Basic application for cash assistance, Food Stamps and Medical Assistance programs. Includes Facts You Should Know, Application form and Rights and Responsibilities form.
Basic application in Spanish for cash assistance, Food Stamps and Medical Assistance programs. Includes Facts You Should Know, Application form and Rights and Responsibilities form.
Eligibility determination document for a child in Long Term Care, Waiver, Kinship Care or any person under 21 not in a family.
This is the Office of Home Energy application.
This is the Office of Home Energy application in Spanish.
This form explains reporting requirements for families in the simplified reporting group and for those in the change reporting group.
Guia para registrar cambios en el programa de cupones para alimentos. This form explains in Spanish reporting requirements for families in the
simplified reporting group and for those in the change reporting group.
Form in English for reporting changes in circumstances.
Form in Spanish for reporting changes in circumstances.
A form for an employer to complete to verify employment information.
A form for the child care or other dependent care provider to complete to verify payments.
A form for an insurance company to use to verify insurance coverage.
A form to give to the bank to verify bank accounts.
This form is completed by a health provider and used to determine eligibility for federal and state programs using Social Security disability criteria.
The form is completed by the parent and school official to verify school attendance of children ages 7 - 18. This form may also be used to verify identity
for Medical Assistance programs.
This form is used to verify rent and household composition.
Form for physician to complete certifying that children and adults receiving TCA meet PPI requirements.
If you need help please call DHR Constituent Services 1-800-332-6347 8:00am - 5:00pm Monday - Friday.
Lawrence J. Hogan, Jr, Governor | Boyd K. Rutherford, Lt.Governor | Sam Malhotra, Secretary
This Page Last Revised on November 18, 2014
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