Domestic Violence Health Care

Location:

Dover, PA, 17315

Salary:

16$

Posted:

November 14, 2024

Contact this candidate

Resume:

PA *** */**

Pennsylvania Application for Benefits

If you have a disability and need this application in large print or another format, please call our helpline at 1-800-***-****. Individuals who are deaf, hard of hearing, or have speech disabilities and wish to communicate with the helpline may call PA Relay Services by dialing 711. You can apply online at: www.compass.state.pa.us.

This is an application for cash, health care and the Supplemental Nutrition Assistance Program (SNAP) benefits. If you need this application in another language or someone to interpret, please contact your local county assistance office. Language assistance will be provided free of charge.

Esta es una solicitud de beneficios en efectivo, beneficios de atención médica y del Programa de Asistencia Nutricional Suplementaria (SNAP). Si necesita esta solicitud en otro idioma o un intérprete, comuníquese con la oficina de asistencia de su condado. La asistencia lingüística se proporcionará de forma gratuita. Đây là đơn xin hưởng các khoản tiền phúc lợi, bảo hiểm y tế và Chương Trình Trợ Cấp Dinh Dưỡng Bổ Sung

(SNAP). Nếu bạn cần đơn này bằng ngôn ngữ khác hay cần thông dịch viên thì vui lòng liên hệ với văn phòng hỗ trợ quận tại địa phương mình. Hỗ trợ ngôn ngữ sẽ được cung cấp miễn phí.

В этом приложении будут содержаться данные о

ваших денежных пособиях, льготах по медицинскому

обслуживанию и пособиях по программе «Программа

дополнительной продовольственной помощи»

(SNAP). Если вы хотите переключить язык

приложения или вам требуются услуги перевода,

обратитесь в окружное отделение социальной

помощи по месту жительства. Языковые услуги

предоставляются бесплатно.

此为现金医疗和补充营养援助计划 (SNAP) 福利

申请表如需其他语言版本或口头翻译,请联系当

地的县援助办公室免费获取语言协助

ន គឺឺជ ព ក្យយស្ន សុំំ ប្រ ក់់ ទំំហ ទ ំំសុុខភ ព និិងអត្ថថ ប្ររយ ជន៍៍កម្មមវិិធីីជំំនួួយអ ហ ររូូបត្ថថម្ភភបន្ថ ម (SNAP)

ប្ររសិិនប អ្ននកត្រូូ វក រដ ក់់ព ក្យយសុំំ ជ ភ ស ផ្ស ង ឬ ត្រូូ វក រអ្ននកបកប្រ សូូមទ ក់់ទងក រិិយ ល័័យជំំនួួយខ នធីី របស់់អ្ននក អ្ននកនឹឹងទទួួលប នជំំនួួយបកប្រ ភ ស ដ យ ឥតគិិតថ្ល

(. إذا كنت تريد تصفح هذا التطبيق بلغةSNAP( هذا تطبيق مخصص للمستحقات النقدية الرعاية الصحية وميزات برنامج مساعدات التغذية التكميلية أخرى أو كنت تريد مترجماً فوريًا فالرجاء الاتصال بمكتب المساعدة المحلي التابع للمقاطعة الخاصة بك وسيتم توفير المساعدة اللغوية مجانًا. PA 600 8/23

Family Safety: Information About Your Benefits and Domestic Violence Domestic violence happens when someone in your life harms you. Abuse can be physical, sexual or emotional. It includes:

• Physically hurting you or your children

• Threatening or trying to hurt you, your children or your property

• Forcing you to have sex

• Sexually abusing your children

• Controlling where you go and who you see

• Not allowing you or your children to have food,

clothing or medical care

• Keeping you from going to work or school

• Following or stalking you

If you are or have been a victim of domestic violence or are at risk of further violence, your caseworker can excuse you from requirements for cash assistance if domestic violence prevents you from complying. Sometimes people cannot safely follow welfare requirements because they fear that they or their children will be abused if they do so. These include:

• Support cooperation

• Time limits

• Work (RESET)

• Requirements that teen parents live at home

• Other requirements on a case-by-case basis

• Verification

If you need to be excused from welfare requirements because of domestic violence, tell your caseworker. If you or your children are or have been victims of domestic violence, or are at risk of further violence, your caseworker can:

• Talk to you if you want to talk. You can ask to talk in private. Your caseworker and the staff will keep your personal information confidential. However, the law says that the Department of Human Services must report child abuse to the Children and Youth Agency.

• Help you find local programs where you can get counseling, safety planning, shelter, legal services and other help.

