Printable PEAK Application

Transcription

1 Printable PEAK Application **Keep in mind that you do not need to mail this print-out to your local application site.** Log in to your PEAK Account today to begin managing your benefits. Angeline Leilani Mesngon, your application has been submitted to El Paso on 12/30/ :10. In your application, you have asked for these benefits: Medical Assistance (including Health First Colorado (Colorado Medicaid), CHP+, Tax Credits, and Cost Sharing Reductions) Basic Information Your Name Date of Birth Gender County Angeline Leilani Mesngon 06/11/1991 Female El Paso I have no home address/i am homeless right now. Preferred Spoken Language American Sign Language Preferred Written Language English Where You Live 2102 BLESIDE DR COLORADO SPRINGS, Colorado Home Phone Cell Phone Message/Work Phone Message/Work Type Mailing Address BLESIDE DR COLORADO SPRINGS, Colorado Address angmesngon@gmail.com Secondary Phone Secondary Phone Type Address tification Method angmesngon@gmail.com US Mail People In Your Home 1 of 11

2 Person: Angeline Leilani Mesngon Date of Birth Gender Marital Status 06/11/1991 Female Married Language Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? Programs received out of state Received from which state Last date person received benefits Programs Requested Medical Assistance (including Health First Colorado (Colorado Medicaid), CHP+, Tax Credits, and Cost Sharing Reductions) Backdate Month for Medical Assistance Has this person applied for a Social Security Number? SSN Reason for not applying? TIN US Citizen? Citizenship Status n-citizenship status n-citizen Document? US Born n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Date Asylum Granted Document Number: Card Number Class Code Spouse or parent a veteran or active-duty member U.S. military? Document Type Was Angeline a U.S citizen in June,May or April? Was Angeline's non-citizenship status different in May,April or March? Month the change occurred n-citizen n-citizen/document n-citizen/document 2 of 11

3 n-citizenship status Document? Number Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Document Type Date Asylum Granted Document Number: Card Number Class Code Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Where does this person live? Is this person living outside of Colorado temporarily? Living in Colorado when he or she returns Has this household member passed away in the coverage year? Date of Death Did this person move in to the household in May,April or March? When did this person move in? Has this person moved out of the household in May,April or March? When did this person move out? Funeral Preference Ethnicity Race Does this person plan to file a Federal Income Tax Return? Does this person expect to be claimed as tax dependent on someone else's tax return? What is this person's tax filing status? Exceptional circumstances apply to this persons case. Married Filing Jointly Is this person living with both parents, but the parents do not expect to file a joint return? Does this person expect to be claimed by a non-custodial parent? Did this person file a Federal Income Tax Return in 2014? Was this person claimed as a tax dependent on someone else's tax return in 2014? Did this person live with both parents, but the parents did not file a joint return in 2014? Was this person claimed by a non-custodial parent in 2014? Secondary Account Holder Does this person have an individual shared responsibility exemption? Exemption Certificate Number Has health insurance coverage? Person: Donovan Mesngon Age: 26 3 of 11

4 Date of Birth Gender Marital Status 08/13/1989 Male Married Language Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? English Programs received out of state Received from which state Last date person received benefits Programs Requested Medical Assistance (including Health First Colorado (Colorado Medicaid), CHP+, Tax Credits, and Cost Sharing Reductions) Backdate Month for Medical Assistance Has this person applied for a Social Security Number? SSN Reason for not applying? TIN US Citizen? Citizenship Status n-citizenship status n-citizen Document? US Born n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Date Asylum Granted Document Number: Card Number Class Code Spouse or parent a veteran or active-duty member U.S. military? Document Type Was Donovan a U.S citizen in June,May or April? Was Donovan's non-citizenship status different in May,April or March? Month the change occurred n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration 4 of 11

5 n-citizen/document Country of Issuance Alternate Name on n-citizen/document Document Type Date Asylum Granted Document Number: Card Number Class Code Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Where does this person live? Is this person living outside of Colorado temporarily? Living in Colorado when he or she returns Has this household member passed away in the coverage year? Date of Death Did this person move in to the household in May,April or March? When did this person move in? Has this person moved out of the household in May,April or March? When did this person move out? Funeral Preference Ethnicity Race Does this person plan to file a Federal Income Tax Return? Does this person expect to be claimed as tax dependent on someone else's tax return? What is this person's tax filing status? Exceptional circumstances apply to this persons case. Married Filing Jointly Is this person living with both parents, but the parents do not expect to file a joint return? Does this person expect to be claimed by a non-custodial parent? Did this person file a Federal Income Tax Return in 2014? Was this person claimed as a tax dependent on someone else's tax return in 2014? Did this person live with both parents, but the parents did not file a joint return in 2014? Was this person claimed by a non-custodial parent in 2014? Secondary Account Holder Does this person have an individual shared responsibility exemption? Exemption Certificate Number Has health insurance coverage? Marital Status Information 5 of 11

