SIGNATURE OF APPLICANT:
SIGNATURE OF APPLICANT: DATE: HOME ADDRESS: __________________________________ MAILING ADDRESS: ________________________________________________ PREGNANT: DISABLED: AGED: TANF: FOSTER CARE: FORMER FOSTER CARE: EMANCIPATED MINOR: Check If No Fixed Address GOVERNMENT OF THE VIRGIN ISLANDS Department of Human Services "Working Together to Make a Difference" MEDICAL ASSISTANCE PROGRAM STATEMENT OF FACTS YOU MUST COMPLETE ALL FIELDS ON THIS APPLICATION TO RECEIVE A TIMELY ELIGIBILITY DETERMINATION MAP CASE NO: HOUSEHOLD COMPOSITION NAME DATE OF BIRTH SEX RACE* RELATIONSHIP TO APPLICANT SOCIAL SECURITY NUMBER INCOME TYPE (Earnings, Social Security, Unemployment, etc.) RESOURCE(S) Saving, Checking, Property) HEALTH INSURANCE PROVIDER *Race Codes: 1=White or Caucasian, 2=Black or African American, 3=Native Alaskan or American Indian, 11=Asian, 16=Hawaiian, Pacific Islander, 17=Decline to Answer, 18=Other I certify through my signature that the answers given are true and correct to the best of my knowledge and belief. …
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SIGNATURE OF APPLICANT: DATE: HOME ADDRESS: __________________________________ MAILING ADDRESS: ________________________________________________ PREGNANT: DISABLED: AGED: TANF: FOSTER CARE: FORMER FOSTER CARE: EMANCIPATED MINOR: Check If No Fixed Address GOVERNMENT OF THE VIRGIN ISLANDS Department of Human Services "Working Together to Make a Difference" MEDICAL ASSISTANCE PROGRAM STATEMENT OF FACTS YOU MUST COMPLETE ALL FIELDS ON THIS APPLICATION TO RECEIVE A TIMELY ELIGIBILITY DETERMINATION MAP CASE NO: HOUSEHOLD COMPOSITION NAME DATE OF BIRTH SEX RACE* RELATIONSHIP TO APPLICANT SOCIAL SECURITY NUMBER INCOME TYPE (Earnings, Social Security, Unemployment, etc.) RESOURCE(S) Saving, Checking, Property) HEALTH INSURANCE PROVIDER *Race Codes: 1=White or Caucasian, 2=Black or African American, 3=Native Alaskan or American Indian, 11=Asian, 16=Hawaiian, Pacific Islander, 17=Decline to Answer, 18=Other I certify through my signature that the answers given are true and correct to the best of my knowledge and belief. I realize that deliberate misrepresentation or concealment of facts may constitute fraud for which I may lose my Medical Assistance coverage or can be prosecuted for a crime. APPLICANT: ______________________________________ MARITAL STATUS: ______ BIRTH DATE: ______________ SSN: ___________________________ MOBILE PHONE: ( )________________________________HOME PHONE: ( )_____________________________WORK PHONE: ( )_________________ EMAIL: ____________________________________________________ PREFERRED METHOD OF CONTACT :______________________________________