Check this box if the person can speak for the applicant.
|
| Ability to Speak for Applicant - No | Checkbox |
Check this box if this person cannot speak for the applicant.
|
| Ability to Speak for Applicant - Yes | Checkbox |
Check this box if this person can speak for the applicant.
|
| Acknowledgement | ||
| Acknowledgement Signature | Text |
Enter your signature to acknowledge the statements above.
|
| Acknowledgement Date | Date |
Enter the date of acknowledgement.
|
| Applicant Name | ||
| Contact information section | Text | |
| Application information section | Text | |
| Applicant First Name | Text |
Enter the first name of the applicant as it appears on their proof of birth document.
|
| Applicant Last Name | Text |
Enter the last name of the applicant as it appears on their proof of birth document.
|
| Applicant Middle Name | Text |
Enter the middle name of the applicant as it appears on their proof of birth document.
|
| Application Completeness Checklist | ||
| Proof of birthdate (first-time applicants) | CheckBox | |
| Proofs of income for all household adults | CheckBox | |
| Proofs of all of the applicant's medical and dental coverage | CheckBox | |
| Your signature and date on the next page | CheckBox | |
| Physician/Dentist Assessment Form signed and dated by your doctor or dentist | CheckBox | |
| Proof of residency | CheckBox | |
| Can this person speak for the applicant? | ||
| No | Checkbox |
Check this box if this person cannot speak for the applicant.
|
| Yes | Checkbox |
Check this box if this person can speak for the applicant.
|
| CHIP Information | ||
| CHIP Yes | Checkbox |
Check this box if the applicant has CHIP.
|
| CHIP No | Checkbox |
Check this box if the applicant does not have CHIP.
|
| CHIP Number | Text |
Enter the CHIP number for the applicant. Fill only if 'CHIP Yes' is 'Yes'.
Depends on:
CHIP Yes
|
| CHIP Coverage Start Date | Date |
Enter the start date of the CHIP coverage. Fill only if 'CHIP Yes' is 'Yes'.
Depends on:
CHIP Yes
|
| Citizenship Status | ||
| U.S. citizen | Checkbox |
Check this box if the applicant's citizenship status is U.S. citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the applicant's citizenship status is Eligible Immigrant. Fill only if 'Non-citizen' is 'Yes'.
Depends on:
Non-citizen
|
| Non-citizen | Checkbox |
Check this box if the applicant's citizenship status is Non-citizen.
|
| U.S. Citizen | Checkbox |
Check this box if the person is a U.S. citizen.
|
| Non-citizen | Checkbox |
Check this box if the person is not a U.S. citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the person is an eligible immigrant. Fill only if 'Non-citizen' is checked.
Depends on:
Non-citizen
|
| U.S. Citizen | Checkbox |
Check this box if the additional household member is a U.S. citizen.
|
| Non-citizen | Checkbox |
Check this box if the additional household member is not a U.S. citizen and not an eligible immigrant.
|
| Eligible Immigrant | Checkbox |
Check this box if the additional household member is an eligible immigrant. Fill only if 'Non-citizen' is 'Yes'.
Depends on:
Non-citizen
|
| U.S. citizen | Checkbox |
Check this box if the additional household member is a U.S. citizen.
|
| Non-citizen | Checkbox |
Check this box if the additional household member is a non-citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the additional household member is an eligible immigrant. Fill only if 'Non-citizen' is 'Yes'.
Depends on:
Non-citizen
|
| U.S. Citizen | Checkbox |
Check this box if the additional household member is a U.S. citizen.
|
| Non-citizen | Checkbox |
Check this box if the additional household member is a non-citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the additional household member is an eligible immigrant. Fill only if 'Non-citizen' is selected.
Depends on:
Non-citizen
|
| Contact Information | ||
| Email Address | Text |
Enter the email address for this person.
|
| Cell Phone | Text |
Enter the cell phone number for this person.
|
| Work Phone | Text |
Enter the work phone number for this person.
|
| Home Phone | Text |
Enter the home phone number for this person.
|
| Email Address | Text |
Enter the email address for this additional household member.
|
| Cell Phone | Text |
Enter the cell phone number for this additional household member.
|
| Work Phone | Text |
Enter the work phone number for this additional household member.
|
| Home Phone | Text |
Enter the home phone number for this additional household member.
|
| Cell Phone | Text |
Enter the cell phone number for the additional household member.
|
| Work Phone | Text |
Enter the work phone number for the additional household member.