6 Person Due Date Number of Babies Expected Has Angeline's pregnancy ended? Angeline Mesngon 08/23/ How did Angeline's pregnancy end? When was Angeline's expected due date? How many babies did Angeline have? Relationship Information Person Relationships Do they buy food and eat meals together? Tax Dependents Angeline Mesngon is the Wife of Donovan Mesngon Responsible Relative American Indian / Alaska Native You've told us that no one in your home is a member of a tribe, or receiving or eligible for Indian or Tribal health services. Legal Information Angeline's Legal Information Prosecution, Custody, Jail, Parole Probation Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Released from Incarceration Current Incarceration Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Donovan's Legal Information Prosecution, Custody, Jail, Parole Probation Food Assistance or Cash Assistance Disqualification Avoiding Prosecution 6 of 11

7 Probation / Parole Drug Felony Conviction Released from Incarceration Current Incarceration Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Questions About the People In Your Home Person: Angeline Mesngon Age:24 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Released from Incarceration Current Incarceration Housing Assistance Food Assistance LEAP/SSI/OAP/Refugee Medical Assistance Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Job Search Person: Donovan Mesngon Age:26 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification 7 of 11

8 Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Released from Incarceration Current Incarceration Housing Assistance Food Assistance LEAP/SSI/OAP/Refugee Medical Assistance Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Job Search Early and Periodic Screening, Diagnostic and Treatment (EPSDT) and Healthy Communities Special Services? Emergency Room Visit? Pregnancy? Blind or Disabled? ne N/A Living in a Medical / Nursing Facility? Job Income Information Person: Donovan Mesngon Age: 26 Name of Employer Address of Employer Job Start Date Job end date Pauley Construction, Inc Seasonal? Commission-based? Minister Compensation? Tribal Income? 8 of 11

9 How Often Paid Recent Paycheck Gross Pay Gross Amount Weekly 12/24/2015 Salary $ Housing Allowance Amount Portion of tribal income from specified sources Hours Actual Annual Amount for 2015 Actual Projected Amount Actual Annual Amount for $ $ $ One time payment from this Employer Date one time payment received Will income from this source be the same or lower in the calendar year? Job Income Deduction Information In-Kind Income Self-Employment Information Household Tax Information Person Relationships Tax Dependents Joint Filing Angeline Mesngon is the Wife of Donovan Mesngon Tax Deductions Information You told us that no one in your home has Tax Deductions Information WIC Information Currently enrolled in WIC? Want WIC to contact you? Other Job Income Questions 9 of 11

10 Person Angeline Mesngon Donovan Mesngon Age: 26 Left or Lost a Job Other Income Questions Person Grants, Loans or Scholarships Room and Meals Past Employment Angeline Mesngon Donovan Mesngon Age: 26 Other Income Information Past Employment Information Actual Projected Amount Actual Annual Amount for 2015 Actual Annual Amount for 2016 $ $ Past Expenses/Deductions Actual Projected Amount Actual Annual Amount for 2015 Actual Annual Amount for 2016 Medicare Information Health Insurance Information TRICARE, Peace Corps, or Other state or federal health program 10 of 11

11 You told us that no one in your home has TRICARE, Peace Corps, or Other state or federal health program. Employer Health Coverage Information You told us that no one in your home has Health Coverage. School Enrollment Information Current Employer Sponsored Health Coverage Information You told us that no one in your home has Employer Health Coverage. COBRA, Retiree, Railroad Retirement, or Veteran's Health Plan Information You told us that no one in your home has COBRA, Retiree, or Veteran's Health Plan Information. Electronic Signature By signing this form, I certify that I have reviewed this application; I understand and agree to the Rights, Responsibilities and Penalties and under penalty of perjury, I certify the information I have given is true including the information concerning citizenship and alien status. I have received information on how to apply, what information is available, and what I may need to give the county to help me with getting benefits. By checking this box and typing my name below, I am electronically signing my application. Angeline L Mesngon 12/30/ :10 11 of 11