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Get and Sign 235 400  Form

Get and Sign 235 400 Form

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Assistance) MEDICAID NONE Case #: _____________________________ SSI FOOD STAMPS If services are being received, proceed to question 5 and answer “YES.” If response is “NONE,” proceed to question 2. 2. Is the child a U.S. Citizen or qualified alien? YES NO If yes, indicate source of citizenship information: Eligibility for TANF, SSI, Food Stamps, or Medicaid or Self-Declaration INS, 3. Is the child under 18 years of age? 4. In order to be eligible for “services for non-placed children,”...
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