|
| Home Phone | Text |
Enter the home phone number for the additional household member.
|
| CSHCN Client ID | ||
| CSHCN Client ID | Text |
Enter the Children with Special Health Care Needs (CSHCN) Client ID number.
|
| Date of birth | ||
| Date of Birth | Date |
Enter the date of birth for this household member.
|
| Date of Birth | Date |
Enter the date of birth.
|
| Date of birth | Date |
Provide the date of birth for the additional household member.
|
| Date of Birth | ||
| Date of Birth | Date |
Enter the applicant's date of birth.
|
| Date of Birth | Date |
Provide the date of birth.
|
| Date of Texas Residency | ||
| Date of Texas Residency | Date |
Enter the date of Texas residency. If born in Texas, use your date of birth; otherwise, enter the first day of the month you moved to Texas.
|
| Email address | ||
| Email Address | Text |
Enter the email address for this additional household member.
|
| Email Address | Text |
Provide the email address for this person.
|
| Email Address | ||
| Email Address | Text |
Please enter the applicant's email address.
|
| Employer Information | ||
| Employer Phone Number | Text |
Please provide the phone number of the employer. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Employer Name | Text |
Please provide the full legal name of the employer. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Gender | ||
| Female | Checkbox |
Check this box if the applicant's gender is female.
|
| Male | Checkbox |
Check this box if the applicant's gender is male.
|
| General | ||
| Household Information section | Text | |
| Insurance Information section | Text | |
| Home Address | ||
| Home Address Street | Text |
Provide the street number and name for the home address.
|
| Home Address City | Text |
Enter the city of the home address.
|
| Home Address State | Text |
Enter the state of the home address.
|
| Home Address ZIP Code | Text |
Enter the ZIP code of the home address.
|
| Household Member Name | ||
| Household Member First Name | Text |
Provide the first name of the household member.
|
| Household Member Middle Name | Text |
Provide the middle name of the household member.
|
| Household Member Last Name | Text |
Provide the last name of the household member.
|
| Household Member's Name | ||
| Household Member's Middle Name | Text |
Enter the middle name of the household member.
|
| Household Member's Last Name | Text |
Enter the last name of the household member.
|
| Household Member's First Name | Text |
Enter the first name of the household member.
|
| Insurance Coverage Status | ||
| Has Coverage | Checkbox |
Check this box if the applicant has medical or dental insurance coverage, which should be described below.
|
| No Medical or Dental Insurance | Checkbox |
Check this box if the applicant is not covered under any medical or dental insurance.
|
| Insurance Provider Information | ||
| Provider Phone Number | Text |
Enter the phone number of the insurance provider. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Insurance Provider Name | Text |
Enter the full name of the insurance provider. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Is this person legally responsible for the applicant? | ||
| Legally Responsible - No | Checkbox |
Check this box if the additional household member is not legally responsible for the applicant.
|
| Legally Responsible - Yes | Checkbox |
Check this box if the additional household member is legally responsible for the applicant.
|
| Legal Responsibility for Applicant | ||
| No | Checkbox |
Check this box if the additional person is not legally responsible for the applicant.
|
| Yes | Checkbox |
Check this box if the additional person is legally responsible for the applicant.
|
| Legal Responsibility No | Checkbox |
Check this box if this person is not legally responsible for the applicant.
|
| Legal Responsibility Yes | Checkbox |
Check this box if this person is legally responsible for the applicant.
|
| Legal Responsibility Question | ||
| Legal Responsibility No | Checkbox |
Check this box if this person is not legally responsible for the applicant.
|
| Legal Responsibility Yes | Checkbox |
Check this box if this person is legally responsible for the applicant.
|
| Mailing Address | ||
| Mailing Address Line 1 | Text |
Enter the street number and street name for the mailing address, if different from the home address.
|
| Mailing Address City | Text |
Enter the city for the mailing address, if different from the home address.
|
| Mailing Address State | Text |
Enter the state for the mailing address, if different from the home address.
|
| Mailing Address ZIP Code | Text |
Enter the ZIP code for the mailing address, if different from the home address.
|
| Medicaid Information | ||
| Medicaid Yes | Checkbox |
Check this box if the applicant has any kind of Medicaid.
|
| Medicaid No | Checkbox |
Check this box if the applicant does not have any kind of Medicaid.
|
| Medicaid Number | Text |
Enter the applicant's Medicaid number. Fill only if 'Medicaid Yes' is 'Yes'.
