Instructions to complete DAS Income Eligibility - DASIE

Address

• List your home address.
• If your mailing address is different from your home address, also write your mailing address in the space provided.

• Write your home telephone and cell phone numbers or another telephone number where we can reach you with area codes. We must have a way to reach you.

Household Members

The term "household" means those persons whose income is included to determine eligibility. The following persons, if they reside with the client, shall be considered members of the client’s household:

1. In the case of a parent or caretaker:
   • the parent or caretaker;
   • the spouse of the parent or caretaker;
   • the parent or caretaker's natural or adoptive children under the age of 21;
   • the blood-related siblings (including those of half-blood) of the parent or caretaker's children who are under the age of 21;
   • the natural or adoptive father of any children in the household.
2. In the case of a single adult who does not meet the definition of dependent child (a child up to age 19), the single adult only;
3. In the case of the couple without dependent children, the couple only;
4. In the case of a child:
   • the child;
   • the child's natural or adoptive parents;
   • the child's blood-related (including half-blood) and adoptive siblings under the age of 21.
   • at the option of the household, the child's stepparent;
5. In the case of a pregnant woman:
   • the pregnant woman and the unborn child (or children, when it is medically verified that there is more than one fetus);
   • The pregnant woman's spouse;
   • the pregnant woman's natural or adoptive children under the age of 21;
   • the blood-related siblings (including those of half-blood) of the pregnant woman's children who are under the age of 21;
   • the natural or adoptive father of any children in the household.

• You must provide a SSN for each person applying for DAS Income Eligibility. Parents of newborns must supply the SSN as soon as it is available.
• SSN is optional for adults or dependents who are not applying. (Your application may be processed faster if your SS# is provided.)

• If you checked “yes”, you may be asked to submit documentation which proves the person requesting DAS services is a U.S. citizen.
• If you checked “no”, you may be asked to submit proof of immigration status. Examples of acceptable proof include:
  • The front and back of a Resident Alien Card
  • The Temporary 1-551 stamp on a passport or Form 1-94
  • Documentation indicating refugee or asylee status
  • Documentation indicating a parent’s US military service

• If you checked “yes”, you will be asked to submit a copy of the front and back of the insurance card. Note: Some people with other insurance may still qualify for DAS Income Eligibility.

• List how each child is related to the 1st and 2nd parents or guardians listed in Section 1. An example of “Other” would be a niece, nephew or grandchild.

Household Income

• List all jobs and employers for each working person in the household. If you are self-employed or the owner of a business, you will be asked to submit a signed copy of your last 1040 (including Schedule C, Form S1120, Form 1065, Schedule E, and all the other related schedules) or your last profit and loss statement.

• Part-time employment is less than 30 hours per week.

• You will sumbit copies of check stubs or other proof showing gross income (before deductions) for the most recent entire month. Be sure to send copies of check stubs for every job listed for each working person.

• You will be asked to indicate the type of other income such as:
  • Supplemental Security Income(SSI);
  • Social Security Survivors/Retirement;
  • Social Security Disability Benefits;
  • Veterans Benefits;
  • Unemployment;
  • State Disability;
  • Workers Compensation;
  • Pension or Annuity;
  • Interest of Dividends;
  • Alimony You Receive;
  • Child Support You Receive;
  • Cash from Friends or Family;
  • Income from Rent (Not What You Pay);
  • Other
• If you have other income, you will receive a letter asking you to send in copies of check stubs from the most recent entire month, award letters, or some proof of each kind of income received.