HomeMy WebLinkAboutApplication For AssistanceApplication for Assistance
HW 2000 | REV 05/22/2025
Food Assistance
The Supplemental Nutrition Assistance Program (SNAP) helps families buy
food for good health. Eligible families get a debit-like card to buy food
items. Participants may be required to participate in work programs and
cooperate with Child Support Services. Benefits are prorated from your
application date.
Cash Assistance
The Temporary Assistance for Families in Idaho program (TAFI) provides
cash assistance for emergency situations to families with children. Eligible
families receive a one-time or ongoing payment, depending on the needs
of the household. The Aid to the Aged, Blind, and Disabled (AABD)
program provides cash assistance to individuals eligible for SSI and who
meet other guidelines.
Medical Assistance
Medicaid offers healthcare coverage for individuals that addresses a
variety of health needs, including coverage for low-income adults,
children, pregnant women, the elderly, and people with disabilities.
Child Care Assistance
The Idaho Child Care Program (ICCP) helps parents and caretakers pay for
a part of their child care costs while working, going to school, or
participating in approved training activities. Eligible families receive a
portion of child care costs paid to the provider.
WHO
can use this application
Anyone can use this application to:
Apply for assistance for themselves and/or their household members
Apply for just one type of assistance or for multiple types of assistance
WHAT
you may need to provide to
apply
Attaching proof of the household's income to this application may help us determine your eligibility faster.
We may need other proof, such as verification of resources or expenses, to process your application, but we will
ask for this only if we need it.
RESOURCES
to help with this application
Online: healthandwelfare.idaho.gov
Phone: 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice)
Email: MyBenefits@dhw.idaho.gov
In person: Visit our website or call using the number above to find a local office.
Language interpretation is available at 1-877-456-1233. See the back of this page for more information on
accessibility and interpretation services.
WHY
we ask for this information
We keep all information private and secure, as required by law. We ask for this information for a few reasons:
To figure out what types of assistance you qualify for
To figure out how much assistance you qualify for
To make sure you get the right amount of assistance based on your situation
Equal opportunity for applicants
In accordance with federal law and U.S. Department of Agriculture (USDA) and Health and Human Service
(HHS) policy, the Idaho Department of Health and Welfare is prohibited from discriminating on the basis of
race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination
is prohibited on the basis of religion or political beliefs. To file a complaint of discrimination, contact USDA or
HHS at:
U.S. Department of Agriculture U.S. Department of Health & Human Services
Office of the Assistant Secretary for Civil Rights Room 506F, 200 Independence Avenue, SW
1400 Independence Avenue, SW Washington, D.C. 20201
Washington, D.C. 20250-9410
Fax: 202-690-7442 Email: OCRcomplaint@hhs.gov
Email: program.intake@usda.gov Phone: 202-619-0403 (Voice)
202-619-3257 (TTY)
HOW
to submit this application
Send your complete, signed application to:
Self-Reliance Programs - Statewide Application Team Fax: 1-866-434-8278
PO Box 83720 Email: MyBenefits@dhw.idaho.gov
Boise, ID 83720-0026
Eligibility determinations are based on the rules and requirements which pertain to the program you are
applying for. We will tell you if you're eligible or not, or give you further instructions for completing your
application. You also can check the status of your application online at idalink.idaho.gov.
Accessibility and interpretation services
The Idaho Department of Health and Welfare (IDHW) offers the following services free to you. Please ask if you need the following assistance to
communicate more effectively with us:
Assistance in understanding this form
Accommodation for a disability
Language Interpreter
To access any of these services, please call: 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice) for those with a hearing
impairment.
Appeal/Hearing rights
You have the right to ask for a hearing if you disagree with the Department's action. You have 90 days to ask for a hearing for Food
Stamps (SNAP), Aid to the Aged, Blind, or Disabled (AABD) cash, and AABD Medicaid. You have 30 days to ask for a hearing for all other
programs including Idaho Child Care Program (ICCP), Temporary Assistance for Families in Idaho (TAFI), and all other Medicaid programs.
These timeframes start the date the Department gave or mailed you a notice.
Please be advised that a re-evaluation of eligibility will be assessed for all members of the household at the time this appeal is considered.
Request a hearing or a legal aid referral via one of the following methods:
Call 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice)
Email us at MyBenefits@dhw.idaho.gov
Fill out and submit the Fair Hearing Request Form at mybenefitforms.dhw.idaho.gov.
