Form T-3, Children with Special Health Care Needs (CSHCN) Services Program Application Instructions
This form contains 255 fields organized into 51 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 | ||
| Ability to Speak for Applicant - No | Checkbox |
Check this box if the person cannot speak for the applicant.
|
| Ability to Speak for Applicant - Yes | Checkbox |
Check this box if the person can speak for the applicant.
|
| Acknowledgement | ||
| Signature | Text |
Provide your signature to acknowledge the statements in the application.
|
| Date of Signature | Date |
Enter the date the signature was provided.
|
| Additional Household Member Name | ||
| Middle name | Text | |
| Last name | Text | |
| First name | Text | |
| Applicant Identification | ||
| Applicant Social Security Number | Text |
Please provide the applicant's Social Security Number.
|
| Applicant Date of Birth | Date |
Please provide the applicant's date of birth.
|
| Applicant Name | ||
| Contact information section | Text | |
| Application information section | Text | |
| Applicant First Name | Text |
Enter the applicant's first name as it appears on their proof of birth document.
|
| Applicant Last Name | Text |
Enter the applicant's last name as it appears on their proof of birth document.
|
| Applicant Middle Name | Text |
Enter the applicant's middle name as it appears on their proof of birth document.
|
| Application Completion 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 Speak for Applicant | ||
| Can Speak for Applicant - No | Checkbox |
Check this box if the additional household member cannot speak for the applicant.
|
| Can Speak for Applicant - Yes | Checkbox |
Check this box if the additional household member can speak for the applicant.
|
| 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 |
Provide the CHIP number. Fill only if 'CHIP Yes' is 'Yes'.
Depends on:
CHIP Yes
|
| CHIP Coverage Start Date | Date |
Provide the date when CHIP coverage started. Fill only if 'CHIP Yes' is 'Yes'.
Depends on:
CHIP Yes
|
| Citizenship Status | ||
| U.S. Citizen | Checkbox |
Check this box if the applicant is a U.S. citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the applicant is an eligible immigrant. Fill only if 'Non-citizen' is checked.
Depends on:
Non-citizen
|
| Non-citizen | Checkbox |
Check this box if the applicant is not a U.S. citizen and is not an eligible immigrant.
|
| U.S. Citizen | Checkbox |
Check this box if the person's citizenship status is U.S. citizen.
|
| Non-citizen | Checkbox |
Check this box if the person's citizenship status is Non-citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the person's citizenship status is Eligible Immigrant. Fill only if 'Non-citizen' is checked.
Depends on:
Non-citizen
|
| U.S. citizen | Checkbox |
Check this box if the household member is a U.S. citizen.
|
| Non-citizen | Checkbox |
Check this box if the household member is not a U.S. citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the 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 household member's citizenship status is U.S. Citizen.
|
| Non-citizen | Checkbox |
Check this box if the household member's citizenship status is Non-citizen.
|
| Eligible Immigrant | Checkbox |
Check this box if the household member's citizenship status is 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 not a citizen of the U.S.
|
| 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 | ||
| Cell Phone | Text |
Enter the cell phone number for the additional person.
|
| Work Phone | Text |
Enter the work phone number for the additional person.
|
| Home Phone | Text |
Enter the home phone number for the additional person.
|
| Email Address | Text |
Enter the email address for the 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.
|
| Cell Phone | Text |
Please provide the cell phone number for the additional household member.
|
| Work Phone | Text |
Please provide the work phone number for the additional household member.
|
| Home Phone | Text |
Please provide the home phone number for the additional household member.
|
| Date of birth | ||
| Date of birth | Date |
Provide the date of birth for this person.
|
| Date of Birth | Date |
Please enter the date of birth.
|
| Date of birth | Date |
Provide the date of birth for this individual.
|
| Date of Birth | ||
| Date of Birth | Date |
Enter the individual's date of birth.
|
| Date of Texas Residency | ||
| Date of Texas Residency | Date |
Enter the date of Texas residency. If born in Texas, use the date of birth. Otherwise, enter the first day of the month the applicant moved to Texas.
|
| Email address | ||
| Email address | Text |
Enter the email address for this person.
|
| Email address | Text |
Enter the email address of the additional household member.
|
| Email address | Text |
Enter the email address.
|
| Email Address | ||
| Email Address | Text |
Enter the email address for contact.
|
| Employer Information | ||
| Employer Phone Number | Text |
Enter the employer's phone number. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Employer Name | Text |
Enter the name of the employer. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Full Name | ||
| First Name | Text |
Enter the first name of the additional household member.
|
| Middle Name | Text |
Enter the middle name of the additional household member.
|
| Last Name | Text |
Enter the last name of the additional household member.
