Dhs Form

Date: Case name: Case number: County number. Supervisor/worker number:

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Request for Benefits

For use with Forms 08MP002E and 08MP003E What you need to do to get started: Read the following descriptions and check all of the programs for which you would like to apply. Fill out this form or have someone else fill it out for you. Program Supplemental Nutrition Assistance Program (SNAP) Child Care Subsidy Health care coverage SoonerCare (Medicaid) Description Helps buy food. Formerly known as the Food Stamp Program. Helps pay for care for your child so you can work, go to school, or attend training Helps pay for medical costs for pregnant women, families with children, and people who are elderly or disabled Helps pay for nursing care in your home or in a nursing home Helps pay Medicare Part A and B premiums State Supplemental Payment (SSP) - gives a small cash payment to low-income people who are blind, 65 years of age or older, or receive Supplemental Security Income (SSI) or Social Security disability Family Planning Services - helps pay for birth control and family planning services Helps low income families with children by providing temporary cash and services Helps pay for services for low-income families with children to retain or obtain employment. This is a short-term program instead of TANF. Apply?

Temporary Assistance for Needy Families (TANF) Diversion Assistance

What to do when you complete the form: • • Sign this form and take, mail, or fax it to the local OKDHS office. After you give us this form, we will set up your interview. During your interview, we will help you complete the rest of the application. We will also tell you which benefits you can receive.

Form 08MP001E (PS-1) revised 12-1-2009 may continue on next page, page 1 of 5

What you will need to bring to your interview: • • • • • • • proof of identity, such as driver license or school identification; Social Security number or card for everyone who wants benefits; proof of...