At the hearing, you may represent yourself or use legal counsel, a relative, a friend, or other spokesperson to represent you.
idalink
idalink is Idaho's online self-service website where you can view information about the benefits you receive,
report a change, and apply for Medicaid programs offered by IDHW. Registering is easy.
Visit idalink.idaho.gov to get started today!
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If none, what number may we use to leave a message?
Tell us about yourself
You will be the primary contact person for this application, even if you may not be applying for assistance for yourself.
Would you like to name
someone as your
authorized
representative?
If applying for SNAP, you may start the application process immediately by filling out your name and address in the questions above and
signing below. You must complete the rest of the application and submit it as soon as possible to receive a benefit determination. Your
filing date is the date we receive an application with your name, address, and signature.
You may give a trusted friend, partner, or third party representative permission as an "authorized representative" to
talk to the Department, see your information, and act on your behalf for all matters relating to your case.
No Yes, complete Appendix A
If applying for SNAP, does your household meet one of the following situations? (check all that apply)
Your household will have less than $150 income and less than $100 liquid resources (cash, checking, savings) this month
Your household's income and resources are less than your monthly housing and utility costs
Your household includes a migrant or seasonal farm worker
Signature of applicant/authorized representative
requesting SNAP
DatePrinted name of applicant/authorized representative
requesting SNAP
Which type of assistance are you
requesting for yourself?
(check all that apply)
SNAP
(Food Assistance)Medicaid TAFI/AABD
(Cash Assistance)
ICCP
(Child Care)None
Full name First Middle Last
Former names (if any)LastMiddleFirst
Social Security number
Date of birth
Sex Male Female
Marital status Married Divorced Separated Widowed Never been married
Physical address CountyZipStateCityStreet
Mailing address
(if different)
Email
Primary phone
CountyZipStateCityStreet
Applying for Food Assistance
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Are you interested in the Medicaid for Workers with Disabilities program?No Yes
If you qualify, emergency SNAP benefits can begin within 7 days of the date on this application.
Phone type:Home Cell Work
Information that is not required :
• Hispanic or Latino
• U.S. citizen or national questions - optional for
household members who are not applying for assistance
• Race
• Social Security number - optional for people not applying and for people applying for
Medicaid or child care assistance only. However, failure to provide a SSN may result in the
denial of SNAP benefits to everyone failing to provide a SSN.
• Immunization or federal tax return questions - optional if applying for SNAP only.
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Pregnant No Yes, complete a and b.
a. Due date?
b. How many are you expecting?
Immunizations up-to-date No Yes
Preferred language
Interpretation services are
listed on the cover page of
this application.
Spoken
Written
Interpreter Do you want an interpreter if you are interviewed? (One will be provided at no cost to you)
¿Quiere usted un interprete si usted sea entrevistado? (Se le proparcionara uno sin costo alguno)
No Yes
Race White Asian Black/African American
Native Hawaiian/Pacific Island, name of Tribe:
American Indian/Alaska Native, name of Tribe:
Hispanic or Latino?No Yes
No Yes
No Yes, complete a and b.
a. Immigration document type:
b. Document ID number:
Alien status will be verified with USCIS. The response from USCIS may affect your household's eligibility and benefit amount.
Do you plan to file a
federal tax return for
the CURRENT YEAR?
No, skip to c below. Yes, complete a-c.
a. Do you plan to file jointly with a spouse?No Yes. If yes, complete i.
i. Name of spouse:
b. Will you claim dependents?No Yes, complete i.
i. Name of dependents
c. Will you be claimed as a dependent on someone else's tax return?No Yes, complete i.
i. Name of tax filer:
Continue telling us about yourself
U.S. Citizen or national
22.
19.
18.
17.
16.
15.
14.
13.
If not a U.S. citizen, do
you have eligible
immigration status?
20.
Veteran or active-duty
member of the U.S.
military?
21.No Yes
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Tell us about everyone in your household
Read the questions down the center of the page and fill in the answers and information under each Person.
Who you need to include on this application:
• Regardless of the types of assistance you apply for, we need information about everyone in your household.
• If applying for Medicaid for anyone under 65 and not disabled, we need information about everyone you plan to include on your federal tax
return this year, even if they don't live with you.
Note: You do not need to file taxes to get Medicaid.
Person 1 Person 2Question
Types of assistance requested
(check all that apply)
Relationship to you
Name
Former names, if any
Social Security number
Date of birth
Sex
Marital status
Immunizations up-to-date
Pregnant
Due date
How many are you expecting?
Hispanic or Latino
US citizen or national
1.
2.
3.
4.