|
| Gender and Client ID | ||
| Gender - Female | Checkbox |
Check this box if the applicant is female.
|
| Gender - Male | Checkbox |
Check this box if the applicant is male.
|
| CSHCN Client ID | Text |
Please enter the client identification number for the Children with Special Health Care Needs (CSHCN) Services Program.
|
| General | ||
| Household Information section | Text | |
| Home Address | ||
| Home Street Address | Text |
Enter the street address of your home.
|
| Home City | Text |
Enter the city of your home address.
|
| Home State | Text |
Enter the state of your home address.
|
| Home ZIP Code | Text |
Enter the ZIP code of your home address.
|
| Household Member's Name | ||
| Household Member's First Name | Text |
Please provide the first name of the household member.
|
| Household Member's Middle Name | Text |
Please provide the middle name of the household member.
|
| Household Member's Last Name | Text |
Please provide the last name of the household member.
|
| Income Pay Cycle | ||
| 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
|
| Insurance Coverage Status | ||
| Applicant Has Coverage | Checkbox |
Check this box if the applicant has medical or dental insurance coverage.
|
| Applicant Not Covered | Checkbox |
Check this box if the applicant is not covered under any medical or dental insurance.
|
| Insurance Information section | Text | |
| Insurance Provider Information | ||
| Insurance Provider Phone Number | Text |
Enter the phone number for the insurance provider. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Insurance Provider Name | Text |
Enter the full name of the insurance provider. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Is this person legally responsible for the applicant? | ||
| No | Checkbox |
Check this box if the person is not legally responsible for the applicant.
|
| Yes | Checkbox |
Check this box if the person is legally responsible for the applicant.
|
| Legal Responsibility for Applicant | ||
| Legally Responsible: No | Checkbox |
Check this box if this person is not legally responsible for the applicant.
|
| Legally Responsible: Yes | Checkbox |
Check this box if this person is legally responsible for the applicant.
|
| Legal Responsibility No | Checkbox |
Check this box if the additional household member is not legally responsible for the applicant.
|
| Legal Responsibility Yes | Checkbox |
Check this box if the additional household member is 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.
|
| Mailing Address | ||
| Mailing Address Line 1 | Text |
Enter the street number and name for the mailing address.
|
| Mailing City | Text |
Enter the city for the mailing address. Fill only if 'Mailing Address Line 1' is filled.
Depends on:
Mailing Address Line 1
|
| Mailing State | Text |
Enter the state for the mailing address. Fill only if 'Mailing Address Line 1' is filled.
Depends on:
Mailing Address Line 1
|
| Mailing ZIP Code | Text |
Enter the ZIP code for the mailing address. Fill only if 'Mailing Address Line 1' is filled.
Depends on:
Mailing Address Line 1
|
| Medicaid Status | ||
| Medicaid Status Yes | Checkbox |
Check this box if the applicant has any kind of Medicaid.
|
| Medicaid Status 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 Status Yes' is 'Yes'.
Depends on:
Medicaid Status Yes
|
| Medical Cost Coverage Status | ||
| Medical Cost Coverage Yes | Checkbox |
Check this box if the policy covers medical costs. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Medical Cost Coverage No | Checkbox |
Check this box if the policy does not cover medical costs. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: 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 |
Provide the applicant's Medicare Part A Health Insurance Claim Number (HICN). Fill only if 'Medicare Part A Yes' is 'Yes'.
Depends on:
Medicare Part A Yes
|
| Medicare Part A Start Date | Date |
Provide the date when the applicant's Medicare Part A coverage started. 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 coverage. Fill only if 'Medicare Part B Yes' is 'Yes'.
Depends on:
Medicare Part B Yes
|
| Medicare Part B Yes | Checkbox |
Check this box if the applicant has Medicare Part B.
|
| Medicare Part B No | Checkbox |
Check this box if the applicant does not have Medicare Part B.
|
| Medicare Part C Information | ||
| Part C Start Date | Date |
Enter the start date for Medicare Part C coverage. 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.
|
| Part D Start Date | Date |
Provide the start date for Medicare Part D. Fill only if 'Medicare Part D Yes' is 'Yes'.
Depends on:
Medicare Part D Yes
|
| Medigap/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 |
Enter 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 coverage 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 started. Fill only if 'Medigap/Medicare Supplemental Coverage Yes' is 'Yes'.
Depends on:
Medigap/Medicare Supplemental Coverage Yes
|
| Medigap Phone Number | Text |
Enter the phone number for the Medigap or Medicare supplemental coverage provider. Fill only if 'Medigap/Medicare Supplemental Coverage Yes' is 'Yes'.
