How to Fill Out Your Application
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Click
here to Download PDF Version of the Application Only
Click here to Download PDF Version of the Application and Instructions 1. Person Applying Give information about the person filling out the application. Be sure to provide the Social Security Number to avoid delays in processing. 2. Mailing Address This is the address where you get your mail. 3. Household Member List everyone who lives with you. Tell us if they want to enroll for this benefit. You need to list the Social Security Numbers for you, your spouse and those who are applying. 4. Citizenship Answer only for people applying. This information is not shared with Immigration Services and will not affect applications for citizenship. 5. Disability If anyone age 19-62 has a disability please check the box and write their name in the space provided. 6. Health Insurance List anyone applying who has health insurance. Tell us about the insurance. MaineCare will pay for covered services after other insurance has paid their part. 7. Income If you are employed please tell us the name of your employer, the amount you can earn, how often you are paid, and your hours worked each week. If you expect changes in income in the next month, please tell us about this. Tell us all the income information for you and your spouse and dependents living with you and any other person in your household who is applying. 8. Assets List any assets owned by you, your children or your spouse who lives with you. Include assets owned jointly or together with anyone else. A. Cashable assets - This includes savings and checking accounts, certificates of deposit (CDs), credit union shares, stocks, bonds, annuities, individual retirement accounts (IRAs), Keogh, or profit sharing. B. Real Estate - This includes any property you own. C. Vehicles - This includes any motorized vehicle such as a car, truck, boat, camper, motor cycle, snowmobile, or ATV. 9. Help With Applying If you would like us to contact someone to help fill out the application, tell us who this is and how to contact them.
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