Depends on:
Medicaid Yes
|
| Medicare Part A Information | ||
| Medicare Part A Yes | Checkbox |
Check this box if the applicant has Medicare Part A.
|
| Medicare Part A No | Checkbox |
Check this box if the applicant does not have Medicare Part A.
|
| Medicare Part A HICN Number | Text |
Enter the applicant's Medicare Health Insurance Claim Number (HICN) for Part A. Fill only if 'Medicare Part A Yes' is 'Yes'.
Depends on:
Medicare Part A Yes
|
| Medicare Part A Start Date | Date |
Enter the date when the applicant's Medicare Part A coverage began. Fill only if 'Medicare Part A Yes' is 'Yes'.
Depends on:
Medicare Part A Yes
|
| Medicare Part B Information | ||
| Part B Start Date | Date |
Provide the start date for Medicare Part B. Fill only if 'Yes' is 'Yes'.
Depends on:
Yes
|
| Yes | CheckBox | |
| Medicare Part B No | Checkbox |
Check this box if the applicant does not have Medicare Part B.
|
| Medicare Part C Information | ||
| Medicare Part C Start Date | Date |
Enter the start date of Medicare Part C coverage for the applicant. Fill only if 'Medicare Part C Yes' is 'Yes'.
Depends on:
Medicare Part C Yes
|
| Medicare Part C Yes | Checkbox |
Check this box if the applicant has Medicare Part C.
|
| Medicare Part C No | Checkbox |
Check this box if the applicant does not have Medicare Part C.
|
| Medicare Part D Information | ||
| Medicare Part D Yes | Checkbox |
Check this box if the applicant has Medicare Part D.
|
| Medicare Part D No | Checkbox |
Check this box if the applicant does not have Medicare Part D.
|
| Medicare Part D Start Date | Date |
Enter the start date of the applicant's Medicare Part D coverage. Fill only if 'Medicare Part D Yes' is 'Yes'.
Depends on:
Medicare Part D Yes
|
| Medigap or Medicare Supplemental Coverage Information | ||
| Medigap/Medicare Supplemental Coverage Yes | Checkbox |
Check this box if the applicant has any kind of Medigap or Medicare supplemental coverage.
|
| Medigap/Medicare Supplemental Coverage No | Checkbox |
Check this box if the applicant does not have any kind of Medigap or Medicare supplemental coverage.
|
| Medigap Member ID Number | Text |
Provide the member identification number for the Medigap or Medicare supplemental coverage. Fill only if 'Medigap/Medicare Supplemental Coverage Yes' is 'Yes'.
Depends on:
Medigap/Medicare Supplemental Coverage Yes
|
| Medigap Plan Name | Text |
Enter the name of the Medigap or Medicare supplemental plan. Fill only if 'Medigap/Medicare Supplemental Coverage Yes' is 'Yes'.
Depends on:
Medigap/Medicare Supplemental Coverage Yes
|
| Medigap Coverage Start Date | Date |
Enter the date when the Medigap or Medicare supplemental coverage began. Fill only if 'Medigap/Medicare Supplemental Coverage Yes' is 'Yes'.
Depends on:
Medigap/Medicare Supplemental Coverage Yes
|
| Medigap Phone Number | Text |
Provide the phone number associated with the Medigap or Medicare supplemental coverage. Fill only if 'Medigap/Medicare Supplemental Coverage Yes' is 'Yes'.
Depends on:
Medigap/Medicare Supplemental Coverage Yes
|
| Monthly Premium | ||
| Monthly Premium | Number |
Provide the monetary amount of the monthly premium. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Name | ||
| First Name | Text |
Please enter the first name of the additional household member.
|
| Middle Name | Text |
Please enter the middle name of the additional household member.
|
| Last Name | Text |
Please enter the last name of the additional household member.
|
| Pay Cycle | ||
| Weekly | CheckBox | |
| Yearly | CheckBox | |
| Monthly | CheckBox | |
| Twice per month | CheckBox | |
| Every two weeks | CheckBox | |
| Weekly Pay Cycle | Checkbox |
Check this box if the pay cycle for the income source is weekly. Fill only if 'No household income' is not selected.
Depends on:
No household income
|
| Yearly Pay Cycle | Checkbox |
Check this box if the pay cycle for the income source is yearly. Fill only if 'No household income' is not selected.