6.
7.
8.
12.
If not a citizen,
has eligible immigration status
1.
2.
3.
4.
6.
7.
8.
9.
10.
a.
b.
12.
11.
14.
a.
b.
a.
b.
11.
13.
Immigration document typea.
Document ID numberb.
Veteran or active-duty member
of the U.S. military
14.
Race15.15.
Name of spouse
Name of Tribe (if applicable)
File federal tax return for CURRENT YEAR
File jointly with a spouse
Claiming dependents
Name of dependents
Name of tax filer
Claimed as a dependent
a.
16.
a.
i.
b.
i.
c.
i.
a.
16.
a.
i.
b.
i.
c.
i.
a.
16.
a.
i.
b.
i.
c.
i.
14.
a.
b.
15.
10.
9.
13.
First
TAFI/AABD None
Medicaid
ICCP
SNAP
Middle
Last
Female Male
Separated Never Married
Widowed Divorced Married
No Yes
No Yes
No Yes
No Yes, complete a and b.
No Yes, complete a and b.
No Yes
Native Hawaiian/Pacific Island
American Indian/Alaska Native
White Asian
No, skip to c. Yes, complete a-c.
No Yes. If yes, complete i and ii.
Black/
African American
No Yes. If yes, complete i
No Yes. If yes, complete i.
First
TAFI/AABD None
Medicaid
ICCP
SNAP
Middle
Last
Female Male
Separated Never Married
Widowed Divorced Married
No Yes
No Yes
No Yes
No Yes, complete a and b.
No Yes, complete a and b.
No Yes
Native Hawaiian/Pacific Island
American Indian/Alaska Native
White Asian
No, skip to c. Yes, complete a-c.
No Yes. If yes, complete i and ii.
Black/
African American
No Yes. If yes, complete i
No Yes. If yes, complete i.
1.
2.
3.
4.
6.
7.
8.
9.
10.
a.
b.
12.
11.
5.
13.
5.5.
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Continue telling us about everyone in your household
Read the questions down the center of the page and fill in the answers and information under each Person.
Person 1 Person 2Question
Types of assistance requested
(check all that apply)
Relationship to you
Name
Former names, if any
Social Security number
Date of birth
Sex
Marital status
Immunizations up-to-date
Pregnant
Due date
How many are you expecting?
Hispanic or Latino
US citizen or national
1.
2.
3.
4.
6.
7.
8.
12.
If not a citizen,
has eligible immigration status
1.
2.
3.
4.
6.
7.
8.
9.
10.
a.
b.
12.
11.
14.
a.
b.
a.
b.
11.
13.
Immigration document typea.
Document ID numberb.
Veteran or active-duty member
of the U.S. military
14.
Race15.15.
Name of spouse
Name of Tribe (if applicable)
File federal tax return for CURRENT YEAR
File jointly with a spouse
Claiming dependents
Name of dependents
Name of tax filer
Claimed as a dependent
a.
16.
a.
i.
b.
i.
c.
i.
a.
16.
a.
i.
b.
i.
c.
i.
a.
16.
a.
i.
b.
i.
c.
i.
14.
a.
b.
15.
10.
9.
13.
1.
2.
3.
4.
6.
7.
8.
9.
10.
a.
b.
12.
11.
5.
13.
5.5.
First
TAFI/AABD None
Medicaid
ICCP
SNAP
Middle
Last
Female Male
Separated Never Married
Widowed Divorced Married
No Yes
No Yes
No Yes
No Yes, complete a and b.
No Yes, complete a and b.
No Yes
Native Hawaiian/Pacific Island
American Indian/Alaska Native
White Asian
No, skip to c. Yes, complete a-c.
No Yes. If yes, complete i and ii.
Black/
African American
No Yes. If yes, complete i
No Yes. If yes, complete i.
First
TAFI/AABD None
Medicaid
ICCP
SNAP
Middle
Last
Female Male
Separated Never Married
Widowed Divorced Married
No Yes
No Yes
No Yes
No Yes, complete a and b.
No Yes, complete a and b.
No Yes
Native Hawaiian/Pacific Island
American Indian/Alaska Native
White Asian
No, skip to c. Yes, complete a-c.
No Yes. If yes, complete i and ii.
Black/
African American
No Yes. If yes, complete i
No Yes. If yes, complete i.
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Tell us about your household situation
1.Is anyone in your household applying for or already receiving tribal
commodities?No Yes, who?
2.Is anyone in your household applying for or already receiving foster care
or adoption assistance?No Yes, who?
