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Sample








  
  
    

  
      





The following sample language may be useful for states which allow family or household members to choose to be non-applicants, and states that do not require Social Security Numbers (SSNs) of applicants for a separate child health program under the State Children's Health Insurance Program (SCHIP). Please review and edit for consistency with state rules.

IMPORTANT NOTICE

IF YOU NEED ANY OF THE FOLLOWING KINDS OF HELP, PLEASE ASK.

Language interpreter
	Help in filling out this form
	Form in alternate format (Braille, large print, reader for the blind)
	Accommodations for a disabilityThese services are free and will be provided to people needing these services.



Sample FormInterpreter Needed

			___________________________
			(Language Provided)
			Alternate Format

			___________________________
			(Type Provided)Assistance in Filling Out the Form Needed ________________________
			                                                                        (Provided By)Accommodation Needed ____________________________
			                                            (Accommodation Provided)NOTES:

If you are not asking for benefits for yourself or for some of the persons in the family or household, you do not have to give a social security number or information about citizenship and immigration status for yourself or for those persons.
	You only have to give us the social security numbers for persons who want help.
	You only have to give us citizenship or immigration status information for persons who want help.
	If a person who wants help does not have a social security number, we will help that person to get one. Getting a social security number will not make the application take longer.
	We may need to check income for some persons who do not want benefits. If you choose not to give social security numbers, we can check income using other information.
	Even though you do not have to do so, you can choose to give us the social security numbers of persons in the family or household who do not want benefits. If you do, we will use the social security numbers only to help get information about income. We do not share social security numbers with the Immigration and Naturalization Service.

MEDICAID/MEDICAID EXPANSION



Social Security Number: Required only for persons who want Medicaid
	Citizenship/immigration information: Required only for persons who want MedicaidSCHIP (State Children's Health Insurance Program) BENEFITS - SEPARATE PROGRAM

Social Security Number: Not required
	Citizenship/immigration information: Required only for those who want SCHIPEMERGENCY MEDICAID

Social Security Number: Not required
	Citizenship/immigration information: Not requiredFOOD STAMPS/Supplemental Nutrition Assistance Program (SNAP)

Social Security Number: Required only for persons who want food stamps
	Citizenship/immigration information: Required only for persons who want food stampsYou must give us names and other information such as income for everyone in your household even if they do not want Food Stamps. We still need to check income of household members even if they are not applying for benefits.

If a person provides information that they know is incorrect, they could be criminally prosecuted (this means you could have problems with the law).

We do not report a person to the Immigration and Naturalization Service for choosing not to give us a social security number. We do not report a person to the Immigration and Naturalization Service for not telling us their immigration and citizenship status.

We do send information about persons applying for Food Stamps to other federal agencies to check that the information is correct.

If any information is incorrect, the persons who apply may not get Food Stamps.

TANF

Social Security Number: Required only for persons who want TANF
	Citizenship/immigration information: Required only for persons who want TANFYou must answer all of the other questions about family members living with you.

If any family member does not want to give us information about their social security number, immigration or citizenship, your family cannot receive TANF. You and your family can still apply for Medicaid, SCHIP, and Food Stamps.

We may decide that certain members of your family are not eligible for TANF, but that other family members can still get benefits.

                    
  


Content created by Office for Civil Rights (OCR) Content last reviewed July 26, 2013Back to top
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