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H. AUXILIARY GRANTS (AG) (continued)

 YES  NO 12. Does anyone have any life insurance? If YES, provide information about each policy. List each policy separately. Attach a separate sheet if necessary.

Owner

Person Insured

Type of Insurance  Whole Life  Term Face Value $ Cash Value $ Company Name

Policy Number

Owner

Person Insured

Type of Insurance  Whole Life  Term Face Value $ Cash Value $ Company Name

Policy Number

Owner

Person Insured

Type of Insurance  Whole Life  Term Face Value $ Cash Value $ Company Name

Policy Number

An application for AG is also an application for Medicaid. The following questions will help determine Medicaid eligibilty through the Department of Social Services or possible eligibility for Advanced Premium Tax Credits (APTC) for private health insurance through the Federal Marketplace (Healthcare.gov).

 YES  NO 13. Does anyone have health insurance? If Yes, complete the following:

Policy Holder: Person(s) Insured: Company Name, Address, Phone: Coverage Type: Begin Date: / / End Date: : / / ID Number: Premium Amount: $

 YES  NO 14. Does anyone have Medicare?

Person Insured Claim Number Coverage

 Part A  Part B

 Part A  Part B

15. List the names of everyone expected to be included on the same tax return as you for this year, whether or not they live in the same home as you. For anyone in the home that does not file taxes and does not expect to be on anyone else’s tax return, list those names under “Non-filer(s)”.

Tax Filer:

Joint Taxpayer:

Tax Dependent(s):

Non-filer(s):

I. Authorized Representative An authorized representative may apply for benefits on your behalf or receive copies of your program notices. Your representative may also receive and use your SNAP benefits on your behalf. If you want to name an authorized representative, please give the information below about the representative and what you want the representative to do on your behalf. Note that you may have only one representative who can access your benefits.

Name, Address and Telephone Number of the Authorized Representative Check () each duty authorized for that person

 Apply for benefits  Receive correspondence  Access or use SNAP benefits

 Apply for benefits  Receive correspondence  Access or use SNAP benefits

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