DHS-6696-ENG, Minnesota Health Care Programs Application (MNsure/DHS) Instructions

Check this box if PERSON 2 is not of Hispanic, Latino, or Spanish origin.

Check this box if PERSON 2 is of Hispanic, Latino, or Spanish origin, then mark any specific origin boxes below that apply.

Check this box if PERSON 2 is of Cuban origin. Fill only if '12a Yes – check all that apply' is 'Yes'.

Check this box if PERSON 2 is Mexican, Mexican American, or Chicano/a. Fill only if '12a Yes – check all that apply' is 'Yes'.

Check this box if PERSON 2 is Puerto Rican. Fill only if '12a Yes – check all that apply' is 'Yes'.

Check this box if PERSON 2 is of another Hispanic/Latino/Spanish origin not listed and write that origin on the line. Fill only if '12a Yes – check all that apply' is 'Yes'.

If PERSON 2's Hispanic, Latino, or Spanish origin is not listed (e.g., not Cuban, Mexican, Puerto Rican), enter the specific origin or group name here; leave blank if not applicable. Fill only if '12a Other' is 'Yes'.

Check this box if PERSON 2 prefers not to answer the question about Hispanic/Latino origin.

Check this box if PERSON 2 identifies as American Indian or Alaska Native.

Check this box if PERSON 2 identifies as Asian Indian.

Check this box if PERSON 2 identifies as Black or African American.

Check this box if PERSON 2 identifies as Chinese.

Check this box if PERSON 2 identifies as Filipino.

Check this box if PERSON 2 identifies as Guamanian or Chamorro.

Check this box if PERSON 2 identifies as Japanese.

Check this box if PERSON 2 identifies as Korean.

Check this box if PERSON 2 identifies as Native Hawaiian.

Check this box if PERSON 2 identifies with an Asian race not listed above.

Check this box if PERSON 2 identifies as a Pacific Islander not listed above.

Check this box if PERSON 2 identifies as Samoan.

Check this box if PERSON 2 identifies as Vietnamese.

Check this box if PERSON 2 identifies as White.

Check this box if PERSON 2 identifies with a race not listed and write that race on the line provided.

Enter the specific race or races not listed above that apply to PERSON 2, using a short descriptive phrase (for example, "Middle Eastern" or "Two or more races: X and Y"). Fill only if '12b - Other (specify)' is 'Yes'.

Check this box if PERSON 2 does not want to report their race.

Check this box if PERSON 2 is a U.S. citizen or U.S. national.

Check this box if PERSON 2 is not a U.S. citizen or U.S. national.

Check this box when PERSON 2 does not want help paying for a medical emergency. Fill only if '13. No – go to question 14.' is 'Yes'.

Check this box when PERSON 2 does want help paying for a medical emergency and you will provide the begin and end dates for that medical emergency. Fill only if '13. No – go to question 14.' is 'Yes'.

Enter the date when the medical emergency began for PERSON 2. Fill only if 'Q14 - Yes (Does PERSON 2 want help paying for a medical emergency?)' is 'Yes'.

Enter the date when the medical emergency ended for PERSON 2, or leave blank if it has not ended. Fill only if 'Q14 - Yes (Does PERSON 2 want help paying for a medical emergency?)' is 'Yes'.

Enter Person 2's A-number or other immigration identification number assigned by USCIS or another agency; leave blank if none. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Enter the date Person 2 entered the United States. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Provide the name or classification of the immigration document Person 2 currently holds (for example, Refugee, LPR, Asylee, Parolee). Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Enter the identifying number shown on the immigration document provided for Person 2. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Enter the expiration date of the immigration document shown for Person 2. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 does not have any immigration status listed here; if checked, skip to question 16. Fill only if '13. No – go to question 14.' is 'Yes'.

Check this box if PERSON 2 does have an immigration status listed here, then select the box for their current status and answer the following questions. Fill only if '13. No – go to question 14.' is 'Yes'.

Check this box if PERSON 2 is a lawful permanent resident (green card holder) or a conditional resident. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 has refugee status. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 has been granted asylum (is an asylee). Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 has applied for asylum and is currently an asylum applicant. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 was paroled into the U.S. and the parole period has lasted at least one year. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 was paroled into the U.S. and the parole period has lasted less than one year. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 was paroled into the U.S. from Ukraine and entered before 9-30-24. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 was paroled into the U.S. from Afghanistan and entered before 9-30-23. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is a temporary nonimmigrant (for example, visitor, student, worker, or U visa holder). Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 has Temporary Protected Status (TPS). Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 has Deferred Action for Childhood Arrivals (DACA). Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 has a form of Deferred Action that is not DACA. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is a Cuban or Haitian entrant. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is under withholding of removal or deportation. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is a victim of severe human trafficking. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is a battered noncitizen (meets the form's definition for a battered noncitizen). Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is an American Indian born in Canada. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is a special Iraqi or Afghan immigrant. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is an Amerasian noncitizen. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 is a citizen of the Marshall Islands, the Federated States of Micronesia, or Palau. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 was admitted as a conditional entrant before 1981. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2 has been granted an Employment Authorization Document (work permit) that is not related to DACA. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Check this box if PERSON 2's immigration status is not listed above and specify the status as directed on page 21. Fill only if '15 Yes – has an immigration status (check current status below)' is 'Yes'.

Enter the code or short identifier from page 21 that corresponds to the 'Other' immigration status selected for PERSON 2. Fill only if '15 Other (Choose from page 21)' is 'Yes'.

Check this box if PERSON 2 did NOT enter the United States before August 22, 1996. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

Check this box if PERSON 2 DID enter the United States before August 22, 1996. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

Check this box if PERSON 2 has NOT had their current immigration status for five years or more (i.e., the current status has been held for less than five years). Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

Check this box if PERSON 2 HAS had their current immigration status for five years or more. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

Check this box if PERSON 2 has not previously had a different immigration status (for example, refugee or asylee). Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

Check this box if PERSON 2 has previously had a different immigration status (for example, refugee or asylee) and you will provide the prior status. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

If PERSON 2 previously had a different immigration status, enter that prior status (for example, “refugee,” “asylee,” “parolee,” etc.); leave blank if not applicable. Fill only if '15f Previously had a different status — Yes' is 'Yes'.

Check this box if PERSON 2 is not a veteran and is not currently serving on active duty in the U.S. military. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

Check this box if PERSON 2 is a veteran or is currently serving on active duty in the U.S. military. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident', '15 Paroled for at least one year', '15 Battered noncitizen' is 'Yes' on any fields.

Check this box if PERSON 2 does not have an I-864 (affidavit of support) sponsor. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident' is 'Yes'.

Check this box if PERSON 2 does have an I-864 (affidavit of support) sponsor and you will provide the sponsor's name on the line provided. Fill only if '15 Lawful Permanent Resident (LPR) or conditional resident' is 'Yes'.

Enter the full name of the I-864 sponsor for PERSON 2 exactly as it appears on the sponsor's I-864 (Affidavit of Support). Fill only if '15h Does PERSON 2 have an I-864 sponsor? — Yes (sponsor's name)' is 'Yes'.

Check this box if PERSON 2 wants help from Medical Assistance to pay for medical bills from the past three months (if checked, answer subquestions a and b).

Check this box if PERSON 2 does not want help from Medical Assistance (if checked, skip to question 17).

Check this box if PERSON 2 is requesting Medical Assistance for the month that is one month before the month of application. Fill only if 'Q16 Yes — want help (answer a and b)' is 'Yes'.

Check this box if PERSON 2 is requesting Medical Assistance for the month that is two months before the month of application. Fill only if 'Q16 Yes — want help (answer a and b)' is 'Yes'.

Check this box if PERSON 2 is requesting Medical Assistance for the month that is three months before the month of application. Fill only if 'Q16 Yes — want help (answer a and b)' is 'Yes'.

Check this box if the information you provided on the application is the same for the selected months (i.e., the applicant's details such as income and family size did not change). Fill only if 'Q16 Yes — want help (answer a and b)' is 'Yes'.

Check this box if the information you provided on the application is not the same for the selected months (i.e., some details such as income or family size changed for those months). Fill only if 'Q16 Yes — want help (answer a and b)' is 'Yes'.

