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Household Composition Social Security Number Application for other Benefits Immigration Status Caretaker Relative Data Source To Be Used at Electronic Data Source Used Application (Y/N) (Y/N) 12. PARIS* YES NO NO NO NO NO NO NO NO NO NO YES YES Citizenship Pregnancy Residency Medicare Age/DOB Other Data Source Used at Renewal (Y/N) YES Data Source Used Post- Enrollment (Y/N) YES If Used for Post- Enrollment Frequency Used (i.e. monthly, quarterly) Other (specify in comments) Comments Used to identify Medicaid benefits in other states. PARIS is pulled at each application and reviewed with our data brokering system. If information is inconsistent with the client statement, we would seek to clarify that info. Utah is entering into an agreement with Utah's Veteran's Administration to share the names of Medicaid applicants who have been identified as eligible for, but not receiving, VA benefits. * Under 42 CFR 435.945(d), all State Medicaid eligibility systems must conduct a match with PARIS for Interstate benefit information. If used for other purposes, please indicate in Section D. MAGI-BASED ELIGIBILITY VERIFICATION PLAN SECTION B2 - Use of Electronic Data Sources, Non-Financial 13