3.Was anyone in your household in foster care when they turned 18?No Yes, who?
4.Is anyone in your household currently receiving assistance from another
state?No Yes, complete a-c.
a. Dates of assistance From (month/year):To (month/year):
b. Where assistance is received from
c. Type of assistance received
5.Is anyone in your household 65 or older?No Yes, who?
6.Is anyone in your household disabled?No Yes, who?
7.Does anyone who is applying have a pending application for Social
Security Disability?No Yes, who?
8.Is anyone in your household working and believe that they would meet
disability status as determined by the Social Security Administration? No Yes, who?
9.If applying for Medicaid, does anyone who is applying need medical
services in the home? (If applying for SNAP only, skip this question)No Yes, who?
10.Does anyone who is applying live in a medical care facility or receive
in-home care? (If applying for SNAP only, skip this question)No Yes, complete a-d.
a. Who?
City County State
Other:Child careMedicaidAABDTANF/CashSNAP
c. Facility/provider name
d. Facility/provider phone
b. Facility/provider type Certified Family HomeAssisted Living FacilityNursing home In-home care
11.Has anyone in your household been disqualified from public
assistance due to an intentional program violation?
No Yes, who?
12.Has anyone in your household been convicted of a felony?No Yes, who?
13.Is anyone in your household fleeing to avoid felony prosecution
or jail time?No Yes, who?
14.Has anyone in your household been convicted of trading Food
Stamp benefits for guns, ammunitions, or explosives?No Yes, who?
15.Has anyone in your household been convicted of buying or
selling SNAP benefits over $500?
16.Has anyone in your household been convicted of receiving
duplicate SNAP benefits in any state?No Yes, who?
17.Is anyone in your household currently violating conditions of
probation or parole?
18.If applying for ICCP, is anyone in your household participating in a
work/training program provided by a homeless shelter?
19.Has anyone in your household received $3,500.00 or more in
lottery or gaming winnings (at one time) within the last 12
months?
No Yes, date of winning:
20.Is anyone listed on this application currently incarcerated?No Yes, who?
When? State:
No Yes, who?
No Yes, who?
No Yes, have the agency complete the Child Care Activity Form.
This form can be found at healthandwelfare.idaho.gov.
(dd/mm/yyyy)
If applying for Medicaid only, and all household members are under 65 and not disabled, skip to question 20.
Are they in compliance with their sentencing requirements?No Yes
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Tell us about students
Tell us about any applicant between the ages of 16 and 49 who is attending school (high school or higher education).
Student name
School name
How many hours per week does the
student attend school?
Anticipated graduation date
School type (check one)
a. Degree type
b. Status
c. Was the student awarded work study?
d. Are all classes online?
Question Person 2Person 1
Read the questions down the center of the page and fill in the answers and information under each Person.
High School College, complete a-d.
Undergraduate Graduate
Full time Half time
Less than half time
No Yes
No Yes
High School College, complete a-d.
Undergraduate Graduate
Full time Half time
Less than half time
No Yes
No Yes
First MI
DOB
SSN
Last
Age
M F
City
Street
State
County
Street
ZipState
Zip
First MI
DOB
SSN
Last
Age
M F
City
Street
State
County
Street
City
Zip
Other Parent 1
Child's name
Name of parent not in the home
Deceased?
Former names of parent not in home, if any
Social Security number and sex
Date of birth and/or approximate age
Physical address
Mailing address (if different)
Email address
Phone number
Last known employer
Last known employer city
Other Parent 2Question
ZipState
1.
8.
7.
6.
5.
3.
2.
No Yes, skip to next section
4.
No Yes, skip to next section3.
12.
11.
10.
9.
City
1.
12.
11.
10.
9.
8.
7.
6.
5.
3.
2.
Child's name 1.
8.
7.
6.
5.
4.
2.
12.
11.
10.
9.
4.
Complete the following for each child in your household who has a parent (or parents) NOT living with them. This information is
optional. However, we may require this information if you are determined eligible for benefits. Any information will be provided to Child
Support Services in order to pursue a child support case if eligible. You must cooperate with Child Support Services. If you do not wish to
open a child support case, you must contact us by dialing 1-877-456-1233 (toll free) or 1-800-377-3529 (TTY) or 1-800-377-1363 (Voice).
Tell us about parents not in the home
Read the questions down the center of the page and fill in the answers and information under each Parent.
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Number of years in businessAverage hours worked each week
Income from a job - Tell us about any income this person gets from working a job.