Check this box if you will file next year’s federal income tax return jointly with a spouse and write the spouse’s name on the line. Fill only if 'Yes — answer questions a, b and c' is 'Yes'.

Check this box if you will not file jointly with a spouse; answer the follow-up question about whether you will file as Married Filing Separately because of domestic abuse/spousal abandonment or as Head of Household. Fill only if '24a Yes — File jointly (name of spouse)' is 'Yes'.

Enter the full name of your spouse if you will file a joint federal income tax return next year; leave blank if you will not file jointly. Fill only if 'Yes — answer questions a, b and c' is 'Yes'.

If you checked 'No' to filing jointly, check this box if you will instead file as Married Filing Separately due to domestic abuse or spousal abandonment, or will file as Head of Household. Fill only if '24a. Spouse's name' is 'No'.

If you checked 'No' to filing jointly, check this box if you will not file as Married Filing Separately or as Head of Household. Fill only if '24a. Spouse's name' is 'No'.

Check this box if you plan to make Minnesota your home (you intend to reside in Minnesota). Fill only if 'Applying for health coverage - Yes' is 'Yes'.

Check this box if you do not plan to make Minnesota your home (you do not intend to reside in Minnesota). Fill only if 'Applying for health coverage - Yes' is 'Yes'.

Check this box if you moved to Minnesota within the past three months (and provide the move date in the adjacent date field). Fill only if 'Applying for health coverage - Yes' is 'Yes'.

Check this box if you did not move to Minnesota within the past three months. Fill only if 'Applying for health coverage - Yes' is 'Yes'.

If you answered Yes to 27b, enter the date you moved to Minnesota. Fill only if '27b Did you move to Minnesota in the last three months? – Yes' is 'Yes'.

Check this box if you entered Minnesota for the purpose of taking a job you had committed to or to look for employment. Fill only if 'Applying for health coverage - Yes' is 'Yes'.

Check this box if you did not enter Minnesota with a job commitment and were not seeking employment when you entered. Fill only if 'Applying for health coverage - Yes' is 'Yes'.

Check this box if you are visiting Minnesota to get medical care or for other personal reasons. Fill only if 'Applying for health coverage - Yes' is 'Yes'.

Check this box if you are not visiting Minnesota to get medical care or for personal reasons. Fill only if 'Applying for health coverage - Yes' is 'Yes'.

Check this box if you are not of Hispanic, Latino, or Spanish origin.

Check this box if you are of Hispanic, Latino, or Spanish origin (then mark any specific origin boxes that apply).

Check this box if you identify your Hispanic/Latino/Spanish origin as Cuban. Fill only if '28a. Yes — check all that apply' is 'Yes'.

Check this box if you identify your Hispanic/Latino/Spanish origin as Mexican, Mexican American, or Chicano/a. Fill only if '28a. Yes — check all that apply' is 'Yes'.

Check this box if you identify your Hispanic/Latino/Spanish origin as Puerto Rican. Fill only if '28a. Yes — check all that apply' is 'Yes'.

Check this box if you have a Hispanic/Latino/Spanish origin not listed here and write the specific origin on the provided line. Fill only if '28a. Yes — check all that apply' is 'Yes'.

Enter the specific Hispanic, Latino, or Spanish origin not listed in the checkboxes (for example, ‘Salvadoran’, ‘Dominican’, or another origin); leave blank if not applicable. Fill only if '28a. Yes — check all that apply' is 'Yes'.

Check this box if you prefer not to disclose whether you are of Hispanic, Latino, or Spanish origin.

Check this box if you identify as American Indian or Alaska Native.

Check this box if you identify as Asian Indian.

Check this box if you identify as Black or African American.

Check this box if you identify as Chinese.

Check this box if you identify as Filipino.

Check this box if you identify as Guamanian or Chamorro.

Check this box if you identify as Japanese.

Check this box if you identify as Korean.

Check this box if you identify as Native Hawaiian.

Check this box if you identify with an Asian group not listed above (other Asian).

Check this box if you identify with a Pacific Islander group not listed above (other Pacific Islander).

Check this box if you identify as Samoan.

Check this box if you identify as Vietnamese.

Check this box if you identify as White.

Check this box if your race is not listed and write your race in the provided space.

Enter the specific race or racial group not listed among the checkboxes for question 28b (e.g., write the other race you identify with).

Check this box if you do not want to report your race.

Check this box if you are a U.S. citizen or U.S. national (then continue to question 32).

Check this box if you are not a U.S. citizen or U.S. national (then continue to question 30).

Check this box if you do NOT want help paying for a medical emergency. Fill only if '29: No — not a U.S. citizen or U.S. national' is 'Yes'.

Check this box if you DO want help paying for a medical emergency, and provide the begin and end dates for the emergency. Fill only if '29: No — not a U.S. citizen or U.S. national' is 'Yes'.

Enter the date when the medical emergency began. Fill only if '29: No — not a U.S. citizen or U.S. national', '30. Yes (Do you want help paying for a medical emergency?)' is 'Yes' for all fields.

Enter the date when the medical emergency ended, or leave blank if it has not ended. Fill only if '29: No — not a U.S. citizen or U.S. national', '30. Yes (Do you want help paying for a medical emergency?)' is 'Yes' for all fields.

Check this box if you do NOT have any of the immigration statuses listed below and should skip to question 32.

Check this box if you DO have an immigration status listed here and will select the specific status below and answer follow-up questions.

Check this box if you are a lawful permanent resident (green card holder) or a conditional resident. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you have been admitted to the United States with refugee status. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you have been granted asylum in the United States. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you have applied for asylum and are an asylum applicant. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you were paroled into the United States and your parole has lasted at least one year. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you were paroled into the United States and your parole has lasted less than one year. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you were paroled into the U.S. from Ukraine with an entry date before 9-30-24. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you were paroled into the U.S. from Afghanistan with an entry date before 9-30-23. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if your current status is a temporary nonimmigrant classification such as visitor, student, worker, or a U visa. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you currently have Temporary Protected Status (TPS). Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you have DACA (Deferred Action for Childhood Arrivals) status. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you have a deferred action status other than DACA. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you are classified as a Cuban or Haitian Entrant. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you have an order of withholding of removal or deportation. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you are identified as a victim of severe trafficking. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you are a noncitizen who has been battered or subject to extreme cruelty. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you are an American Indian born in Canada. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you are a special Iraqi or Afghan immigrant. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you are an Amerasian noncitizen. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you are a citizen of the Marshall Islands, the Federated States of Micronesia, or Palau. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you were admitted as a conditional entrant before 1981. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you have been granted an Employment Authorization Document (work permit) that is not related to DACA. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if your immigration status is not listed above and matches an 'Other' option defined on page 21. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

If you selected "Other" for your immigration status, enter the specific status or brief description here. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Enter your Alien Registration Number (A-number) or other immigration identification number associated with this status. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Enter the date you entered the United States under this immigration status. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Enter the name or type of the immigration document that supports this status (for example, green card, visa type, or form name). Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Enter the identifying number printed on the immigration document you listed (such as card number, passport number, or visa number). Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Enter the expiration date of the immigration document provided for this status. Fill only if '31. Yes - check the box for your current status' is 'Yes'.

Check this box if you did NOT enter the United States before August 22, 1996. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

Check this box if you entered the United States before August 22, 1996. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

Check this box if you have NOT had your current immigration status for five years or more. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

Check this box if you have had your current immigration status for five years or more. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

Check this box if you have not previously held a different immigration status (for example, refugee or asylee). Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

Check this box if you previously held a different immigration status and you will list that prior status. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

If you answered that you previously had a different status, enter the prior immigration status here. Fill only if '31.f Yes - previously had a different status' is 'Yes'.

Check this box if neither you nor your spouse or parent is a veteran or an active-duty member of the military. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

Check this box if you or your spouse or parent is a veteran or an active-duty member of the military. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident', '31. Paroled for at least one year', '31. Battered noncitizen' is 'Yes' for any fields.

Check this box if you do NOT have an I-864 (affidavit of support) sponsor. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident' is 'Yes'.

Check this box if you have an I-864 sponsor and you will provide the sponsor's name. Fill only if '31. Lawful Permanent Resident (LPR) or conditional resident' is 'Yes'.