• Help you understand the rules for applying for cash assistance, and how they affect you if you apply. Certain TANF requirements may be waived based upon domestic violence. For more information about crisis intervention, counseling, accompaniment to police, medical and court facilities, temporary emergency shelter, and prevention and education programs, call: The Pennsylvania Coalition Against Domestic Violence 1-800-***-**** (in PA) 303-***-**** (National)

PA CareerLink® - Important Information

PA CareerLink® is a program of the Pennsylvania Department of Labor and Industry to help job seekers find jobs. The Labor and Industry staff knows about current labor market conditions and can give you information and resources to help your job search. It is recommended that you register with PA CareerLink® to get started. You can register with PA CareerLink® at www.pacareerlink.pa.gov/.

PA 600 8/23

Application for Benefits

Pennsylvania receives information from other state and federal agencies to verify the information you give us. If you misrepresent, hide or withhold facts which may affect your eligibility for benefits, you may be required to repay your benefits and you may be prosecuted and disqualified from receiving certain future benefits. You can apply online at: www.compass.state.pa.us.

It’s easy to apply!

1. Fill out this form.

2. Sign and date it on page 1 and page 15

3. Bring, fax or mail your form to your county assistance office (CAO). Are you interested in any other services?

Put a check in the box if you are interested in information on any of these other services: Supplemental Security Income (SSI) Well Baby Clinic Child care Intellectual disability services Immunizations (shots) Head Start (for children ages 3 to 6) LIHEAP (energy assistance) Veterans’ services Child support services Food banks Employment and training Family planning/birth control School meals (free or reduced cost) Vocational rehabilitation Lifeline (reduced cost phone service) Long Term Care (nursing home care) Housing assistance WIC (Women, Infants and Children) Home and Community Based Services (Waiver Services) Special allowances for employment and training such as tools) Other: Medical Providers Use Only

PROVIDER NAME PROVIDER NUMBER EMERGENCY

CAO Use Only

APPLICATION REGISTRATION NUMBER CASELOAD COUNTY DISTRICT RECORD NUMBER DATE STAMP Questions?

Call your county assistance office or our CUSTOMER SERVICE CENTER at 1-877-***-****. In Philadelphia, call 1-215-***-****.

We are here to help you. Call Monday thru Friday 8:30 a.m. to 5 p.m. TDD Services are available by calling PA Relay Services at 711. PA 600 8/23

Quick SNAP!

Get SNAP Benefits Now!

(SNAP was formerly known as the Food Stamp program.)

• Does your household have $100 or less in available cash and bank accounts and expect to receive less than $150 in income this month?

• Are you a migrant or seasonal farm worker?

• Are your monthly gross income and cash and bank accounts less than your rent/mortgage and utility costs for this month?

If the answer to any of these questions is yes, you may have a right to expedited SNAP benefits. This means you can get SNAP benefits within five calendar days of the date you apply. Ask for more information by contacting the local county assistance office. File your SNAP benefits application today!

It is your right to file an application today at any time before 5 p.m. The person at the county assistance office should date-stamp your application while you watch. If you are denied expedited SNAP benefits, you have the right to an agency conference within two working days with a supervisor at the county assistance office. If you believe you are being denied your rights or services, or if the county assistance office does not take your application when you hand it in and date- stamp it while you watch, ask to talk with a supervisor or call the Helpline toll free at 1-800-***-****. You can get free legal help at the local legal services office. Page 1 PA 600 8/23

What language do you prefer? Qué idioma prefiere usted? English/Inglés Spanish/Español Other/Otro (specify/especifique) Do you need an interpreter? Necesita un intérprete? Yes/Sí No If yes, what language? En caso afirmativo, de qué idioma? Go paperless! Would you like to receive your notices online? Go to www.compass.state.pa.us and enroll on your MyCOMPASS Account.

• We can start your application as soon as you write your name and address, and sign and return this application.

• We encourage you to answer as many questions as you can unless the instructions tell you that you can choose not to answer. The more complete information we have, the faster we can process your application.

• If you are eligible, SNAP benefits start from the date we receive your application. We will tell you within 30 days if you are eligible or not. IMPORTANT: All persons applying must provide or apply for a Social Security number (SSN) and answer citizenship questions. Providing an SSN is optional for persons not applying for benefits, but providing it can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health care coverage costs. If someone wants help getting an SSN, call 1-800-***-**** or visit www.ssa.gov. TTY users should call 1-800-***-****. Note: If you are a non-citizen applying for Emergency Medical Services only, you do not need to provide information about your immigration status or apply for or provide an SSN. Tell us about you, the applicant: We will need to contact an adult/parent/caretaker. Name (Include first, middle initial, last, suffix - Jr./Sr./etc.): Home address (Include street, apt. number, city, state & ZIP code+4) School district: Township or municipality: How long have you lived at this address? Phone number: Phone type:

Home Work Cell

Second phone number: Phone type:

Home Work Cell

Check here if you do not have a home address.

You still need to give a mailing address.