Depends on:
No household income
|
| Monthly Pay Cycle | Checkbox |
Check this box if the pay cycle for the income source is monthly. Fill only if 'No household income' is not selected.
Depends on:
No household income
|
| Twice Per Month Pay Cycle | Checkbox |
Check this box if the pay cycle for the income source is twice per month. Fill only if 'No household income' is not selected.
Depends on:
No household income
|
| Every Two Weeks Pay Cycle | Checkbox |
Check this box if the pay cycle for the income source is every two weeks. Fill only if 'No household income' is not selected.
Depends on:
No household income
|
| Pay cycle for source of income | ||
| Weekly | Checkbox |
Check this box if the income is received weekly. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Yearly | Checkbox |
Check this box if the income is received yearly. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Monthly | Checkbox |
Check this box if the income is received monthly. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Twice per month | Checkbox |
Check this box if the income is received twice per month. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Every two weeks | Checkbox |
Check this box if the income is received every two weeks. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Pay Cycle for Source of Income | ||
| Yearly | Checkbox |
Check this box if the source of income is paid yearly. Fill only if 'No Household Income' is 'No'.
Depends on:
No Household Income
|
| Monthly | Checkbox |
Check this box if the source of income is paid monthly. Fill only if 'No Household Income' is 'No'.
Depends on:
No Household Income
|
| Twice per month | Checkbox |
Check this box if the source of income is paid twice per month. Fill only if 'No Household Income' is 'No'.
Depends on:
No Household Income
|
| Every two weeks | Checkbox |
Check this box if the source of income is paid every two weeks. Fill only if 'No Household Income' is 'No'.
Depends on:
No Household Income
|
| Weekly | Checkbox |
Check this box if the source of income is paid weekly. Fill only if 'No Household Income' is 'No'.
Depends on:
No Household Income
|
| Weekly | Checkbox |
Check this box if the pay cycle for the source of income is weekly. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Yearly | Checkbox |
Check this box if the pay cycle for the source of income is yearly. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Monthly | Checkbox |
Check this box if the pay cycle for the source of income is monthly. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Twice per month | Checkbox |
Check this box if the pay cycle for the source of income is twice per month. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Every two weeks | Checkbox |
Check this box if the pay cycle for the source of income is every two weeks. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Person's Name | ||
| Middle Name | Text |
Enter the person's middle name.
|
| Last Name | Text |
Enter the person's last name.
|
| First Name | Text |
Enter the person's first name.
|
| Phone Numbers | ||
| Work Phone | Text |
Enter the applicant's work phone number.
|
| Cell Phone | Text |
Enter the applicant's cell phone number.
|
| Home Phone | Text |
Enter the applicant's home phone number.
|
| Cell Phone | Text |
Enter the cell phone number for this additional household member.
|
| Work Phone | Text |
Enter the work phone number for this additional household member.
|
| Home Phone | Text |
Enter the home phone number for this additional household member.
|
| Policy Details | ||
| Policy Number | Text |
Enter the member or policy number for the private insurance. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Coverage Start Date | Date |
Enter the date when the private insurance coverage began. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Policy Holder Information | ||
| Member Social Security Number | Text |
Please provide the member's Social Security number. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Member Policy Holder Name | Text |
Please provide the full name of the member or policy holder. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Policy Medical Cost Coverage | ||
| Policy Medical Cost Coverage Yes | Checkbox |
Check this box if the policy covers medical costs. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Policy Medical Cost Coverage No | Checkbox |
Check this box if the policy does not cover medical costs. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Policy Prescription Coverage | ||
| Prescription Coverage Yes | Checkbox |
Check this box if the policy covers prescriptions. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Prescription Coverage No | Checkbox |
Check this box if the policy does not cover prescriptions. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Preferred Spoken Language | ||
| Spanish | Checkbox |
Check this box if Spanish is your preferred spoken language.
|
| English | Checkbox |
Check this box if English is your preferred spoken language.
|
| Premium Payment Assistance | ||
| Premium Payment Assistance: Yes | Checkbox |
Check this box if you need help paying the premium. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Premium Payment Assistance: No | Checkbox |
Check this box if you do not need help paying the premium. Fill only if 'Private Insurance Yes' is 'Yes'.