Employer's name Employer's phone number
Average hours worked each week
Name of person with income:
Wages/tips (before taxes)
How often paid? (check one)
Is income expected to change? No Yes, why? (raise, hours changes, etc.)
Name of business Type of work
Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is
zero, indicate this by writing "0" or "none" for the estimated gross income question.
Estimated gross income this month
Source of income Amount
Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits,
cash gifts, and gaming/lottery winnings.
How often paid? (check one)
Income from alimony - Tell us about any alimony this person receives.
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Alimony source
How often paid? (check one)Semi-monthly, which days (i.e.: 5th & 20th)?Every 2 weeksYearlyMonthlyWeekly
Alimony amountDate ordered by judge (month/year)
Source of income Amount
How often paid? (check one)Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
When?
Income 2
Number of years in businessAverage hours worked each week
Income from a job - Tell us about any income this person gets from working a job.
Employer's name Employer's phone number
Average hours worked each week
Name of person with income:
Wages/tips (before taxes)
How often paid? (check one)
Is income expected to change? No Yes, why? (raise, hours changes, etc.)
Name of business Type of work
Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is
zero, indicate this by writing "0" or "none" for the estimated gross income question.
Estimated gross income this month
Source of income Amount
Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits,
cash gifts, and gaming/lottery winnings.
How often paid? (check one)
Income from alimony - Tell us about any alimony this person receives.
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Alimony source
How often paid? (check one)Semi-monthly, which days (i.e.: 5th & 20th)?Every 2 weeksYearlyMonthlyWeekly
Alimony amountDate ordered by judge (month/year)
Source of income Amount
How often paid? (check one)Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
When?
Note: If applying for Medicaid only, and all household members are under 65 and not disabled, report your taxable income.
For all other programs, tell us about all income your household receives. This includes any money received by an adult, or by children, aged 16 or older,
and not attending high school. We want to know about the last 30 days, as well as any money received quarterly or annually. We also want to know about
income from any job you have just started or will start within the next 30 days. Types of income include:
Tell us about your household income
Earned
Wages or salary from:
• Unemployment benefits
• Gaming/lottery winnings
• Rental income
• Social Security/Veterans
• Disability income
• Retirement/Pension income
Unearned
Income from sources such as:
Income 1
• Job
• Self-employment (including owning your own business, odd jobs,
baby-sitting, collecting cans, donating plasma, etc.).
• Cash gifts
• Child Support
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Number of years in businessAverage hours worked each week
Income from a job - Tell us about any income this person gets from working a job.
Employer's name Employer's phone number
Average hours worked each week
Name of person with income:
Wages/tips (before taxes)
How often paid? (check one)
Is income expected to change? No Yes, why? (raise, hours changes, etc.)
Name of business Type of work
Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is
zero, indicate this by writing "0" or "none" for the estimated gross income question.
Estimated gross income this month
Source of income Amount
Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits,
cash gifts, and gaming/lottery winnings.
How often paid? (check one)
Income from alimony - Tell us about any alimony this person receives.
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Alimony source
How often paid? (check one)Semi-monthly, which days (i.e.: 5th & 20th)?Every 2 weeksYearlyMonthlyWeekly
Alimony amountDate ordered by judge (month/year)
Source of income Amount
How often paid? (check one)Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
When?
Continue telling us about your household income
Number of years in businessAverage hours worked each week
Income from a job - Tell us about any income this person gets from working a job.
Employer's name Employer's phone number
Average hours worked each week
Name of person with income:
Wages/tips (before taxes)
How often paid? (check one)
Is income expected to change? No Yes, why? (raise, hours changes, etc.)
Name of business Type of work
Income from own business - Tell us about any income this person gets from a business they own. If self-employed and estimated income is
zero, indicate this by writing "0" or "none" for the estimated gross income question.
Estimated gross income this month
Source of income Amount
Income from other sources - Tell us about any other income for this person, such as Social Security, retirement, unemployment benefits,
cash gifts, and gaming/lottery winnings.
How often paid? (check one)
Income from alimony - Tell us about any alimony this person receives.
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
Alimony source
How often paid? (check one)Semi-monthly, which days (i.e.: 5th & 20th)?Every 2 weeksYearlyMonthlyWeekly
Alimony amountDate ordered by judge (month/year)
Source of income Amount
How often paid? (check one)Weekly Every 2 weeks Semi-monthly, which days (i.e.: 5th & 20th)?Monthly Yearly
When?
Income 4
Income 3
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Used for self-employment business
Medical reasons/transport disabled person(s)
Travel to and from work
Recreational
Residence
Income producing (taxi, ride-sharing, deliveries, etc.)
