State of Illinois Department of Human Services Medical, Cash and SNAP ...
Date:
State of Illinois Department of Human Services
Medical, Cash and SNAP
Redetermination Notice
NAME: ADDRESS: ADDRESS: CITY, ST. ZIP
Tenemos este aviso en espa?ol. Para solicitar avisos en espa?ol, por Internet vaya al sitio ABE-MMC o llame al 1-800-843-6154, (TTY: 1-866-324-5553 TTY/ Nextalk, 711 TTY Relay).
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Case Number: Office Name: Office Address:
Phone: TTY: Fax: You can manage your account online at abe.
SNAP and/or Cash Redetermination Form (Interview Required)
(and) Medical Benefits Renewal Form
Your Medical Cash SNAP benefit period is ending
. If you do not complete a redetermination your
benefits will stop. To keep getting benefits without a break and to allow time for us to process your redetermination, please
complete it by
, but, no later than
.
Use one of the 3 easy ways below:
1. Complete the electronic version of this form online in ABE Manage My Case at abe.; or
2. Fill out, sign, and send us this form and all verifications we ask for.
You may send the form by mail or fax.
* Mail to Central Processing Unit, P.O. Box 19138, Springfield, IL 62763; or
* Fax the form to 1-844-736-3563; or
3. Complete your redetermination in person. Bring this form and your verifications to the office listed above.
You have the right to immediately file this Redetermination Application as long as it contains your Name, Address, and Signature. The filing of the signed form starts the application timetable.
Failure to complete the interview requirements may result in delay or denial of benefits.
You must have an interview with a caseworker to reapply for SNAP and/or Cash.
An interview is not needed for Medical Benefits. Check one of the boxes below if you are returning this form to the Family Community Resource Center. Check one of the boxes below so we can schedule your interview.
I am elderly, ill, disabled, employed, or have some other hardship and need to be interviewed by phone.
Enter Telephone Number Here: I am able to come to the office for an interview.
We will schedule your interview when your application is returned to us. If you do not keep a scheduled interview, it is up to you to ask for another one.
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination Printed by Authority of the State of Illinois -0- Copies
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State of Illinois Department of Human Services
Medical, Cash and SNAP Redetermination Notice
Date:
Case Number:
1. Do these people still live with you? Individual Name
Individual DOB
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Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
2. Are there other people living with you not listed above? If yes, list them here.
Full Name
Birth Date
Relationship
For additional persons, please attach a separate sheet.
Eats with you?
Yes
No
Yes
No
Yes
No
Yes
No
3. Does anyone get paid for working?
Yes
No If YES, enter their name below. Attach copies of the last 4 pay
stubs if paid weekly, last 2 pay stubs if paid every other week or twice a month, and the last pay stub if paid monthly.
If self-employed, attach your income and expense statement for the last 30 days. If someone got tips that are not on their pay
stubs, tell us Who?:
and the total amount of tips received in the last 30 days.
Total Tips $
List the Name of Everybody Who is Working
Name of Employer If a person works more than one job list all the employers.
Rate of Pay
How often is the person paid? Hours Worked Weekly Weekly, every 2 weeks, twice a
month, monthly, other?
Attach a sheet of paper if you need more room to list your family's income.
4. Did you or anyone start a new job? Yes
No If YES, complete the information above.
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination Printed by Authority of the State of Illinois -0- Copies
Attach a sheet of paper if you need more room to list your family's income.
COMPLETE AND SEND
Page 2 of 14
State of Illinois Department of Human Services
Medical, Cash and SNAP Redetermination Notice
Date:
Case Number:
5. Did anyone stop working, or did their job end?
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Yes
No If YES, enter name, reason and final pay date.
6. During the last 30 days did anyone receive any other income such as Child Support, Social Security, SSI, Unemployment,
VA, Worker's Compensation, Contributions, or any other money? Yes
No If YES, complete the box below.
Name
Type of Income
Amount
How Often
$ $
Attach a sheet of paper if you need more room to list your family's income.
Note: If everyone in your SNAP case receives or plans to apply for SSI, you may apply for SNAP at your local Social Security Administration (SSA) office.
You must do this by
. The SSA office will forward your application to us to process.
7. Do you expect any changes in anyone's income or employment?
Yes
No If YES, what is the change?
When do you expect this change to happen?
8. Is the address at the top of the first page your correct mailing address?
Yes
No
If NO, tell us the correct mailing address:
Our records show that you live at:
Is this correct?
Yes
No
If NO, tell us the correct address where you live:
9. How much is your:
Rent? $
Lot Rent? $
Enter any taxes and homeowner's insurance paid separately: $
Yes
No If YES, tell us who and how much:
Mortgage? $ Are any of these paid by someone else?
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State of Illinois Department of Human Services
Medical, Cash and SNAP
Redetermination Notice
Date:
Case Number:
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
10. Did you receive an energy assistance payment of $21 or more this month or in any of the last 12 months from the Low
Income Home Energy Assistance Program (LIHEAP) (in Chicago paid through CEDA)? Yes No
Answering YES will not reduce your benefits. If NO, do you pay for or are you billed separately from your rent or mortgage
for heat or air conditioning, or excess cost for heat or air conditioning?
Yes
No
Note: Air conditioning is a window air or central air conditioning unit.
If NO, do you pay any other utilities?