If you have an I-864 sponsor, enter the sponsor's full name here. Fill only if '31.h Yes - have an I-864 sponsor' is 'Yes'.

Check this box if you want help from Medical Assistance (MA) to pay medical bills from the past three months (then answer questions a and b).

Check this box if you do not want MA help for medical bills from the past three months (if checked, go to question 33).

Check this box if you want MA help for medical bills from one month before the month of application.

Check this box if you want MA help for medical bills from two months before the month of application. Fill only if '32: Yes — I want help from Medical Assistance (MA)' is 'Yes'.

Check this box if you want MA help for medical bills from three months before the month of application. Fill only if '32: Yes — I want help from Medical Assistance (MA)' is 'Yes'.

Check this box if everything you reported on the application (for example income and family size) is the same for the months you selected above. Fill only if '32: Yes — I want help from Medical Assistance (MA)' is 'Yes'.

Check this box if the information you reported on the application is not the same for the months you selected above. Fill only if '32: Yes — I want help from Medical Assistance (MA)' is 'Yes'.

Check this box if no one on the application is currently getting medical care for an accident or injury.

Check this box if someone on the application is currently getting medical care for an accident or injury, and provide the name(s) of the person(s) receiving care.

Enter the full name (first and last) of the person or persons who are currently getting medical care for an accident or injury. Fill only if 'Accident/Injury Care – Yes, who?' is 'Yes'.

Check this box if PERSON 2 paid qualifying educator expenses (up to $300) that they want to claim as an adjustment to income on Schedule 1 (i.e., to report the educator expense deduction).

Enter the total yearly dollar amount PERSON 2 expects to pay for qualifying educator expenses (up to $300).

Check this box if PERSON 2 expects to claim an IRA deduction as an adjustment to income (enter the yearly amount on the line to the right).

Enter the yearly dollar amount PERSON 2 expects to claim as an IRA deduction (amount expected to be paid/claimed over the next 12 months).

Check this box if PERSON 2 expects to pay student loan interest (the deductible student loan interest amount) and will list the yearly amount for the next 12 months.

Enter the amount PERSON 2 expects to pay in student loan interest over the next 12 months to be deducted from gross income.

Check this box if PERSON 2 has deductible business expenses as a reservist, performing artist, or fee-basis government official that they expect to pay (and want to report as an adjustment to income) over the next 12 months.

Enter the total amount PERSON 2 expects to pay over the next 12 months for certain business expenses of reservists, performing artists, and fee-basis government officials.

Check this box if PERSON 2 expects to claim a health savings account (HSA) deduction (contributions or allowable HSA amounts) that can be subtracted from gross income for the tax year and you will list the yearly amount on the form.

Enter the dollar amount PERSON 2 expects to pay over the next 12 months for health savings account (HSA) deductions.

Check this box if PERSON 2 expects to have moving expenses related to active duty military service that should be listed as an adjustment to income for the next 12 months.

Enter the yearly amount PERSON 2 expects to pay for moving expenses related to active duty military service that can be subtracted from gross income over the next 12 months.

Check this box if PERSON 2 can claim the deductible portion of self-employment tax as an adjustment to income and you will provide the yearly amount.

Check this box if PERSON 2 expects to pay contributions to a self‑employed SEP, SIMPLE, or other qualified retirement plan that should be reported as an adjustment to income for the next 12 months, and enter the yearly amount.

Enter the annual dollar amount PERSON 2 expects to pay or deduct for self‑employed SEP, SIMPLE, and other qualified retirement plans over the next 12 months.

Check this box if PERSON 2 expects to pay self‑employed health insurance premiums in the next 12 months that are deductible on their federal income tax return and should be included as an adjustment to income.

Enter the yearly amount PERSON 2 expects to pay for self‑employed health insurance to claim as an adjustment to income for the next 12 months.

Check this box if PERSON 2 expects to pay a penalty for early withdrawal of savings (enter the expected yearly amount on the corresponding 'Yearly amount' line).

Enter the total amount PERSON 2 expects to pay in the next 12 months for penalties on early withdrawal of savings (yearly dollar amount).

Check this box if PERSON 2 expects to pay alimony under a divorce or separation agreement dated before January 1, 2019, and enter the yearly amount in the adjacent amount field.

Enter the total yearly amount PERSON 2 expects to pay in alimony under a divorce or separation agreement dated before January 1, 2019.

Check this box if you paid alimony under a divorce or separation agreement dated before January 1, 2019 and are reporting that alimony as an adjustment to income (enter the yearly amount).

Enter the total amount of alimony you expect to pay over the next 12 months under a divorce or separation agreement dated before January 1, 2019. Fill only if 'Alimony paid (divorce or separation agreement dated before 1/1/2019)' is 'Yes'.

Check this box if PERSON 2 received alimony and the divorce or separation agreement ordering the payments is dated before January 1, 2019.

Enter the monthly amount of alimony you received under a divorce or separation agreement dated before January 1, 2019, reported before taxes and deductions.

Check this box if you received alimony under a divorce or separation agreement dated before January 1, 2019, and then report the amount and frequency.

Enter the monthly dollar amount of alimony you received under a divorce or separation agreement dated before January 1, 2019. Fill only if 'Alimony received, if your divorce or separation agreement is dated before 1/1/2019' is 'Yes'.

Check this box if neither you nor anyone in your family is American Indian or Alaska Native.

Check this box if you or anyone in your family is American Indian or Alaska Native, and you must complete Appendix B.

Check this box if you are applying for health care coverage for yourself and want to continue to question 27.

Check this box if you are NOT applying for health care coverage for yourself and want to skip to the job and income questions on page 4.

Check this box if you want someone to act on your behalf as an authorized representative (you will need to complete Appendix C).

Check this box if you do not want anyone to act on your behalf as an authorized representative.

Check this box if you paid (or expect to pay within the next 12 months) deductible business expenses as a reservist, performing artist, or fee-basis government official and you will enter the yearly amount on the line provided.

Enter the total yearly dollar amount of allowable business expenses for reservists, performing artists, and fee-basis government officials that you expect to claim. Fill only if 'Certain business expenses of reservists, performing artists, and fee-basis government officials' is 'Yes'.

Check this box if you will claim one or more dependents on your federal tax return next year and you will list their names on the form. Fill only if 'Yes — answer questions a, b and c' is 'Yes'.

Check this box if you will not claim any dependents on your federal tax return next year. Fill only if 'Yes — answer questions a, b and c' is 'Yes'.

Enter the full name(s) of any dependent(s) you will claim on your tax return; list each name separated by a comma. Fill only if '24b. Will you claim any dependents on your tax return? — Yes (list names)' is 'Yes'.

Check this box to consent to MNsure/DHS using information from your tax returns to verify and renew your eligibility for health coverage for 5 years.

Check this box to consent to MNsure/DHS using information from your tax returns to verify and renew your eligibility for health coverage for 4 years.

Check this box to consent to MNsure/DHS using information from your tax returns to verify and renew your eligibility for health coverage for 3 years.

Check this box to consent to MNsure/DHS using information from your tax returns to verify and renew your eligibility for health coverage for 2 years.

Check this box to consent to MNsure/DHS using information from your tax returns to verify and renew your eligibility for health coverage for 1 year.

Check this box to withhold consent and prevent MNsure/DHS from using information from your tax returns to verify or renew your eligibility for health coverage.

Check if the person is currently enrolled in Medical Assistance (MA) health coverage. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is currently enrolled in MinnesotaCare. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is currently enrolled in Medicare. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person has COBRA continuation health coverage. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is enrolled in health insurance provided by an employer. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is enrolled in private or any other non-listed health insurance. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is enrolled in Veterans Affairs (VA) health care programs. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person has prescription drug coverage as part of their health benefits. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is enrolled in TRICARE (do not check if coverage is direct care or line-of-duty). Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is enrolled in Peace Corps health coverage. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person is enrolled in long-term-care (LTC) insurance. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person has dental insurance coverage. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check if the person has vision insurance coverage. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the full name (first and last) of the first person listed as covered by this insurance policy. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the insurance policy number for the first person covered by this policy as shown on the insurance documents. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the full name (first and last) of the second person listed as covered by this insurance policy. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the insurance policy number for the second person covered by this policy as shown on the insurance documents. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the full name (first and last) of the first person covered by this policy listed on row 2. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the insurance policy or member ID number for the first person listed on row 2. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the full name (first and last) of the second person covered by this policy listed on row 2. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the insurance policy or member ID number for the second person listed on row 2. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check this box if PERSON 2 is currently employed by an employer and receives wages or a salary.

