For MaineCare and Food Stamps ARE YOU: If you live with your spouse: Married Spouse’s name (first, middle initial, last)  Widowed Date of birth Sex Able to work?  Yes No Single (month /day/year)  Divorced Place of birth _______________________Maiden name ______________________  Separated Spouse’s Social Security number  (Check only one box) Spouse's Medicare number List people who live with you: Last name First name Middle Sex Birth Social Security Relationship to Initial Number you Is everyone you are applying for a citizen? Yes No If no, please list their names and Alien Registration Numbers. Please list place of birth for each person for whom you are requesting assistance First Name Place of Birth First Name Place of Birth First Name Place of Birth List household income monthly Your spouse Other family members Source Yourself (who lives with you) (please list amount and name of member) Social Security $ $ $ SSI $ $ $ Other Income or Pensions $ $ $ (such as railroad retirement, interest, dividends, etc., please explain) List household earnings for yourself and your spouse (who lives with you): (please provide the last 4 pay stubs or copies of them) Name Employer’s name and Amount How often worked phone number earned are you paid each week Is anyone in your household self-employed? If YES, Who? ______________ Yes No Source? _______________ How often? _____________ Please provide a copy of your most recent tax return or business records. List assets for yourself and your spouse (who lives with you), including jointly owned assets: (If you are applying for Food Stamps, also list the assets of others in your household.) Checking or Savings Account Credit Union Shares IRA, 401K, Keogh Certificate of Deposit • • • • Accounts • Profit Sharing Safety Deposit Box Assets with Others Stocks Annuities Prepaid Burials • • • • • • • Trusts Name(s) on account Type of asset Name of Account number Current balance (see above) bank or institution or value
For MaineCare and Food Stamps ARE YOU:  Married  Widowed  Single  Divorced  Separated (Check only one box) If you live with your spouse: Spouse’s name (first, middle initial, last) Date of birth Sex Able to work? Yes No (month /day/year) Place of birth _______________________Maiden name ______________________ Spouse’s Social Security number Spouse's Medicare number List people who live with you: Last name First name Middle Initial Sex Birth Social Security Number Relationship to you Is everyone you are applying for a citizen? Yes No If no, please list their names and Alien Registration Numbers. Please list place of birth for each person for whom you are requesting assistance First Name Place of Birth First Name Place of Birth First Name Place of Birth List monthly household income Source Yourself Your spouse (who lives with you) Other family members (please list amount and name of member) Social Security $ $ $ SSI $ $ $ Other Income or Pensions (such as railroad retirement, interest, dividends, etc., please explain) $ $ $ List household earnings for yourself and your spouse (who lives with you): (please provide the last 4 pay stubs or copies of them) Name Employer’s name and phone number Amount earned How often are you paid worked each week Is anyone in your household self-employed? Yes No If YES, Who? ______________ Source? _______________ How often? _____________ Please provide a copy of your most recent tax return or business records. List assets for yourself and your spouse (who lives with you), including jointly owned assets: (If you are applying for Food Stamps, also list the assets of others in your household.) • Checking or Savings Account • Credit Union Shares • IRA, 401K, Keogh • Certificate of Deposit • Accounts • Profit Sharing • Safety Deposit Box • Assets with Others • Stocks • Annuities • Prepaid Burials • Trusts Name(s) on account Type of asset (see above) Name of bank or institution Account number Current balance or value
IMS01.docx