Personal/Everyday use
Seeking employment
Other
Current valueOwner
Year, make, model
Primary use
(choose one)
Tell us about all vehicles, including cars, trucks, motorcycles, trailers, boats, snowmobiles, and other recreational
vehicles that your household owns. Motor Vehicles
Used for self-employment business
Medical reasons/transport disabled person(s)
Travel to and from work
Recreational
Residence
Income producing (taxi, ride-sharing, deliveries, etc.)
Personal/Everyday use
Seeking employment
Other
Current valueOwner
Year, make, model
Primary use
(choose one)
If applying for Medicaid only, and all household members are under 65 and not disabled, skip to page 12. Otherwise, complete this section.
Tell us about your vehicles and bank accounts
Current Balance
Account Type
Current Balance
Tell us about all bank accounts your household has.Checking/Savings
Primary Account Holder
Name of Financial Institution
Account Number
Account Type
Current Balance
Primary Account Holder
Name of Financial Institution
Account Number
Account Type
Current Balance
Primary Account Holder
Name of Financial Institution
Account Number
Account TypePrimary Account Holder
Name of Financial Institution
Account Number
Used for self-employment business
Medical reasons/transport disabled person(s)
Travel to and from work
Recreational
Residence
Income producing (taxi, ride-sharing, deliveries, etc.)
Personal/Everyday use
Seeking employment
Other
Current valueOwner
Year, make, model
Primary use
(choose one)
Used for self-employment business
Medical reasons/transport disabled person(s)
Travel to and from work
Recreational
Residence
Income producing (taxi, ride-sharing, deliveries, etc.)
Personal/Everyday use
Seeking employment
Other
Current valueOwner
Year, make, model
Primary use
(choose one)
Copy this page or attach another sheet if you need to provide more information than space allows.HW2000 | Rev. 05/22/2025 Page 10 of 13
What asset
What asset
Amount received Fair market value
What asset
Amount received Fair market value
Owner
Date of Transaction
Sale or transfer of resources and property Tell us about everyone in your home who has sold, transferred, or given away
cash, property, vehicles, or other assets within the last five years.
Owner
Date of Transaction
Resource Type
Current Value
Resource Type
Current Value
Tell us about all resources your household owns, including cash on-hand, stocks, bonds, mutual funds, 401Ks, IRAs,
trusts, CDs, life insurance policies, burial funds, etc.Resources
Owner
Name of Financial Institution
Account Number
Owner
Name of Financial Institution
Account Number
Resource Type
Current Value
Owner
Name of Financial Institution
Account Number
Property type
Value
Property type
Value
Tell us about all other property (including your home) owned by anyone in your household. This includes land,
buildings, rental properties, etc.Property
Owner
Property address
Primary use Home Rental income Business/Self-employment Other:
Owner
Property address
Primary use Home Rental income Business/Self-employment Other:
If applying for Medicaid only, and all household members are under 65 and not disabled, skip to page 12. Otherwise, complete this section.
Tell us about your resources and property
Property type
Value
Owner
Property address
Primary use Home Rental income Business/Self-employment Other:
Property type
Value
Owner
Property address
Primary use Home Rental income Business/Self-employment Other:
What asset
Amount received Fair market value
Owner
Date of Transaction
What asset
Amount received Fair market value
Owner
Date of Transaction
Amount received Fair market value
Owner
Date of Transaction
Resource Type
Current Value
Owner
Name of Financial Institution
Account Number
Copy this page or attach another sheet if you need to provide more information than space allows.HW2000 | Rev. 05/22/2025 Page 11 of 13
Is anyone in your household currently experiencing homelessness or at risk of becoming
homeless?
Amount you pay
How often you pay
If applying for Medicaid only, and all household members are under 65 and not disabled, skip to page 12. Otherwise, complete this section.
Tell us about your household expenses
Tell us about your shelter expenses. When telling us the amount of each expense, include only the amount YOU pay.Shelter expenses
Rent (for residence)
Space rent
Mortgage
No Yes, monthly amount:
No Yes, monthly amount:
No Yes, monthly amount:
Does your mortgage amount include
any of the following expenses:
If you do not pay a mortgage expense,
indicate this by writing "0" or "none" in
the expense field.