Check this box if PERSON 2 is currently self-employed, runs their own business, or works as an independent contractor.

Check this box if PERSON 2 works only during certain seasons or on a seasonal/temporary basis.

Check this box if PERSON 2 is currently not employed and does not have a job.

Enter the name and address of the employer that appears on your paycheck or that pays you in cash. Fill only if 'Employed' is 'Yes'.

Enter the employer's Employer Identification Number (EIN) for this job. Fill only if 'Employed' is 'Yes'.

Enter the amount of taxable wages and tips paid by this employer before taxes are deducted for the selected frequency. Fill only if 'Employed' is 'Yes'.

Enter the average number of hours you work per week at this job. Fill only if 'Employed' is 'Yes'.

Check this box if the amount you entered for taxable wages is an hourly rate (you are paid by the hour). Fill only if 'Employed' is 'Yes'.

Check this box if the amount you entered for taxable wages represents your weekly pay (you are paid once per week). Fill only if 'Employed' is 'Yes'.

Check this box if the amount you entered for taxable wages is paid every two weeks (biweekly pay). Fill only if 'Employed' is 'Yes'.

Check this box if the amount you entered for taxable wages is paid twice a month (semi-monthly pay). Fill only if 'Employed' is 'Yes'.

Check this box if the amount you entered for taxable wages is your monthly pay (you are paid once per month). Fill only if 'Employed' is 'Yes'.

Check this box if the amount you entered for taxable wages represents your yearly (annual) pay. Fill only if 'Employed' is 'Yes'.

Enter the name and full address of the employer that appears on PERSON 2's paycheck or that pays PERSON 2 in cash. Fill only if 'Employed' is 'Yes'.

Enter the Employer Identification Number (EIN) for the employer of this job. Fill only if 'Employed' is 'Yes'.

Enter the amount of taxable wages and tips paid by this employer before taxes and pre-tax deductions are subtracted. Fill only if 'Employed' is 'Yes'.

Enter the average number of hours PERSON 2 works each week at this job. Fill only if 'Employed' is 'Yes'.

Check this box if the pay frequency for Current Job 1 is hourly. Fill only if 'Employed' is 'Yes'.

Check this box if the pay frequency for Current Job 1 is weekly. Fill only if 'Employed' is 'Yes'.

Check this box if the pay frequency for Current Job 1 is every two weeks (biweekly). Fill only if 'Employed' is 'Yes'.

Check this box if the pay frequency for Current Job 1 is twice a month (semimonthly). Fill only if 'Employed' is 'Yes'.

Check this box if the pay frequency for Current Job 1 is monthly. Fill only if 'Employed' is 'Yes'.

Check this box if the pay frequency for Current Job 1 is yearly (annually). Fill only if 'Employed' is 'Yes'.

Write the full name and mailing address of the employer that appears on your paycheck or pays you in cash. Fill only if 'Employed' is 'Yes'.

Enter the employer's Employer Identification Number (EIN) exactly as issued for tax reporting (typically nine digits). Fill only if 'Employed' is 'Yes'.

Enter the total amount of taxable wages and tips expected from this employer for the next 12 months before taxes are deducted. Fill only if 'Employed' is 'Yes'.

Enter the average number of hours you work for this employer each week. Fill only if 'Employed' is 'Yes'.

Check this box if your taxable wages from Current Job 2 are paid on an hourly basis. Fill only if 'Employed' is 'Yes'.

Check this box if your taxable wages from Current Job 2 are paid weekly (once per week). Fill only if 'Employed' is 'Yes'.

Check this box if your taxable wages from Current Job 2 are paid every two weeks (biweekly). Fill only if 'Employed' is 'Yes'.

Check this box if your taxable wages from Current Job 2 are paid twice a month (semi-monthly). Fill only if 'Employed' is 'Yes'.

Check this box if your taxable wages from Current Job 2 are paid monthly. Fill only if 'Employed' is 'Yes'.

Check this box if your taxable wages from Current Job 2 are reported or expected on a yearly basis. Fill only if 'Employed' is 'Yes'.

Enter the name and full address of PERSON 2's employer for this job as it appears on pay records or paychecks. Fill only if 'Employed' is 'Yes'.

Enter the Employer Identification Number (EIN) for PERSON 2's employer for this job. Fill only if 'Employed' is 'Yes'.

Enter the dollar amount of taxable wages and tips PERSON 2 receives from this job before taxes and deductions. Fill only if 'Employed' is 'Yes'.

Enter the average number of hours PERSON 2 works per week at this job. Fill only if 'Employed' is 'Yes'.

Check this box if the amount listed for Current Job 2 (question 21.a) is paid on an hourly basis. Fill only if 'Employed' is 'Yes'.

Check this box if the amount listed for Current Job 2 (question 21.a) is paid weekly. Fill only if 'Employed' is 'Yes'.

Check this box if the amount listed for Current Job 2 (question 21.a) is paid every two weeks (biweekly). Fill only if 'Employed' is 'Yes'.

Check this box if the amount listed for Current Job 2 (question 21.a) is paid twice a month (semimonthly). Fill only if 'Employed' is 'Yes'.

Check this box if the amount listed for Current Job 2 (question 21.a) is paid monthly. Fill only if 'Employed' is 'Yes'.

Check this box if the amount listed for Current Job 2 (question 21.a) represents yearly earnings. Fill only if 'Employed' is 'Yes'.

Check this box if you are currently employed (have a job); if checked, start with question 34.

Check this box if you are currently self-employed or run your own business; if checked, answer question 38.

Check this box if you work only during certain seasons (seasonal employment); if checked, answer question 39.

Check this box if you are not currently employed (unemployed); if checked, go to question 40.

Check this box if you are self-employed and will claim the deductible portion of your self‑employment tax as an adjustment to income (enter the amount you expect to pay). Fill only if 'Self-employed' is 'Yes'.

Enter the dollar amount of the deductible portion of your self‑employment tax you expect to pay (yearly amount to be reported for adjustments to income). Fill only if 'Deductible part of self-employment tax' is 'Yes'.

Check this box if you paid or expect to pay qualifying educator expenses (up to $300) and want to report them as an adjustment to income for the next 12 months.

Enter the total yearly amount you expect to pay for qualified educator expenses (up to $300) to be claimed as an adjustment to income. Fill only if 'Educator expenses (up to $300)' is 'Yes'.

Check this box if you do NOT give consent to be contacted by email and do not want the program to send email notifications to you.

Check this box if you give consent to be contacted by email, and provide the email address on the line provided for notifications and messages.

Enter the email address where you agree to receive electronic notifications and updates about your case if you checked consent to be contacted by email. Fill only if 'OK to contact via email - Yes (provide email address)' is 'Yes'.

Check this box if someone in the household is currently enrolled in health coverage; after checking it, indicate which type(s) of coverage they have and provide the requested details.

Check this box if no one in the household is currently enrolled in any health coverage so you can proceed to the next question.

Check this box if your family size has changed since last year or you expect it to change this year (for example, due to a new baby).

Check this box if your family size has not changed since last year and you do not expect it to change this year.

Check this box if you plan to file a federal income tax return next year; selecting it means you should answer the follow-up questions a, b and c.

Check this box if you do not plan to file a federal income tax return next year; selecting it indicates you should skip to question c.

Enter the full name of PERSON 2’s former employer (company or organization) if they changed jobs or stopped working in the last six months. Fill only if 'Change jobs', 'Stop working' is 'Yes' for any of these fields.

Enter the Employer Identification Number (EIN) for PERSON 2’s former employer. Fill only if 'Change jobs', 'Stop working' is 'Yes' for any of these fields.

Check this box if you expect to claim a deduction for contributions to a Health Savings Account (HSA) and will report the expected yearly amount on this form.

Enter the yearly amount you expect to contribute or deduct for your Health Savings Account (HSA) over the next 12 months. Fill only if 'Health savings account deduction' is 'Yes'.

Enter your home street address (number and street name); do not enter a P.O. Box.