Depends on:
Medigap/Medicare Supplemental Coverage Yes
|
| Pay Cycle | ||
| Yearly | Checkbox |
Check this box if the pay cycle for this 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 this 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 this 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 this source of income is every two weeks. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Weekly | Checkbox |
Check this box if the pay cycle for this source of income is weekly. Fill only if 'No household income' is 'No'.
Depends on:
No household income
|
| Pay Cycle for Source of Income | ||
| Weekly Pay Cycle | Checkbox |
Check this box if the source of income is received weekly.
|
| Yearly Pay Cycle | Checkbox |
Check this box if the source of income is received yearly.
|
| Monthly Pay Cycle | Checkbox |
Check this box if the source of income is received monthly.
|
| Twice Per Month Pay Cycle | Checkbox |
Check this box if the source of income is received twice per month.
|
| Every Two Weeks Pay Cycle | Checkbox |
Check this box if the source of income is received every two weeks.
|
| Weekly | CheckBox |
Depends on:
No Household Income
|
| Yearly | CheckBox |
Depends on:
No Household Income
|
| Monthly | CheckBox |
Depends on:
No Household Income
|
| Twice per month | CheckBox |
Depends on:
No Household Income
|
| Every two weeks | CheckBox |
Depends on:
No Household Income
|
| Weekly | Checkbox |
Check this box if the income is received weekly. Fill only if 'No household income' is not selected.
Depends on:
No household income
|
| Yearly | Checkbox |
Check this box if the income is received yearly. Fill only if 'No household income' is not selected.
Depends on:
No household income
|
| Monthly | Checkbox |
Check this box if the income is received monthly. Fill only if 'No household income' is not selected.
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 not selected.
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 not selected.
Depends on:
No household income
|
| Permission to Speak for Applicant | ||
| Permission to Speak for Applicant No | Checkbox |
Check this box if this person is not permitted to speak for the applicant.
|
| Permission to Speak for Applicant Yes | Checkbox |
Check this box if this person is permitted to speak for the applicant.
|
| Person's Name | ||
| Person's Middle Name | Text |
Enter the middle name of the additional person.
|
| Person's Last Name | Text |
Enter the last name of the additional person.
|
| Person's First Name | Text |
Enter the first name of the additional person.
|
| Phone Numbers | ||
| Work Phone Number | Text |
Enter the applicant's work phone number.
|
| Cell Phone Number | Text |
Enter the applicant's cell phone number.
|
| Home Phone Number | Text |
Enter the applicant's home phone number.
|
| Cell Phone Number | Text |
Enter the cell phone number for this person.
|
| Work Phone Number | Text |
Enter the work phone number for this person.
|
| Home Phone Number | Text |
Enter the home phone number for this person.
|
| Policy Holder Information | ||
| Member Social Security Number | Text |
Please enter the Social Security number of the policy member. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Member/Policy Holder Name | Text |
Please enter the full name of the member or policy holder. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Policy Information | ||
| Policy Number | Text |
Enter the member or policy number for the insurance. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Coverage Start Date | Date |
Enter the date when the insurance coverage began. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: 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 Information | ||
| Monthly Premium | Number |
Please enter the monthly premium amount. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Premium Help Yes | Checkbox |
Check this box if you need help paying this premium. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Premium Help No | Checkbox |
Check this box if you do not need help paying this premium. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Prescription Coverage Status | ||
| Prescription Coverage Yes | Checkbox |
Check this box if the insurance policy covers prescription costs. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Prescription Coverage No | Checkbox |
Check this box if the insurance policy does not cover prescription costs. Fill only if 'Private Insurance Status: Yes' is 'Yes'.
Depends on:
Private Insurance Status: Yes
|
| Private Insurance Status | ||
| Private Insurance Status: Yes | Checkbox |
Check this box if the applicant has any kind of private insurance.
|
| Private Insurance Status: 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 dental provider.
|
| Medical Provider Name | Text |
Enter the name of the medical provider.
|
| Relationship to applicant | ||
| Parent/Guardian | Checkbox |
Check this box if the additional household member is the applicant's parent or guardian.
|
| Other | Checkbox |
Check this box if the additional household member's relationship to the applicant is not listed among the other options.
|
| Other Relationship to Applicant | Text |
Provide the relationship of this person to the applicant if none of the pre-defined options apply. 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 parent or guardian of the applicant.
|
| Other | Checkbox |
Check this box if the additional household member has a relationship to the applicant not listed above.
|
| Other Relationship to Applicant | Text |
Enter the additional household member's relationship to the applicant if not listed. Fill only if 'Other' is selected.
