DEMOGRAPHICS. Last (Please Print) First MI. Street/Avenue (Please Print)
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1 Application Date: DEMOGRAPHICS County Office: Social Security #: Birth Date: / / Gender: [ ] Male [ ] Female Last & First Name: Last (Please Print) First MI Maiden Name: (If applicable) Current Address: City, State, Zip: Street/Avenue (Please Print) How long at this address: County: Mailing Address: Street, City, State,Zip: CONTACT DETAILS Phone # s: Cell Phone: Home Phone: Marital Status: DETAILS Divorced Married or Common Law Separated Single (Never Married) Widowed Race: White Asian or Pacific Islander Other(biracial; Sudanese; etc) Native American Black or African American Unknown Ethnicity: Hispanic or Latino Non Hispanic or Latino US Citizen? Yes No Legal Status: Voluntary Involuntary, civil commitment Voluntary, criminal commitment Veteran Status: Military Branch: Type of Discharge: Discharge Date: RESIDENTIAL ARRANGEMENTS Alone-Private Residence 24 Hr Habilitation RCF/ID Correctional Facility w/relatives-private Residence 24 Hr SCL RCF/PMI Foster Care Family Life Home w/unrelated Persons-Private Residence ICF/ID Residential Care Facility Other (Specify): Homeless/Shelter/Street ICF/Nursing Home State MHI Is this a treatment center? ICF/PMI State Resource Center If yes, location: OTHERS IN HOUSEHOLD First and Last Name: Relationship: Date of Birth: Revised Date 2/1/2018 1
2 LEGAL REPRESENTATIVE, CONSERVATOR, POWER OF ATTORNEY OR PROTECTIVE PAYEE Do you have a legal representative, conservator, power of attorney or protective payee? Yes No Legal Representative Protective Payee Conservator Power of Attorney EDUCATION LEVEL REFERRAL SOURCE None Years of Education: Community Corrections Physician H.S. Diploma Family and/or Friends RCF/ICF GED Hospital Self Associates Social Service Other Bachelors or Higher CURRENT EMPLOYMENT STATUS Employed, Full Time Retired Unemployed, available for work Employed, Part Time Seasonally employed Unemployed, unavailable for work Homemaker Sheltered work employment Vocational Rehabilitation In the Armed Forces Student Volunteer Other, Not applicable Supported employment Work Activity Employment HEALTH INSURANCE TYPE No Insurance Medicare MEPD-Medicaid for Employed Persons w/disabilities Other Private Third Party Health Insurance Iowa Medicaid (Iowa DHS) Policy #: Medicaid State ID #: Name of Health Insurance Plan: MCOs (circle one if applicable): 1. Amerigroup 2. UnitedHealthcare (UHC) APPLICATION FOR BENEFITS If you are NOT already receiving any benefits, have you applied for any of the following? FIP Health Insurance Care Coverage RR-Railroad Retirement Benefits SSDI (Social Security Disability) SSI (Supplemental Security Income) SS (Social Security Retirement) Unemployment Compensation Veteran s Benefits Workers compensation What is the status of your benefit application(s) Approved, but not started Denied Pending Other Revised Date 2/1/2018 2
3 FINANCIAL DISCLOSURE of INCOME and RESOURCES Monthly Income Source: $ GROSS (Check Type, Fill in amount) Employment Wages Child Support Received Dividend interest Family & Friends FIP RR-Railroad Retirement Benefits SS-Social Security Retirement SSI (Supplemental Security Income) SSDI (Social Security Disability) Unemployment Compensation Veterans Benefit Workers Compensation Other (please specify) GROSS MONTHLY INCOME DETAILS Applicant Others in Household TOTAL INCOME: HOUSEHOLD RESOURCES Resource Type: (Check all that apply) Applicant Others in Household Location Cash on hand Checking Account Saving Account Annuity Certificate of Deposit (CD s) Individual Retirement Account (IRA) Trust Funds Stocks & Bond Whole Life Insurance (cash value) Other Resources (List type): TOTAL RESOURCES: Vehicle Value: Year: Property/Business Interest Type: Address: Revised Date 2/1/2018 3
4 Name: CURRENT CASE MANAGER, SOCIAL WORKER, CARE COORDINATOR Agency Name: City, Zip Code Name EMERGENCY CONTACT Relationship: City, Zip Code Name: PERSON COMPLETING THE FORM (IF OTHER THAN APPLICANT) Relationship: City, Zip, Code Required Documents to validate data listed in application: Picture ID Proof of Social Security # Proof of Address Proof of Income Services Requested: Mental Health Services Residential Services Vocational Services Other Services-Please list: Letter of Court Appointment (If applicable) Disability Group: (40) MI (42) ID (43) DD (47) BI Diagnosis (if known): Revised Date 2/1/2018 4
5 PLEASE READ BEFORE SIGNING Your application must be complete or there may be a delay in the funding decision. If you need assistance to complete this application, please contact your local county office. I agree to inform the local county office of any changes provided in this application within 10 days of the change. I understand I may be expected to contribute toward the cost of my services after receiving a Notice of Decision. This includes client participation at a Residential Care Facility. Failure to comply with the Notice of Decision may result in the termination of funding. I hereby attest that the information I have provided is true and correct to the best of my knowledge. I also give permission to release this information to verify and/or communicate eligibility for the assistance requested. I also understand that this is a government document and if I knowingly provide false information, the Region has the right to pursue collection of funds. x Signature of Applicant Date x Signature of Legal Representative Date (Application must be signed or witnessed and dated to be considered for assistance.) RIGHT OF APPEAL If you do not agree with the action of the local County office or the Region you may request a reconsideration of the decision. You will receive a Notice of Decision that will explain the appeal process. REGIONAL CONTACT INFORMATION County Member: Cedar County Clinton County Jackson County Muscatine County Scott County Cedar County Courthouse 400 Cedar St Tipton IA, Clinton County Administrative Building 1900 N 3 rd St Clinton IA, Jackson County Courthouse 201 W Platt St Maquoketa, IA Muscatine County Community Services 315 Iowa Ave Suite 1 Muscatine, IA Scott County Administrative Center 4 th Floor 600 W 4 th St Davenport, IA Revised Date 2/1/2018 5
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