Enter your apartment, unit, or suite number for the home address, or leave blank if none.

Enter the city or town for your home address.

Enter the U.S. state where you live, using the full state name or the two-letter postal abbreviation.

Enter the ZIP code for your home address (5-digit ZIP or ZIP+4 if applicable).

Enter the county in which your home address is located.

Check this box if you are currently homeless (i.e., do not have a regular, fixed nighttime residence).

Enter the name of the county where you usually stay if you are homeless. Fill only if 'Check here if you are homeless' is 'Yes'.

Check this box if the income of any tax filer included in the application has decreased compared to last year.

Check this box if the income of no tax filer included in the application has decreased compared to last year (i.e., income did not decrease).

Enter the full name of the person listed as the policyholder on the insurance documents. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the policyholder's date of birth for the insured individual. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the name of the insurance company that issues the policy. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the date when the insurance coverage under this policy begins. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the date when the insurance coverage under this policy ends, if applicable. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the group or employer number associated with the insurance policy as shown on the card or documents. Fill only if 'Yes — check the type of coverage' is 'Yes'.

Enter the official name or plan name of the insurance policy (e.g., plan title or product name). Fill only if 'Yes — check the type of coverage' is 'Yes'.

Check this box if you received interest income; then enter the total interest amount and indicate how much of that interest is not taxable.

Enter the total annual interest income amount received before taxes and deductions. Fill only if 'Interest' is 'Yes'.

Enter the portion of the interest amount that is nontaxable. Fill only if 'Interest' is 'Yes'.

Check this box if PERSON 2 received interest income; provide the total (gross) interest amount and, on the line provided, the portion that is not taxable.

Enter the total gross interest income received by PERSON 2 for the year before taxes and deductions.

Enter the portion of the interest amount listed above that is nontaxable for PERSON 2.

Check this box if you expect to claim a deduction for contributions to an Individual Retirement Account (IRA) on your federal tax return and want to report the expected amount as an adjustment to income.

Enter the total amount you expect to deduct for an Individual Retirement Account (IRA) for Person 1 over the next 12 months. Fill only if 'IRA deduction' is 'Yes'.

Check this box if someone listed on this application is currently in jail or prison; selecting Yes means you must answer questions a–d about that person.

Check this box if no one listed on this application is currently in jail or prison and you should continue to question 6.

Enter the full name of the person who is in jail or prison, including first and last name and relationship to the applicant if relevant. Fill only if 'Is anyone in jail or prison? — Yes (answer questions a–d)' is 'Yes'.

Check this box if the person in jail or prison is currently awaiting the court's disposition of charges (their case is pending). Fill only if 'Is anyone in jail or prison? — Yes (answer questions a–d)' is 'Yes'.

Check this box if the person in jail or prison is not awaiting the court's disposition of charges. Fill only if 'Is anyone in jail or prison? — Yes (answer questions a–d)' is 'Yes'.

Enter the name of the county where this person lived immediately before entering jail or prison (use the full county name). Fill only if 'Is anyone in jail or prison? — Yes (answer questions a–d)' is 'Yes'.

Enter the full name and street address of the jail or prison facility where the person is being held, including city and state. Fill only if 'Is anyone in jail or prison? — Yes (answer questions a–d)' is 'Yes'.

Enter the offender, booking, or inmate identification number assigned by the facility, exactly as shown (include any letters or punctuation). Fill only if 'Is anyone in jail or prison? — Yes (answer questions a–d)' is 'Yes'.

Check this box if PERSON 2 received lottery or gambling winnings greater than $80,000 since January 2018, and then list the total amount of winnings and the month and year they were received.

Enter the total dollar amount of lottery or gambling winnings greater than $80,000 received since January 2018 before taxes and deductions.

Enter the month and year when the winnings were received (for example, June 2020).

Check this box if you received lottery or gambling winnings totaling more than $80,000 at any time since January 2018 (then enter the total amount and the month and year the winnings were received).

Enter the total dollar amount of lottery or gambling winnings greater than $80,000 received since January 2018. Fill only if 'Lottery or gambling winnings greater than $80,000 since January of 2018' is 'Yes'.

Provide the month and year when the winnings were received (for example, June 2019). Fill only if 'Lottery or gambling winnings greater than $80,000 since January of 2018' is 'Yes'.

Enter the mailing street address where you receive mail, including house number and street name (do not enter a PO Box).

Enter the apartment, unit, or suite number for the mailing address if applicable; leave blank if none.

Enter the city for the mailing address.

Enter the state for the mailing address (two-letter abbreviation or full state name).

Enter the postal ZIP code for the mailing address (5-digit or ZIP+4 format).

Enter the county where the mailing address is located.

Check this box if you are an active duty military member who expects to claim moving expenses (e.g., for a permanent change of station) and will report the amount you expect to pay over the next 12 months.

Enter the total amount you expect to pay for moving expenses as an active duty military member over the next 12 months. Fill only if 'Moving expenses for active duty military members' is 'Yes'.

Check this box if you receive net rental or royalty income; report the amount before taxes and deductions and enter the yearly amount on the form.

Enter the total net rental or royalty income you received for the year before taxes and deductions. Fill only if 'Net rental or royalty' is 'Yes'.

Check this box if PERSON 2 receives net rental income or royalty payments and enter the amount (yearly).

Enter the total net rental or royalty income PERSON 2 receives for the year (amount before taxes and deductions).

Check this box if anyone listed on the application was offered health insurance from a job but is not currently enrolled in that job-based coverage (even if the offer is from someone else’s job).

Check this box if no one listed on the application was offered job-based health insurance but is not currently enrolled.

Enter the name and mailing address of PERSON 2's other employer as it appears on paychecks or employer records. Fill only if 'Seasonally employed' is 'Yes'.

Enter the Employer Identification Number (EIN) for that employer, typically nine digits (include the hyphen if you normally record it). Fill only if 'Seasonally employed' is 'Yes'.

Enter an alternate phone number where we can call you, including the area code.

Check this box if the 'Other phone number' you provided is a cell (mobile) phone number.

Check this box if the 'Other phone number' you provided is a home (landline) phone number.

Check this box if the 'Other phone number' you provided is a work phone number.

Check this box if PERSON 2 expects any other taxable income within the next 12 months; then list the type, the amount, and how often it will be received.

Enter a short description of the type of other taxable income expected within the next 12 months (for example: bonus, rental, freelance income, pension).

Enter the dollar amount of that expected taxable income before taxes and deductions for the specified period.

Enter how often this income will be received (for example: weekly, biweekly, monthly, yearly).

Check this box if you expect to receive other taxable income within the next 12 months (income you would report on the IRS Form 1040) and you will provide the type, amount, and frequency in the adjacent fields.

Enter the type or source of the other taxable income you expect to receive within the next 12 months (for example: freelance, bonus, rental, royalties). Fill only if 'Other taxable income expected within the next 12 months' is 'Yes'.

Enter the dollar amount of that expected taxable income for the next 12 months. Fill only if 'Other taxable income expected within the next 12 months' is 'Yes'.

Enter how often this income is paid (for example: weekly, biweekly, monthly, yearly). Fill only if 'Other taxable income expected within the next 12 months' is 'Yes'.

Check this box if you received any other taxable income during this month — then list the type, the amount before taxes/deductions, and how often it is received.

Enter a brief description of the type or source of this other taxable income (for example: bonus, freelance work, royalty). Fill only if 'Other taxable income this month' is 'Yes'.

Enter the dollar amount of this other taxable income before taxes and deductions. Fill only if 'Other taxable income this month' is 'Yes'.

Enter how often this income is received (for example: weekly, monthly, yearly, or one-time). Fill only if 'Other taxable income this month' is 'Yes'.

Check this box if PERSON 2 received any other taxable income this month; then list the type, amount, and how often it is received.

Enter a short description of the other taxable income received this month (for example: freelance pay, bonus, rental, etc.).

Enter the amount of this other taxable income received this month (the gross amount before taxes and deductions).

Enter how often this income is received (for example: one-time, weekly, biweekly, monthly, yearly).

Check this box if you paid (or expect to pay) a penalty for withdrawing funds from a savings account early and you will list the amount you expect to pay over the next 12 months.