Depends on:
Private Insurance Yes
|
| Private Insurance Status | ||
| Private Insurance Yes | Checkbox |
Check this box if the applicant has any kind of private insurance.
|
| Private Insurance No | Checkbox |
Check this box if the applicant does not have any kind of private insurance.
|
| Provider Information | ||
| Dental Provider Name | Text |
Enter the name of the applicant's dental provider.
|
| Medical Provider Name | Text |
Enter the name of the applicant's medical provider.
|
| Relationship to applicant | ||
| Parent/Guardian | Checkbox |
Check this box if the additional household member is the applicant's parent or legal guardian.
|
| Other | Checkbox |
Check this box if the additional household member's relationship to the applicant is not listed above.
|
| Relationship to applicant (Other) | Text |
Provide the relationship of the additional household member to the applicant if it is not one of the predefined options. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Child | Checkbox |
Check this box if the additional household member is the applicant's child.
|
| Spouse | Checkbox |
Check this box if the additional household member is the applicant's spouse.
|
| Brother/sister | Checkbox |
Check this box if the additional household member is the applicant's brother or sister.
|
| Caregiver | Checkbox |
Check this box if the additional household member is the applicant's caregiver.
|
| Parent/Guardian | Checkbox |
Check this box if the additional household member is the applicant's parent or legal guardian.
|
| Other Relationship | Checkbox |
Check this box if the additional household member's relationship to the applicant is not listed in the other options.
|
| Other Relationship to Applicant | Text |
Please specify the relationship of this person to the applicant if it is not listed in the options above. Fill only if 'Other Relationship' is 'Yes'.
Depends on:
Other Relationship
|
| Child | Checkbox |
Check this box if the additional household member is the applicant's child.
|
| Spouse | Checkbox |
Check this box if the additional household member is the applicant's spouse.
|
| Brother/sister | Checkbox |
Check this box if the additional household member is the applicant's brother or sister.
|
| Caregiver | Checkbox |
Check this box if the additional household member is a caregiver for the applicant.
|
| Relationship to Applicant | ||
| Relationship to Applicant - Parent/Guardian | Checkbox |
Check this box if the additional person is the applicant's parent or guardian.
|
| Relationship to Applicant - Other | Checkbox |
Check this box if the additional person's relationship to the applicant is not listed.
|
| Other Relationship to Applicant | Text |
Provide the relationship of the person to the applicant if it is not one of the options listed. Fill only if 'Relationship to Applicant - Other' is checked.
Depends on:
Relationship to Applicant - Other
|
| Relationship to Applicant - Child | Checkbox |
Check this box if the additional person is the applicant's child.
|
| Relationship to Applicant - Spouse | Checkbox |
Check this box if the additional person is the applicant's spouse.
|
| Relationship to Applicant - Brother/sister | Checkbox |
Check this box if the additional person is the applicant's brother or sister.
|
| Relationship to Applicant - Caregiver | Checkbox |
Check this box if the additional person is the applicant's caregiver.
|
| Parent/Guardian | CheckBox | |
| Other | Checkbox |
Check this box if the additional household member's relationship to the applicant is not listed above.
|
| Other Relationship to Applicant | Text |
Please specify this person's relationship to the applicant if it is not one of the provided options. Fill only if 'Other' is selected.
Depends on:
Other
|
| Child | Checkbox |
Check this box if the additional household member is the applicant's child.
|
| Spouse | Checkbox |
Check this box if the additional household member is the applicant's spouse.
|
| Brother/sister | Checkbox |
Check this box if the additional household member is the applicant's brother or sister.
|
| Caregiver | Checkbox |
Check this box if the additional household member is the applicant's caregiver.
|
| Social Security Number | ||
| Social Security Number | Text |
Provide the applicant's Social Security Number.
|
| Sources of income | ||
| No household income | Checkbox |
Check this box if the person does not have any source of income.
|
| Employment | Checkbox |
Check this box if the person receives income from employment.
|
| Self-employment | Checkbox |
Check this box if the person receives income from self-employment.
|
| Unemployment benefits | Checkbox |
Check this box if the person receives unemployment benefits.
|
| SSI | Checkbox |
Check this box if the person receives Supplemental Security Income (SSI), but do not include the applicant's SSI income.
|
| Child support | Checkbox |
Check this box if the person receives child support payments.
|
| VA, retirement, or railroad pension | Checkbox |
Check this box if the person receives income from VA benefits, retirement, or a railroad pension.
|
| Rental property | Checkbox |
Check this box if the person receives income from rental property.
|
| Dividends or royalties | Checkbox |
Check this box if the person receives income from dividends or royalties.
|
| Other | Checkbox |
Check this box if the person has other sources of income not listed above.
|
| Other Source of Income | Text |
Provide a description of the other source of income. Fill only if 'Other' is 'Yes'.
