Who Referred You? to Name: applicant: Agency: Phone: Email: Primary Source of Family/Friends Personal Public Support (SSI, SSDI, TANF, etc.) Support Other Personal Income: Interest, Dividend and rent Disability Benefits: Application Status Other Income Type of Amount Benefit Received Pending Denied Source Amount SSI-Aged $ General Assistance $ SSI-Disabled $ Worker’s Compensation $ $ Unemployment $ $ Other Disability $ Other (Family income, VA $ wages, etc.) $ If you receive TANF will your benefits exhaust TANF $ within two years? Yes No Medical Insurance: Maine Care (Medicaid) Medicare Private through means Private through own work pending Private through own work Public insurance from other sources None Not available State/Federal Affordable Care Act Exchange If NO, date last Are you working: Yes No employed? Are you requesting services to maintain your current employment? Yes No Work History: (Please list starting with the most recent or present job and attach a resume if you have one) Note: if applying for IL services, no need to complete this section. Job Title: Hours per Start End week: Rate of pay: Date: Date: Leave Reason: Job Hours per Start End week: Rate of pay: Date: Date: Leave Reason: Job Title: Hours per Start End week: Rate of pay: Date: Date: Leave Reason:
Who Referred You? Name: to applicant: Agency: Phone: Email: Primary Source of Support Family/Friends Personal Public Support (SSI, SSDI, TANF, etc.) Other Personal Income: Interest, Dividend and rent Disability Benefits: Type of Benefit Amount Received Application Status Other Income Pending Denied Source Amount SSI-Aged $ General Assistance $ SSI-Disabled $ Worker’s Compensation $ $ Unemployment $ $ Other Disability $ VA $ Other (Family income, wages, etc.) $ TANF $ If you receive TANF will your benefits exhaust within two years? Yes No Medical Insurance: Maine Care (Medicaid) Medicare Private through means Private through own work pending Private through own work Public insurance from other sources None Not available State/Federal Affordable Care Act Exchange Are you working: Yes No If NO, date last employed? Are you requesting services to maintain your current employment? Yes No Work History: (Please list starting with the most recent or present job and attach a resume if you have one) Note: if applying for IL services, no need to complete this section. Job Title: Hours per week: Rate of pay: Start Date: End Date: Leave Reason: Job Hours per week: Rate of pay: Start Date: End Date: Leave Reason: Job Title: Hours per week: Rate of pay: Start Date: End Date: Leave Reason:
Online%20Application%20DBVI.docx