Enter the yearly amount you expect to pay in penalties for withdrawing savings early over the next 12 months. Fill only if 'Penalty on early withdrawal of savings' is 'Yes'.

Enter the person's date of birth.

Check this box if Person 1 is legally separated from their spouse.

Check this box if Person 1 is currently married.

Check this box if Person 1 is divorced and not currently married.

Check this box if Person 1's spouse has died and they are widowed.

Check this box if Person 1 has never been married.

Enter Person 1's first (given) name as you want it recorded on the application, without titles.

Enter Person 1's middle name or middle initial; leave this field blank if they have no middle name.

Enter Person 1's last name (family or surname) exactly as it should appear on the application.

Enter Person 1's name suffix (for example, Jr., Sr., II, III) if applicable, otherwise leave blank.

Check this box if Person 1's sex is male.

Check this box if Person 1's sex is female.

Check this box if Person 1 has a Social Security number and you will provide their SSN on the form.

Check this box if Person 1 does not have a Social Security number and you need to indicate whether they have applied for one.

Check this box if Person 1 is not applying for health coverage and chooses not to provide a Social Security number (SSN is optional in this case).

Enter Person 1’s Social Security number as a nine-digit number (do not include dashes or spaces). Fill only if 'Person 1 - Yes (I have a Social Security number)' is 'Yes'.

Check this box if Person 1 does not have an SSN but has applied for one. Fill only if 'Person 1 - No — have you applied for an SSN?' is 'Yes'.

Check this box if Person 1 does not have an SSN and has not applied for one. Fill only if 'Person 1 - No — have you applied for an SSN?' is 'Yes'.

Check this box if Person 1 does not have an SSN because they are a noncitizen who is not eligible for a Social Security number. Fill only if 'Person 1 - Applied for an SSN — No' is 'Yes'.

Check this box if Person 1 does not have an SSN because they are a noncitizen who is not authorized to work in the U.S. Fill only if 'Person 1 - Applied for an SSN — No' is 'Yes'.

Check this box if Person 1 does not have an SSN because of a religious objection to obtaining one. Fill only if 'Person 1 - Applied for an SSN — No' is 'Yes'.

Check this box if Person 1 does not have an SSN for some other reason not listed and you will provide an explanation if requested. Fill only if 'Person 1 - Applied for an SSN — No' is 'Yes'.

Check this box if Person 2 is not currently pregnant.

Check this box if Person 2 is currently pregnant; if checked, provide how many babies are expected and the due date.

Enter how many babies Person 2 is expected to have from the current pregnancy as a numeric count. Fill only if 'Person 2 - Q9: Yes (Pregnant)' is 'Yes'.

Enter the expected due date for Person 2's current pregnancy. Fill only if 'Person 2 - Q9: Yes (Pregnant)' is 'Yes'.

Check this box if Person 2 entered Minnesota with a job commitment or specifically to look for work. Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Check this box if Person 2 did not enter Minnesota with a job commitment and was not coming to Minnesota to seek employment. Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Check this box if Person 2 plans to file a federal income tax return next year (if checked, answer questions a, b, and c).

Check this box if Person 2 does not plan to file a federal income tax return next year (if checked, skip to question c).

Check this box if Person 2 will file a federal tax return jointly with a spouse. Fill only if 'Person 2 - Plans to file federal income tax return next year: Yes' is 'Yes'.

Check this box if Person 2 will not file a federal tax return jointly with a spouse. Fill only if 'Person 2 - Plans to file federal income tax return next year: Yes' is 'Yes'.

Enter the full name of the spouse Person 2 will use to file a joint federal income tax return next year. Fill only if 'Person 2 - Will file jointly with a spouse: Yes' is 'Yes'.

Check this box if Person 2 (who will not file jointly) will file as Married Filing Separately because of domestic abuse or spousal abandonment, or will file as Head of Household. Fill only if 'Person 2 - Will file jointly with a spouse: No' is 'Yes'.

Check this box if Person 2 (who will not file jointly) will not file as Married Filing Separately due to domestic abuse/spousal abandonment and will not file as Head of Household. Fill only if 'Person 2 - Will file jointly with a spouse: No' is 'Yes'.

Check this box if Person 2 is legally separated.

Check this box if Person 2 is married.

Check this box if Person 2 is divorced.

Check this box if Person 2 is widowed.

Check this box if Person 2 has never been married.

Check this box if Person 2 DID move to Minnesota within the past three months. Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Check this box if Person 2 DID NOT move to Minnesota within the past three months. Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Enter the date Person 2 moved to Minnesota. Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11', 'Person 2 - Q11b: Yes (moved to Minnesota in last three months)' is 'Yes' for all fields.

Enter Person 2's first (given) name exactly as it appears on legal documents.

Enter Person 2's middle name or middle initial; if none, leave blank or enter 'N/A'.

Enter Person 2's last (family/surname) name exactly as it appears on legal documents.

Enter Person 2's name suffix (for example, Jr., Sr., II, III) if applicable; otherwise leave blank.

Check this box if Person 2 intends to make Minnesota their primary home (plans to reside in Minnesota). Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Check this box if Person 2 does not intend to make Minnesota their primary home (does not plan to reside in Minnesota). Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Check this box if PERSON 2 was NOT pregnant at any time during the past three months.

Check this box if PERSON 2 WAS pregnant at any time during the past three months (and then provide the pregnancy end date).

Enter the date when Person 2's pregnancy ended within the past three months. Fill only if '9a. Was PERSON 2 pregnant in the past three months? — Yes' is 'Yes'.

Enter Person 2's relationship to the applicant (for example: spouse, child, friend, roommate).

Enter Person 2's date of birth.

Check if Person 2 is under age 18 and is under the legal control of a parent. Fill only if 'Person 2 - Date of Birth' indicates person is under age 18.

Check if Person 2 is under age 18 and is not under the legal control of a parent. Fill only if 'Person 2 - Date of Birth' indicates person is under age 18.

Check if Person 2's sex is male.

Check if Person 2's sex is female.

Check this box if Person 2 currently lives at the same address as the primary applicant.

Check this box if Person 2 does not live at the same address as the primary applicant, and provide Person 2's address in the space provided.

If Person 2 does not live at the same address as you, enter Person 2's full mailing/residence address (street, city, state and ZIP); leave blank if they live with you. Fill only if 'Person 2 - Residence: No (list address)' is 'Yes'.

Check this box if Person 2 already has a Social Security number and you will provide that SSN on the form.

Check this box if Person 2 does not have an SSN (then indicate below whether they have applied for one).

Check this box if Person 2 is not applying for health coverage and therefore chooses not to answer the SSN question.

Enter Person 2's Social Security Number (SSN). Fill only if 'Person 2 - Yes — what is PERSON 2's SSN?' is 'Yes'.

Check this box if Person 2 does not yet have an SSN but has already applied for one. Fill only if 'Person 2 - No — has PERSON 2 applied for an SSN?' is 'Yes'.

Check this box if Person 2 has not applied for an SSN and you must select a reason below. Fill only if 'Person 2 - No — has PERSON 2 applied for an SSN?' is 'Yes'.

Check this box if Person 2 is a noncitizen who is not eligible to receive a Social Security number. Fill only if 'Person 2 - No (has not applied for an SSN)' is 'Yes'.

Check this box if Person 2 is a noncitizen who is not authorized to work in the U.S. and therefore has not applied for an SSN. Fill only if 'Person 2 - No (has not applied for an SSN)' is 'Yes'.

Check this box if Person 2 has a religious objection to obtaining a Social Security number. Fill only if 'Person 2 - No (has not applied for an SSN)' is 'Yes'.

Check this box if Person 2 has another reason for not applying for an SSN (provide explanation if requested). Fill only if 'Person 2 - No (has not applied for an SSN)' is 'Yes'.

Check this box if PERSON 2 is visiting Minnesota specifically to get medical care or for personal reasons. Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Check this box if PERSON 2 is not visiting Minnesota to get medical care or for personal reasons. Fill only if 'Person 2 - Yes (wants to apply for health coverage) - go to question 11' is 'Yes'.

Check this box if Person 2 wants to apply for health coverage; selecting it directs you to continue to question 11.

Check this box if Person 2 does not want to apply for health coverage; selecting it directs you to the job and income questions on page 8.

