Documents To Send With Your Application



Items We Need

Items we need from you: Look below for the items to bring or mail with this form. We only need copies of these items. Keep the originals for your records. We only need items that apply to your case. For example, if you don’t have a bank account, we do not need bank statements.

|Identity |Current driver’s license or Department of Public Safety ID card. If a person has the right to act for you (as your |

|(proof of who you are) |authorized representative), that person needs to give: (1) proof of his or her identity, and (2) proof of your identity.|

|Social Security number |Social Security card or statement. (We need this only for new people added to your case.) |

|Citizenship |U.S. Passport, certificate of Naturalization, U.S. birth certificate, hospital record of birth or Medicare card. (We |

| |need this only if your status changed. Or if a new person has been added to your case.) |

|Immigration status |Registration card or papers from the U.S. Citizenship and Immigration Services. We need copies of the front and back of |

| |these forms. (We need this only if your status changed. Or if a new person has been added to your case.) |

|Legal representative |Power of attorney papers, guardianship order, court order, or similar court documents. |

|Income from a job |The last 6 pay stubs or paychecks, a statement from employer or self-employment records. |

|Social Security, pension, veterans |Award letter or pay stubs. |

|benefits, Supplemental Security Income | |

|(SSI), worker’s compensation, or | |

|unemployment benefits | |

|Child support you pay |Divorce decree, court order, or district clerk record showing how much you pay. |

|Child support you get |District clerk record or letter from parent who pays showing how much was paid and when. Must show the name, address, |

| |phone number, and signature of the parent who pays. It also must be dated. |

|Loans, gifts, and contributions |Promissory note, loan agreement, or statement from person providing the money. It must show that person’s name, address,|

|(includes someone paying bills for you) |phone number, signature, and date. |

|Bank accounts |Statements you received this month and the past 3 months. |

|Stocks, bonds, trusts, annuities |Trust agreement, annuity contract, stock certificate, bond instrument, or current statements. |

|Real estate, oil, gas, mineral rights |Current tax statements, division orders, deeds, or royalty statements. |

|Medical, dental, and private insurance |Bills, receipts, statements, or cancelled checks. |

|costs | |

|Insurance policies |Life, burial and health insurance statements showing the current value. We might also need your spouse or ex-spouse’s |

| |job-related health insurance information and policies. |

Form H5017-MEPD

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