Depends on:
Other
|
| Child | Checkbox |
Check this box if the additional household member is the child of the applicant.
|
| Spouse | Checkbox |
Check this box if the additional household member is the spouse of the applicant.
|
| Brother/sister | Checkbox |
Check this box if the additional household member is the brother or sister of the applicant.
|
| Caregiver | Checkbox |
Check this box if the additional household member is a caregiver for the applicant.
|
| Relationship to Applicant | ||
| Parent/Guardian | Checkbox |
Check this box if the additional person is the applicant's parent or legal guardian.
|
| Other | Checkbox |
Check this box if the additional person's relationship to the applicant is not listed among the other options.
|
| Other Relationship to Applicant | Text |
Enter the specific relationship to the applicant if it is not listed among the provided options. Fill only if 'Other' is checked.
Depends on:
Other
|
| Child | Checkbox |
Check this box if the additional person is the applicant's child.
|
| Spouse | Checkbox |
Check this box if the additional person is the applicant's spouse.
|
| Brother/sister | Checkbox |
Check this box if the additional person is the applicant's brother or sister.
|
| Caregiver | Checkbox |
Check this box if the additional person is the applicant's caregiver.
|
| Parent/Guardian | Checkbox |
Check this box if the additional household member is the applicant's parent or guardian.
|
| Other | Checkbox |
Check this box if the additional household member has a relationship to the applicant not listed above.
|
| Other Relationship to Applicant | Text |
Specify the relationship of this person to the applicant if it is not listed in the provided 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.
|
| Sources of Income | ||
| 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 | |
| Dividends or royalties | CheckBox | |
| Rental property | CheckBox | |
| Other (fill in) | CheckBox | |
| Other Source of Income | Text |
Please specify any other source of income not listed above. Fill only if 'Other (fill in)' is 'Yes'.
Depends on:
Other (fill in)
|
| 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 |
Please specify any other source of income not listed above. Fill only if 'Other (fill in)' is checked.
Depends on:
Other (fill in)
|
| No Household Income | Checkbox |
Check this box if the additional household member has no sources of income.
|
| Employment | Checkbox |
Check this box if the additional household member receives income from employment.
|
| Self-employment | Checkbox |
Check this box if the additional household member receives income from self-employment.
|
| Unemployment Benefits | Checkbox |
Check this box if the additional household member receives unemployment benefits.
|
| SSI (Supplemental Security Income) | Checkbox |
Check this box if the additional household member receives Supplemental Security Income (SSI), excluding the applicant's SSI income.
|
| Child Support | Checkbox |
Check this box if the additional household member receives child support payments.
|
| VA, Retirement, or Railroad Pension | Checkbox |
Check this box if the additional household member receives income from VA benefits, retirement plans, or a railroad pension.
|
| Rental Property Income | Checkbox |
Check this box if the additional household member receives income from rental property.
|
| Dividends or Royalties | Checkbox |
Check this box if the additional household member receives income from dividends or royalties.
|
| Other Sources of Income | Checkbox |
Check this box if the additional household member has other sources of income not specifically listed.
|
| Other Source of Income | Text |
Please specify any other source of income not listed. Fill only if 'Other Sources of Income' is 'Yes'.
Depends on:
Other Sources of Income
|
| No household income | Checkbox |
Check this box if the person does not have any sources 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), 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.
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| Rental property | Checkbox |
Check this box if the person receives income from rental property.
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| Dividends or royalties | Checkbox |
Check this box if the person receives income from dividends or royalties.
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| Other | Checkbox |
Check this box if the person receives income from a source not listed above.
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| Other Source of Income | Text |
Provide the other source of income not explicitly listed. Fill only if 'Other' is 'Yes'.
Depends on:
Other
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| No household income | Checkbox |
Check this box if the person has no sources of household income. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Employment | Checkbox |
Check this box if the person's source of income is from employment. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Self-employment | Checkbox |
Check this box if the person's source of income is from self-employment. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Unemployment benefits | Checkbox |
Check this box if the person's source of income includes unemployment benefits. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| SSI | Checkbox |
Check this box if the person's source of income is Supplemental Security Income (SSI). Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Child support | Checkbox |
Check this box if the person's source of income is child support. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| VA, retirement, or railroad pension | Checkbox |
Check this box if the person's source of income is from VA benefits, retirement, or a railroad pension. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Rental property | Checkbox |
Check this box if the person's source of income is from rental property. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Dividends or royalties | Checkbox |
Check this box if the person's source of income includes dividends or royalties. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Other Sources of Income | Checkbox |
Check this box if the person has other sources of income not explicitly listed. Fill only if 'Is this person legally responsible for the applicant?' is 'Yes'.
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| Other Source of Income | Text |
Enter any other source of income not explicitly listed. Fill only if 'Other Sources of Income' is selected.
Depends on:
Other Sources of Income
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| Written Correspondence Language | ||
| English | Checkbox |
Check this box if you would like to receive written correspondence in English.
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| Spanish | Checkbox |
Check this box if you would like to receive written correspondence in Spanish.
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