Check this box if Person 2 will be claimed as a dependent on someone else's federal tax return next year; provide the name of the tax filer and relationship where requested.

Check this box if Person 2 will not be claimed as a dependent on someone else's federal tax return next year.

Enter the full name of the person (tax filer) who will claim Person 2 as a dependent on their federal tax return. Fill only if 'Person 2 - Q8c Yes (Will be claimed as a dependent)' is 'Yes'.

Enter how Person 2 is related to the tax filer who will claim them (for example: parent, spouse, sibling, guardian, etc.). Fill only if 'Person 2 - Q8c Yes (Will be claimed as a dependent)' is 'Yes'.

Check this box if Person 2 will claim one or more dependents on Person 2's own federal income tax return next year (then list the dependents' names). Fill only if 'Person 2 - Plans to file federal income tax return next year: Yes' is 'Yes'.

Check this box if Person 2 will not claim any dependents on Person 2's own federal income tax return next year. Fill only if 'Person 2 - Plans to file federal income tax return next year: Yes' is 'Yes'.

Enter the full name(s) of any dependent(s) PERSON 2 will claim on their federal income tax return next year; list multiple names separated by commas.

Check this box if you want the agency to contact you about this application by regular postal mail.

Check this box if you prefer to be contacted by email and provide your email address on the line next to this box.

Enter the email address where you want to receive communications about this application. Fill only if 'Email Address' is 'Yes'.

Enter the language you prefer to speak for communications (for example, English, Spanish, Chinese).

Enter the language you prefer to receive written materials in (for example, English, Spanish, Chinese).

Check this box if you need an interpreter to help you communicate (spoken or written) for this application.

Check this box if you do not need an interpreter to communicate for this application.

Check this box if you are not currently pregnant.

Check this box if you are currently pregnant, and provide the number of babies expected (and the due date) in the adjacent fields.

Enter the number of babies expected in the current pregnancy (for example 1, 2, 3). Fill only if 'Yes (Pregnant — how many babies are expected?)' is 'Yes'.

Enter the expected delivery date for the current pregnancy. Fill only if 'Yes (Pregnant — how many babies are expected?)' is 'Yes'.

Check this box if you were NOT pregnant at any time during the past three months.

Check this box if you WERE pregnant at any time during the past three months, and provide the pregnancy end date in the adjacent date field.

Enter the date the pregnancy ended in the past three months. Fill only if 'Were you pregnant in the past three months? — Yes' is 'Yes'.

Check this box if the application includes anyone (you or a household member) who is currently pregnant.

Enter the primary phone number where we can call you for Person 1, including area code and any extension if applicable.

Check this box if the primary phone number entered in item 18 is a cell (mobile) number and you can be reached at that number.

Check this box if the primary phone number entered in item 18 is a home (landline) number and you can be reached at that number.

Check this box if the primary phone number entered in item 18 is a work number and you can be reached at that number.

Check this box if PERSON 2 expects their total annual income for 2026 to be the same as the income already shown on this application.

Check this box if PERSON 2 expects a different total annual income for 2026 and enter the expected dollar amount in the adjacent field.

Enter the dollar amount of PERSON 2's expected total annual income for 2026 (the sum of income received to date plus expected income through December 31). Fill only if 'No – projected 2026 income different (enter amount)' is 'Yes'.

Check this box if you expect your total annual income for 2026 to be the same as the income you reported on this application.

Check this box if you do NOT expect your 2026 total annual income to match the reported amount, and enter the projected 2026 total in the adjacent dollar field.

Enter the total dollar amount you expect to receive for all income in 2026 (add income received from January 1 to today plus all income you expect to receive through December 31). Fill only if 'No — My total income expected for 2026 will be' is 'Yes'.

Check this box if no one applying has outstanding medical bills or ongoing medical expenses that can be used to meet a medical spenddown.

Check this box if at least one person applying has outstanding medical bills or ongoing medical expenses that can be used to meet a medical spenddown, and provide the name(s) on the line provided.

Enter the name(s) of the person(s) with outstanding medical bills or ongoing medical expenses that can be used to meet a medical spenddown, and include brief details such as relationship to the applicant and any known amounts or nature of the expenses. Fill only if 'Yes — who?' is 'Yes'.

Check this box if the person applying does NOT receive services from the Center for Victims of Torture.

Check this box if the person applying DOES receive services from the Center for Victims of Torture, and provide the name(s) or details of who receives the services.

Enter the name of the applicant who gets services from the Center for Victims of Torture; leave blank if no one does. Fill only if 'Q11 Yes — who?' is 'Yes'.

Check this box if no child on the application has a parent living outside of the home.

Check this box if one or more children on the application have a parent living outside of the home, and then list which child or children on the provided line.

Enter the name or names of the child or children on the application who have a parent living outside the home (list multiple names separated by commas). Fill only if 'Yes – which child or children?' is 'Yes'.

Check this box if no one on the application was in foster care on the person's 18th birthday.

Check this box if one or more people on the application were in foster care on the person's 18th birthday, and provide the name(s) on the line.

Enter the name(s) of the person or child who was in foster care on their 18th birthday (if more than one, list each name). Fill only if 'Q7 — Was anyone in foster care on that person's 18th birthday? Yes — who?' is 'Yes'.

Check this box if the person who was in foster care was receiving healthcare through Medical Assistance or another state's Medicaid program.

Check this box if the person who was in foster care was not receiving healthcare through Medical Assistance or another state's Medicaid program.

Enter the name of the state where that person was receiving Medical Assistance or another state's Medicaid program. Fill only if 'Q7 — Was this person getting healthcare through Medical Assistance/Medicaid? Yes' is 'Yes'.

Check this box if no one applying on this application is blind.

Check this box if at least one person applying on this application is blind (then list who in the space provided).

Enter the name(s) of the applicant(s) who are blind; provide the person’s full name as it should appear on the application. Fill only if 'Q8a (8a) Is anyone applying blind — Yes' is 'Yes'.

Check this box if the person applying does NOT have a physical, mental, or emotional health condition that limits their ability to perform daily activities.

Check this box if the person applying DOES have a physical, mental, or emotional health condition that limits daily activities, and provide the name(s) of the affected person(s) on the line provided.

Enter the name of the person applying who has a physical, mental, or emotional health condition that limits their ability to perform daily activities (for example bathing, dressing, or chores). Fill only if 'Q8b Yes – who?' is 'Yes'.

Check this box if no one on the application is seeking services and supports through a home and community-based services (HCBS) waiver.

Check this box if someone on the application is seeking services and supports through a home and community-based services (HCBS) waiver, and then provide the name(s) of the person(s).

Enter the full name of the person applying for or seeking home and community-based services (HCBS) waiver services. Fill only if 'Q8c Yes – who?' is 'Yes'.

Check this box if no one applying needs help paying for care in a long-term care facility (such as a nursing home).

Check this box if at least one person applying needs help paying for care in a long-term care facility, and provide the name of who needs the help.

Enter the name(s) of the person or people who need help paying for care in a long-term care facility (for example, a nursing home). Fill only if 'Q8d Yes — who?' is 'Yes'.

Check this box if no one applying has been determined blind or disabled by the Social Security Administration (SSA) or the State Medical Review Team (SMRT).

Check this box if at least one person applying has been determined blind or disabled by the SSA or SMRT, and provide the name(s) of the person(s) in the space provided.

Enter the full name of the person who has been determined blind or disabled by the Social Security Administration (SSA) or the State Medical Review Team (SMRT). Fill only if 'Q8e - Yes – who?' is 'Yes'.

Check this box if no one applying under age 21 has a chronic condition that is disabling or has been certified disabled and does not need additional services or supports.

Check this box if someone applying under age 21 has a chronic condition you believe is disabling or has been certified disabled and needs additional services or supports, and provide the person's name.

Enter the name of the child under age 21 who has (or has been certified as having) a chronic disabling condition and needs additional services or supports; leave blank if not applicable. Fill only if 'Q8f f. Yes – who?' is 'Yes'.

Check this box if no one applying is currently in or applying to a residential treatment program for mental illness or drug/alcohol dependency.

Check this box if anyone applying is currently in or applying to a residential treatment program for mental illness or drug/alcohol dependency (and provide the person's name on the line).