Depends on:
Other
|
| Sources of Income | ||
| No Household Income | Checkbox |
Check this box if there is no income for the household.
|
| Employment | Checkbox |
Check this box if you receive income from employment.
|
| Self-employment | Checkbox |
Check this box if you receive income from self-employment.
|
| Unemployment Benefits | Checkbox |
Check this box if you receive unemployment benefits.
|
| SSI | Checkbox |
Check this box if you receive SSI (Supplemental Security Income), but do not include the applicant's SSI income.
|
| Child Support | Checkbox |
Check this box if you receive child support.
|
| VA, Retirement, or Railroad Pension | Checkbox |
Check this box if you receive income from VA benefits, retirement, or a railroad pension.
|
| Dividends or Royalties | Checkbox |
Check this box if you receive income from dividends or royalties.
|
| Rental Property | Checkbox |
Check this box if you receive income from rental property.
|
| Other Income | Checkbox |
Check this box if you have sources of income not listed above.
|
| Other Income Source | Text |
Please specify any other source of income not listed. Fill only if 'Other Income' is 'Yes'.
Depends on:
Other Income
|
| No household income | Checkbox |
Check this box if the person receives no income from any source.
|
| Employment | Checkbox |
Check this box if the person receives income from employment.
|
| Self-employment | Checkbox |
Check this box if the person receives income from self-employment.
|
| Unemployment benefits | Checkbox |
Check this box if the person receives income from unemployment benefits.
|
| SSI | Checkbox |
Check this box if the person receives income from Supplemental Security Income (SSI), but do not include the applicant's SSI income.
|
| Child support | Checkbox |
Check this box if the person receives income from child support.
|
| VA, retirement, or railroad pension | Checkbox |
Check this box if the person receives income from Veterans Affairs (VA) benefits, retirement, or a railroad pension.
|
| Rental property | Checkbox |
Check this box if the person receives income from rental property.
|
| Dividends or royalties | Checkbox |
Check this box if the person receives income from dividends or royalties.
|
| Other | Checkbox |
Check this box if the person receives income from a source not listed.
|
| Other Source of Income | Text |
Specify any source of income this person has that is not listed in the provided options. Fill only if 'Other' is checked.
Depends on:
Other
|
| No household income | CheckBox | |
| Employment | CheckBox | |
| Self-employment | CheckBox | |
| Unemployment benefits | CheckBox | |
| SSI (Do not include the applicant's SSI income.) | CheckBox | |
| Child support | CheckBox | |
| VA, retirement, or railroad pension | CheckBox | |
| Rental property | CheckBox | |
| Dividends or royalties | CheckBox | |
| Other (fill in) | CheckBox | |
| Other Source of Income | Text |
Enter any other source of income this person has. Fill only if 'Other (fill in)' is 'Yes'.
Depends on:
Other (fill in)
|
| No household income | Checkbox |
Check this box if the person has no sources of income.
|
| Employment | Checkbox |
Check this box if the person earns income from employment.
|
| Self-employment | Checkbox |
Check this box if the person earns income from self-employment.
|
| Unemployment benefits | Checkbox |
Check this box if the person receives income from unemployment benefits.
|
| SSI | Checkbox |
Check this box if the person receives income from SSI (Supplemental Security Income), excluding the applicant's SSI income.
|
| Child support | Checkbox |
Check this box if the person receives income from child support.
|
| VA, retirement, or railroad pension | Checkbox |
Check this box if the person receives income from VA benefits, retirement, or a railroad pension.
|
| Rental property | Checkbox |
Check this box if the person receives income from rental property.
|
| Dividends or royalties | Checkbox |
Check this box if the person receives income from dividends or royalties.
|
| Other | Checkbox |
Check this box if the person has other sources of income not listed.
|
| Other Income Source | Text |
Provide a description of the other source of income. Fill only if 'Other' is selected.
Depends on:
Other
|
| Spokesperson Question | ||
| Spokesperson No | Checkbox |
Check this box if this household member cannot speak for the applicant.
|
| Spokesperson Yes | Checkbox |
Check this box if this household member can speak for the applicant.
|
| Written Correspondence Language | ||
| English | Checkbox |
Check this box if you would like to receive written correspondence in English.
|
| Spanish | Checkbox |
Check this box if you would like to receive written correspondence in Spanish.
|