Yes No, monthly amount:Irrigation
Property tax
HOA fees
Homeowners insurance
Yes No, monthly amount:
Yes No, monthly amount:
Yes No, monthly amount:
Check the boxes for each utility you pay that
is NOT included in your rent or mortgage Heating Cooling Water Sewer Trash Telephone
2nd Mortgage No Yes, monthly amount:
Phone numberLandlord's Name
Amount you pay
Amount you pay
Amount you pay
Provider's phone number
Tell us about any child care, adult disabled care, or elderly care you pay. If applying for ICCP, your
provider must also complete a Child Care Provider form, found at mybenefitforms.dhw.idaho.gov.Dependent care expenses
Dependent's name
Provider's name
Provider's address
Total charge for care How often you pay
Provider's phone number
Dependent's name
Provider's name
Total charge for care How often you pay
Provider's phone number
Dependent's name
Provider's name
Provider's address
Total charge for care How often you pay
Provider's address
Amount you pay
How often you pay
How often you pay
Amount you pay
Tell us about any court ordered child support expense or arrears you pay to someone who is not in your
household.Child Support Expense
Name of person with expense
Who receives payment?
Name of person with expense
Who receives payment?
Name of person with expense
Who receives payment?
Your Food Stamps may increase if you have expenses such as child or adult care costs, child support paid for children not living with you, housing costs, medical
costs (including prescriptions) for people with disabilities or who are over 65, and utility costs. However, if you do not report or verify any of these expenses, it will
mean that you do not want a deduction for the unreported or unverified expenses.
Tell us about any individual expenses ONLY for the individuals in your household who are 65 or older
(60 if applying for SNAP) or disabled. Allowable expenses include some medical expenses and health
insurance premiums you pay.
Individual Expenses
Name of person with expense
Expense type
Amount paid
How often paid
Name of person with expense
Expense type
Amount paid
How often paid
No Yes
This includes lacking a stable address, staying in a shelter or motel, couch surfing, living with family
temporarily, facing imminent loss of housing, or other circumstances.
Copy this page or attach another sheet if you need to provide more information than space allows.HW2000 | Rev. 05/22/2025 Page 12 of 13
If applying for SNAP or ICCP only, skip to page 13.
Tell us about your health coverage situation
Does anyone who is applying for
Medicaid want help paying for
medical costs from the last three (3)
months?
1.No Yes, complete a and b.
a. Name of person with costs:
b. For which of the last 3 months do you need assistance? Include the gross
household income (before taxes) received by your family in each of those months.
Month name:
Gross income for month:
Month name:
Gross income for month:
Month name:
Gross income for month:
2. Does anyone applying for Medicaid
currently receive health coverage
from another health insurance?
a. Who?
Are any children (under the age of 19)
who are applying, currently
receiving health coverage?
3.No Yes, complete a and b for each child receiving coverage.
b. Which of the following services are covered by this child's health insurance? (check all that apply)
a. Name of child:
X-ray servicesLab servicesPhysicians medical/
surgical services
Inpatient/outpatient
hospital services
b. Which of the following services are covered by this child's health insurance? (check all that apply)
a. Name of child:
X-ray servicesLab servicesPhysicians medical/
surgical services
Inpatient/outpatient
hospital services
b. Which of the following services are covered by this child's health insurance? (check all that apply)
a. Name of child:
X-ray servicesLab servicesPhysicians medical/
surgical services
Inpatient/outpatient
hospital services
No Yes, complete a and b.
b. Insurance type
Copy this page or attach another sheet if you need to provide more information than space allows.HW2000 | Rev. 05/22/2025 Page 13 of 13
Read and initial each statement below if anyone is applying for Medicaid
Read and initial the statement below if anyone is applying for TAFI or AABD
Rights and Responsibilities
I understand that all adult household members may be
responsible for repaying benefits if the household received
benefits it was not entitled to receive. This applies to an
over-issuance of benefits as a result of an agency error, an
inadvertent household error, and intentional program
violations. If a there is an overpayment of benefits to your
household, the information on this application, including
all adult SSNs, may be referred to Federal and State
agencies, as well as private claims collection agencies for
collection action.
I am required to report when my household's monthly
income exceeds the gross limit for my household size.
Information available through the Income Eligibility
Verification System (IEVS), and other online sources, is used
and may be verified through a third-party contact when
differences are discovered between the system and what
you report. This information may affect your eligibility and
level of benefits.
I will be notified of the right to appeal Department
decisions and I can contact the Department for information
on the appeal process.
I may be required to cooperate with state or federal
reviewers who are making sure my benefits are correct. I
may not be eligible to receive benefits if I do not cooperate.