Enter the name(s) of the person or people applying who are currently in a residential treatment program for mental illness or drug or alcohol dependency. Fill only if 'Q9 Yes' is 'Yes'.

Enter the name of the employer you worked for or left within the past six months (optional). Fill only if 'Change jobs', 'Stop working' is 'Yes' for any fields 1 or 2.

Provide the Employer Identification Number (EIN) for that former employer to help speed up the application process (optional). Fill only if 'Change jobs', 'Stop working' is 'Yes' for any fields 1 or 2.

Check this box if PERSON 2 changed employers or started a new job at any time in the past six months.

Check this box if PERSON 2 stopped working (became unemployed or left the workforce) within the past six months.

Check this box if PERSON 2’s hours were reduced or their pay/salary was cut during the past six months.

Check this box if you have changed jobs at any time in the past six months.

Check this box if you stopped working (became unemployed) at any time in the past six months.

Check this box if, within the past six months, you began working fewer hours or experienced a reduction in salary.

Check this box if no one in the household has returned from a tour of active military duty in the last 24 months.

Check this box if someone in the household has returned from a tour of active military duty in the last 24 months; provide the person's name and the date the last active tour of duty ended.

Enter the full name of the person who returned from a tour of active military duty within the last 24 months. Fill only if 'Yes — who?' is 'Yes'.

Enter the date the person's last active tour of duty ended. Fill only if 'Yes — who?' is 'Yes'.

Enter the full name and mailing address of the seasonal employer as it appears on your paycheck or pays you in cash. Fill only if 'Seasonally employed' is 'Yes'.

Enter the Employer Identification Number (EIN) for the seasonal employer associated with the name you entered. Fill only if 'Seasonally employed' is 'Yes'.

Enter the total amount of income PERSON 2 expects to receive from seasonal employment over the next 12 months. Fill only if 'Seasonally employed' is 'Yes'.

Enter the total amount of unemployment benefits PERSON 2 expects to receive during the next 12 months. Fill only if 'Seasonally employed' is 'Yes'.

Enter the total seasonal income you expect to receive over the next 12 months. Fill only if 'Seasonally employed' is 'Yes'.

Enter the total unemployment benefit amount you expect to receive over the next 12 months. Fill only if 'Seasonally employed' is 'Yes'.

Check this box if you pay (or expect to pay) health insurance premiums for yourself as a self-employed person and want to report that deduction as an adjustment to income for the next 12 months. Fill only if 'Self-employed' is 'Yes'.

Enter the yearly dollar amount you expect to deduct for self-employed health insurance for Person 1. Fill only if 'Self-employed health insurance deduction' is 'Yes'.

Check this box if you are self-employed and you make (or expect to make) contributions to a SEP, SIMPLE, or other qualified retirement plan that you will deduct or pay over the next 12 months. Fill only if 'Self-employed' is 'Yes'.

Enter the total amount you expect to pay over the next 12 months for self‑employed SEP, SIMPLE, and other qualified retirement plans. Fill only if 'Self-employed SEP, SIMPLE and qualified plans' is 'Yes'.

Describe the kind of farming, fishing, or other self-employment work PERSON 2 does (e.g., landscaping, freelance writing, taxi driver). Fill only if 'Self-employed' is 'Yes'.

Enter the total amount of income PERSON 2 expects to earn from self-employment over the next 12 months. Fill only if 'Self-employed' is 'Yes'.

If a loss is expected, enter the total loss amount PERSON 2 anticipates from self-employment for the next 12 months. Fill only if 'Self-employed' is 'Yes'.

Enter a brief description of the type of self-employment work or business you do (for example: landscaping, freelance graphic design, online retail). Fill only if 'Self-employed' is 'Yes'.

Enter the total expected income from self-employment for the next 12 months as a numeric amount. Fill only if 'Self-employed' is 'Yes'.

If you expect a net loss from self-employment for the next 12 months, enter the loss amount here as a numeric value; leave blank if not applicable. Fill only if 'Self-employed' is 'Yes'.

Enter the date the applicant signed the form.

Check this box if you (Person 1) receive Social Security benefits as other income; enter the amount before taxes and deductions on the adjacent line.

Enter the total monthly Social Security benefit amount you receive before taxes and deductions. Fill only if 'Social Security benefits' is 'Yes'.

Check this box if PERSON 2 receives Social Security benefits as other income (before taxes and deductions) and enter the amount in the adjacent amount field.

Enter the total gross monthly Social Security benefit amount PERSON 2 receives before taxes and deductions.

Check this box if you expect to pay student loan interest during the next 12 months and want to report it as an adjustment to income on this form.

Enter the dollar amount of student loan interest you expect to pay over the next 12 months. Fill only if 'Student loan interest' is 'Yes'.

Check this box if your tax filing status has changed or you expect it to change within the next year.

Check this box if your tax filing status has not changed and you do not expect it to change within the next year.

Check this box if you received Minnesota Paid Leave benefits that are taxable and you will report the gross amount (before taxes and deductions) for the indicated frequency.

Enter the weekly amount of Taxable Minnesota Paid Leave benefits you received before taxes and deductions. Fill only if 'Taxable Minnesota Paid Leave benefits' is 'Yes'.

Check this box if PERSON 2 received Minnesota Paid Leave benefits that are taxable; enter the amount before taxes and deductions on the line provided.

Enter the total weekly amount of Taxable Minnesota Paid Leave benefits PERSON 2 receives before taxes and deductions.

Check this box if you receive taxable pension or retirement income; list the amount before taxes and deductions and indicate the payment frequency.

Enter the total pre-tax monthly amount of any taxable pensions or retirement income you receive; leave blank if none. Fill only if 'Taxable pensions or retirement' is 'Yes'.

Check this box if PERSON 2 receives taxable pension or retirement income; then list the amount before taxes and deductions and indicate the payment frequency.

Enter Person 2's taxable pension or retirement income amount before taxes and deductions for the monthly period.

Check this box if no one on the application is temporarily outside of Minnesota for more than 30 days.

Check this box if someone on the application is temporarily outside of Minnesota for more than 30 days and provide the person's name, dates, and reason in the fields that follow.

Enter the full name of the household member who is temporarily residing outside Minnesota. Fill only if 'Yes — who?' is 'Yes'.

Enter the date when the person began being temporarily outside Minnesota. Fill only if 'Yes — who?' is 'Yes'.

Enter the date when the person is expected to return to Minnesota. Fill only if 'Yes — who?' is 'Yes'.

Provide a brief explanation of why the person is temporarily outside Minnesota (for example, work, school, medical care, or family reasons). Fill only if 'Yes — who?' is 'Yes'.

Check this box if you do NOT consent to be contacted by the program via text message.

Check this box if you DO consent to be contacted by the program via text message (then provide the number that should receive texts).

Enter the phone number that should receive text message updates and reminders if you answered Yes to receiving texts. Fill only if 'Text message consent — Yes' is 'Yes'.

Check this box if no one listed on the application has ever been in the United States military.

Check this box if anyone listed on the application has ever been in the United States military (then provide who it is in the space provided).

Enter the full name(s) of the person or people on this application who have ever served in the United States military. Fill only if 'Military service – Yes' is 'Yes'.

Check this box if you (Person 1) receive unemployment benefits and will report the gross amount before taxes and deductions (enter the weekly amount).

Enter the amount of unemployment benefits you receive before taxes and deductions for the weekly period. Fill only if 'Unemployment benefits' is 'Yes'.

Check this box if PERSON 2 receives unemployment benefits; enter the amount before taxes and deductions (weekly) next to the box.

Enter the weekly amount of Person 2's unemployment benefits before taxes and deductions.

Check this box if anyone listed on the application has applied for unemployment benefits.

Check this box if no one listed on the application has applied for unemployment benefits.

Check this box if you do NOT want the agency to send a voter registration form to you or someone in your household.

Check this box if you WANT the agency to send a voter registration form to you or someone in your household who is at least 18 years old and a U.S. citizen.

Check this box if you will be claimed as a dependent on someone else's tax return and you will provide the name of the tax filer.

Check this box if you will not be claimed as a dependent on someone else's tax return.

Enter the full name of the person (tax filer) who will claim you as a dependent on their tax return. Fill only if 'Yes — name of tax filer' is 'Yes'.