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Sample

(The following sample language may be useful for states which allow family or household members to choose to be non-applicants, and states that do not require SSNs of applicants for a separate child health program under SCHIP. Please review and edit for consistency with state rules.)

IMPORTANT NOTICE

IF YOU NEED ANY OF THE FOLLOWING KINDS OF HELP, PLEASE ASK.

  • Language interpreter
  • Help in filling out this form
  • Form in alternate format (Braille, large print, reader for the blind)
  • Accommodations for a disability

These services are free and will be provided to people needing these services.

 

Interpreter Needed ___________________
                            (Language Provided)

Alternate Format Needed ___________________
                                     (Type Provided)

Assistance in Filling Out the Form Needed ___________________
                                                            (Provided By)

Accommodation Needed _______________________
                                 (Accommodation Provided)

NOTICE:

When you fill out this form, please remember to keep this information in mind.

  • If you are not asking for benefits for yourself or for some of the persons in the family or household, you do not have to give a social security number or information about citizenship and immigration status for yourself or for those persons.
  • You only have to give us the social security numbers for persons who want help.
  • You only have to give us citizenship or immigration status information for persons who want help.
  • If a person who wants help does not have a social security number, we will help that person to get one. Getting a social security number will not make the application take longer.
  • We may need to check income for some persons who do not want benefits. If you choose not to give social security numbers, we can check income using other information.
  • Even though you do not have to do so, you can choose to give us the social security numbers of persons in the family or household who do not want benefits. If you do, we will use the social security numbers only to help get information about income. We do not share social security numbers with the Immigration and Naturalization Service.

MEDICAID/MEDICAID EXPANSION

You only have to give us the social security numbers for those who want Medicaid. You only have to give us citizenship and immigration information for those who want Medicaid.

SCHIP (State Children's Health Insurance Program) BENEFITS - SEPARATE PROGRAM

You do not have to give us any social security number information.

You only have to give us citizenship and immigration information for those who want SCHIP.

EMERGENCY MEDICAID

If you want emergency Medicaid only, you do not have to give any social security number or immigration information.

FOOD STAMPS

You only have to give us social security numbers for those who want Food Stamps.

You only have to give us citizenship and immigration information for those who want Food Stamps.

You must give us names and other information such as income for everyone in your household even if they do not want Food Stamps. We still need to check income of household members even if they are not applying for benefits.

If a person provides information that they know is incorrect, they could be criminally prosecuted (this means you could have problems with the law).

TANF

You only have to give us social security numbers for those who want TANF.

You only have to give us citizenship and immigration information for those who want TANF.

You must answer all of the other questions about family members living with you.

(The following sample language may be useful for states which allow family or household members to choose to be non-applicants, and states that do not require SSNs of applicants for a separate child health program under SCHIP. Please review and edit for consistency with state rules.)

IMPORTANT NOTICE

IF YOU NEED ANY OF THE FOLLOWING KINDS OF HELP, PLEASE ASK.

  • Language interpreter
  • Help in filling out this form
  • Form in alternate format (Braille, large print, reader for the blind)
  • Accommodations for a disability

These services are free and will be provided to people needing these services.

 

Interpreter Needed ___________________
                            (Language Provided)

Alternate Format Needed ___________________
                                     (Type Provided)

Assistance in Filling Out the Form Needed ___________________
                                                            (Provided By)

Accommodation Needed _______________________
                                 (Accommodation Provided)

NOTICE:

  • In some cases, you do not have to give us immigration and citizenship information for all persons in the family or household. Please read the instructions carefully.
  • In some cases, you do not have to give us social security numbers for all persons in the family or household. Please read the instructions carefully.
  • You can decide to give us the social security number of a person in the family or household even when you do not have to do so. We do not share social security numbers with the Immigration and Naturalization Service.
  • If a person who wants help does not have a social security number, we will help get one. Getting a social security number will not make the application take longer.

MEDICAID/MEDICAID EXPANSION

You only have to give us the social security numbers for those who want Medicaid. You only have to give us citizenship and immigration information for those who want Medicaid.

SCHIP (State Children's Health Insurance Program) BENEFITS - SEPARATE PROGRAM

You only have to give us the social security numbers for those who want SCHIP.

You only have to give us citizenship and immigration information for those who want SCHIP.

EMERGENCY MEDICAID

If you want emergency Medicaid only, you do not have to give any social security number or immigration information.

FOOD STAMPS

If a person in your household does not want to give us a social security number, or information about immigration or citizenship, that person will not be eligible for Food Stamps.

We will still decide whether other persons in your household can get Food Stamps.

We do not report a person to the Immigration and Naturalization Service for choosing not to give us a social security number.

We do not report a person to the Immigration and Naturalization Service for not telling us their immigration and citizenship status.

We do send information about persons applying for Food Stamps to other Federal agencies to check that the information is correct.

If any information is incorrect, the persons who apply may not get Food Stamps.

If a person provides information that they know is incorrect, they could be criminally prosecuted (this means they could have problems with the law).

TANF

  1. You must give us information on citizenship, immigration status, and social security numbers for everyone in your family.
  2. If any family member does not want to give us information about their social security number, immigration or citizenship, your family cannot receive TANF.
  3. You and your family can still apply for Medicaid, SCHIP and Food Stamps.
  4. We may decide that certain members of your family are not eligible for TANF, but that other family members can still get benefits.