Yes
No If YES, what utilities?
11. Does anyone in your household pay child support? Yes
No
If YES, who makes the payments,
how much and how often?
12. Does anyone in your household pay for the care of a child or disabled adult living in your home so someone can work, attend training, or school to prepare for a job?
Yes
No If YES, who is the care for, who provides the care, how much do you pay for the care, and how often?
13. Does anyone who is age 18 or over attend a school, other than a high school, half-time or more? Yes
No
If YES, who?
14. Does someone in your unit who is 60 or older or is blind or disabled have monthly medical expenses of $36 or more that are
paid by you and not reimbursed or paid by someone else?
Yes
No
For your ( Cash and) Medical benefits, please answer the following questions.
Has any person who is receiving Cash Assistance from DHS been convicted of a felony involving drugs?
Yes No
Answer the following questions if the box is checked. Are you or is anyone who lives with you pregnant?
If YES, name?
Due date:
Expected number of babies:
Do you or anyone living with you have health insurance? If YES, name of insurance plan: Who is covered by this health insurance? Name of insurance plan: Who is covered by this health insurance?
Yes
No
Policy Number
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination Printed by Authority of the State of Illinois -0- Copies
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State of Illinois Department of Human Services
Medical, Cash and SNAP
Redetermination Notice
Date:
Case Number:
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
Answer the following questions if the box is checked.
Will you or anyone who lives with you file a federal income tax return next year to report income earned this year?
Yes
No
If YES, name of person(s) filing tax return: If this person will file jointly with a spouse, write name of spouse: If this person will claim dependents on the tax return, write name(s) of dependents:
Will you or anyone who lives with you be claimed as a dependent on anyone's tax return for this year? If YES, name of dependent: Tax filer's name and relationship to dependent:
Yes No
Do you or anyone living with you pay any expense that can be deducted on your federal income tax return?
If YES, list the expense: How often?
How much?
Yes
No
Answer the following questions if the box is checked. Do you or anyone living with you pay any of these expenses? Check all that apply.
Spousal support paid to someone else
How much?
How often?
Student loan interest paid
Employment expenses (lunches/meals, tools, uniforms, union dues)
How much? How much?
How often? How often?
Child Support Child care expenses Other:
How much? How much? How much?
How often? How often?
How often? (Continued)
IL444-1893 (R-01-18) Medical, Cash and SNAP Redetermination Printed by Authority of the State of Illinois -0- Copies
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Date:
State of Illinois Department of Human Services
Medical, Cash and SNAP
Redetermination Notice
Case Number:
Do you or anyone living with you own other resources (assets)? Check all that apply.
Cash and bank accounts Life insurance (cash value) Nursing home residence account Burial funds Certificate of deposit Annuities Trust funds Oil, coal, gas, mineral rights Car, truck or motor vehicle Mutual funds, stocks, bonds 401(k), IRA or Keough accounts Loan (Money that is owed to you) Inheritance Other property or land Other:
What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $ What is the value? $
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Attach proof showing who owns these resources and the current value. You do not need to attach proof of the value of the vehicle or your home.
Answer the following questions if the box is checked.
Do you own or pay on a house or mobile home?
If YES: a. Do you regard the property as your home and intend to return to it? b. Does your spouse, minor child, disabled child, or your dependent brother or sister live in the property? c. Is the property vacant? d. Does the property produce income? e. Is the property listed for sale?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
(Continued)
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Date:
State of Illinois Department of Human Services
Medical, Cash and SNAP
Redetermination Notice
Case Number:
Do you own or pay on any other land or buildings? If YES: a. Is the property listed for sale? b. Does the property produce income?
Answer the following questions if the box is checked.
Do you have life insurance?
Yes
No
Name of Company Policy Number
Name of Company
Policy Number
Do you have health insurance? Does it cover long term care? Name of Company Premium Amount $
Yes
No
Yes
No
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Yes
No
Yes
No
Yes
No
Face Value $ Face Value $
Policy Number How Often Paid
Do you have other insurance? Does it cover long term care? Name of Company Premium Amount $
Yes
No
Yes
No
Policy Number How Often Paid
(Continued)
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Date:
State of Illinois Department of Human Services
Medical, Cash and SNAP
Redetermination Notice
Case Number:
0dc34c1e-5492-4ced-99ae-161cee6bf3dc
Transfer of Resources During the past year, have you: * Sold or given away any resources such as cash, house, land, insurance, stocks, certificates of deposit, etc.? * Closed any savings, checking or other financial institution accounts?
* Changed the way any resource is held? This includes, but is not limited to, adding a name to a house or deed or creating a trust.
Yes
No
Yes
No
Yes
No
If YES to any of the above, enter the following information about each transfer:
1. Person who Transferred the resources:
Description of resources:
Date transferred:
Value
Amount Received
Action taken (check only one):
Resources Sold
Resources Given Away
Change in Ownership
If ownership changed, describe the change in the way the resource is held:
Reason for Transfer:
2. Person who Transferred the resources:
Description of resources:
Date transferred: Action taken (check only one):
Value
Amount Received
Resources Sold
Resources Given Away
Change in Ownership
If ownership changed, describe the change in the way the resource is held:
Reason for Transfer: If more transfers were made, please attach an additional page. During the past year, have you spoken with a financial planner or an attorney?
Yes
No
(Continued)
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