I consent to the gathering, use, and disclosure of my
information, including my SSN, by the Idaho
Department of Health and Welfare or its designees. I
understand the information is needed for the purpose
of providing benefits or services, obtaining payment for
my benefits or services, and for normal business
operations of the Department.
My signature indicates I have received a copy of the
Department Privacy Practices.
This information may be disclosed to other federal and
state agencies for official examination, and to law
enforcement officials, for apprehending persons fleeing to
avoid the law.
My signature certifies that the information on this
application is true and accurate. I could be sanctioned
and required to return any benefit I receive if my
information is not true. Sanctions may include
administrative, civil, or criminal actions against me,
including prosecution.
I have the right to revoke this consent, in writing, at any
time, except to the extent the Department has already used
and disclosed my information. If I revoke this consent, the
Department will not provide further benefits or services.
If I receive Medicaid after age 55, my estate may be subject to recovery
of medical expenses paid on my behalf, and that any transfer of assets
may be set aside by a court if I do not receive adequate value.
I have the right to choose a Healthy Connections primary care doctor to
request referrals for services, and to change the doctor/clinic if my
circumstances change.
My signature or the signature of my representative authorizes state
offices to communicate with insurance companies related to my/my
child's medical assistance.
If I am determined eligible for Medicaid, the plan I will be enrolled in
depends on my individual needs.
It is illegal to give my EBT card away or to trade the benefits on my card
for cash, firearms, drugs, or other goods and services. Penalties include
fines, imprisonment, and disqualification from future benefits. The
benefits I receive are for me and members of my household only. I may
not use my SNAP benefits on individuals outside of my household.
To receive SNAP, I may be required to participate in work programs.
Failure to do so may result in a loss or decrease in benefits.
If I receive cash assistance (TAFI or AABD), I may not withdraw cash
benefits or use cash benefit funds to purchase products and services in
gambling establishments, liquor and tobacco stores, adult
entertainment venues, other establishments prohibiting persons under
the age of 18, or tattoo, body piercing, or other branding parlors.
If I am determined eligible for the Idaho Child Care Program (ICCP), I
may be responsible for paying part of my child care costs.
Read and initial each statement below for all types of assistance.
Read and initial each statement below if anyone is applying for SNAP,
formerly Food Stamps.
Read and initial the statement below if anyone is applying for ICCP
As part of my application, I understand that IDHW will open
a Child Support case and I must cooperate with Child
Support Services.
Printed name of applicant/authorized representative
Printed name of applicant/authorized representative
Date
Date
Signature (must be completed)
Under penalty of perjury, I swear or affirm the information I have provided is true and complete. My signature confirms that I have read and understand
the Rights and Responsibilities listed on this page and my reporting requirements.
Signature of applicant/authorized representative
Signature of applicant/authorized representative
Phone type
Authorized Representative Form
Appendix A
You may give a trusted person, such as a friend, partner, third party caseworker or an organization permission to talk about this application with us, see
your information, and act for you on all matters related to this application, including getting information about your application and signing your
application and/or renewal information on your behalf. This person is called an "authorized representative."
If you ever need to change your authorized representative or revoke the access to your information, contact the Department to complete a new
Authorized Representative Form or to update your information about who can access your account.
If you are a legally appointed representative for someone on this application, you must submit proof, such as Power of Attorney, with the
application.
Full name First Middle Last
Social Security number
Date of birth
1.
3.
2.
Tell us about yourself
Full name First Middle Last
Relationship to applicant
Organization name
Organization ID
(if applicable)
1.
2.
1.
2.
Tell us who you want to name as your authorized representative
Mailing address CountyZipStateCityStreet3.
Phone4.
Email5.
Home Work Cell
DateSignature of authorized representativePrinted name of authorized representative
As an authorized representative, I understand that I agree to maintain the confidentiality of any information regarding the applicant or beneficiary
provided by the Department of Health and Welfare. For Medicaid, I understand that any person who knowingly and willfully uses or discloses
information in violation of section 1411(g) of the Affordable Care Act will be subject to a Civil Monetary Penalty (CMP) of not more than $25,000 as
adjusted annually under 45 CFR part 102 per person or entity, per use or disclosure, consistent with the bases and process for imposing civil penalties
specified at §155.285, in addition to other penalties that may be prescribed by law.
Signature
Complete this section for an organization to be your authorized representative
Mailing address CountyZipStateCityStreet3.
Phone4.
Email
(if applicable)
5.
DateSignature of applicantPrinted name of applicant
(In the case of an Organization, please provide a name of someone attesting to the terms and conditions of this form)