4. Household Members (List *If the people who live with you) you are only applying for help with the family planning benefit, and do not want full MaineCare for yourself or any other household member, then answer the remaining questions just for yourself. You do not need to list information about other household members. Last name First name Middle Sex Date of Requesting Social Security Relationship initial birth Coverage? Number to you (Optional if Not Requesting Coverage) 5. Household Wages From Work (You are not required to submit proof of your wages at this time, but you may be asked at a later date to provide paystubs or photocopies of paystubs for the last 4 weeks if electronic verification is not possible.) Amount you are paid (before any How often Hours worked Employer’s Name name and phone deductions) you are paid each week *Check here if your wages change a lot. [ ] 6. Self-Employment (Attach a copy of your most recent tax return including all schedules) Name of person(s), if any, who is self-employed If you did not file a tax return, check here If you did not file a tax return, check here 7. Unearned Income (You are not required to submit proof of your income at this time, but you may be asked to at a later date if electronic verification is not possible.) Note: You don’t need to tell us about child support, veteran’s payments, or Supplemental Security Income (SSI). Name of person Where is income from? How often received? Amount receiving income (Social Security, Unemployment, etc.) (monthly, weekly, etc.) before deductions
4. Household Members (List the people who live with you) *If you are only applying for help with the family planning benefit, and do not want full MaineCare for yourself or any other household member, then answer the remaining questions just for yourself. You do not need to list information about other household members. Last name First name Middle initial Sex Date of birth Requesting Coverage? Social Security Number (Optional if Not Requesting Coverage) Relationship to you 5. Household Wages From Work (You are not required to submit proof of your wages at this time, but you may be asked at a later date to provide paystubs or photocopies of paystubs for the last 4 weeks if electronic verification is not possible.) Name Employer’s name and phone Amount you are paid (before any deductions) How often you are paid Hours worked each week *Check here if your wages change a lot. [ ] 6. Self-Employment (Attach a copy of your most recent tax return including all schedules) Name of person(s), if any, who is self-employed If you did not file a tax return, check here If you did not file a tax return, check here 7. Unearned Income (You are not required to submit proof of your income at this time, but you may be asked to at a later date if electronic verification is not possible.) Note: You don’t need to tell us about child support, veteran’s payments, or Supplemental Security Income (SSI). Name of person receiving income Where is income from? (Social Security, Unemployment, etc.) How often received? (monthly, weekly, etc.) Amount before deductions