Mailing address (if different from home address):

Quick SNAP: You may be able to get SNAP within 5 days! Answer these questions, then sign this application and give it to your county assistance office by 5 p.m. today! Your county assistance office will set up an interview with you. Total monthly income, for you and anyone

who is applying, before taxes are taken out:

Are you, or anyone you are applying

for, getting SNAP now?

Yes No

Do you pay for utilities other than telephone? Yes No If yes, which utilities?

Total resources (resources are money in cash,

checking and savings accounts):

Do you pay for telephone services?

Yes No

Are you, or anyone you are applying for, a seasonal or migrant farm worker?

Yes No

Total monthly rent or mortgage for you and

anyone who is applying:

Do you pay for heating or the cost to

run air conditioning?

Yes No

Do you, or anyone you are applying for, live in a shelter for abused or battered women and children?

Yes No

Sign here:

Your signature or your representative’s signature Date Getting Started

What do you want to apply for?

Cash assistance Health Care Coverage SNAP (Supplemental Nutrition Assistance Program) SIGNATURE REQUIRED

PA 600 8/23 Page 2

Tell us about people in your home:

We need to gather information about everyone who lives at your address, even if they are not applying for benefits. For health care applicants, be sure to include anyone on your federal income tax return, even if they do not live with you. Note: You do not need to file a tax return to get benefits. Person 1 (Start with yourself) CAO Use Only Line #: Name (Include first, middle initial, last, suffix-Jr./Sr./etc.) Are you applying for yourself? Yes No

Social Security number:

Birthdate (MM/DD/YYYY): Sex

M F

Driver’s license or state ID number

if you have one: Marital

Status

Single Separated Married

Divorced Widowed

Are you in school?

Yes No

If yes, what grade? Name of school:

Full-time student? Yes No

Are you pregnant? Yes No If yes, due date? How many babies are expected? Answer the questions below if you are applying for yourself. You do not

need to

answer these

questions

if you are

applying only

for SNAP.

Yes No

If not eligible for full Medical Assistance coverage, do you want to be reviewed for coverage for the Family Planning Services program only?

Yes No

If you are under 21, we will consider only your income in our determination for the Family Planning Services program. If you wish to be reviewed for full Medical Assistance coverage, we will need to evaluate your household income, including your parent(s)’ income. Do you want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No

Regardless of age, are you afraid that information you may receive where you live about family planning services could cause physical, emotional, or other harm from your spouse, parents, or other person? If yes, do you have another address (other than where you live) where you’d like to get information about family planning services?

Are you a U.S. citizen or national? Yes No

If you are not a U.S.

citizen or national,

answer the following

questions:

Do you have eligible

immigration status? Yes

If yes, fill in the

document type

and ID number:

Document type: Document ID number:

Do you have a sponsor? Yes No Have you lived in the U.S. since 1996? Yes No RACE (Optional)

(Check all that apply)

Black or African American Asian Native Hawaiian or Pacific Islander American Indian or Alaska Native (See Appendix A) White Other ETHNICITY (Optional) Hispanic or Latino Non Hispanic or Latino Page 3 PA 600 8/23

Person 2 CAO Use Only Line #:

Name (Include first, middle initial, last, suffix-Jr./Sr./etc.) Are you applying for this person? Yes No

Social Security number:

Birthdate (MM/DD/YYYY): Sex

M F

Driver’s license or state ID number

if this person has one: Marital

Status

Single Separated Married

Divorced Widowed

How is this person related to you?

Spouse Child Stepchild Not Related

Other Does this person live with you?

Yes No

Is this person in school?

Yes No

If yes, what grade? Name of school:

Full-time student? Yes No

Is this person pregnant? Yes No If yes, due date? How many babies are expected? Answer the questions below if you are applying for this person. You do not

need to

answer these

questions

if you are

applying only

for SNAP.

Yes No

If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only?

Yes No

If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income. Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No

Regardless of age, are they afraid that information they may receive where they live about family planning services could cause physical, emotional, or other harm from their spouse, parents, or other person? If yes, do they have another address (other than where they live) where they’d like to get information about family planning services?

Is this person a U.S. citizen or national? Yes No

If this person is not

a U.S. citizen or

national, answer the

following questions:

Does this person have

eligible immigration

status?

Yes

If yes, fill in the

document type

and ID number:

Document type: Document ID number:

Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes No RACE (Optional)

(Check all that apply)

Name (Include first, middle initial, last, suffix-Jr./Sr./etc.) Are you applying for this person? Yes No

Social Security number:

Birthdate (MM/DD/YYYY): Sex

M F

Driver’s license or state ID number

if this person has one: Marital

Status

Single Separated Married

Divorced Widowed

How is this person related to you?

Spouse Child Stepchild Not Related

Other Does this person live with you?

Yes No

Is this person in school?

Yes No

If yes, what grade? Name of school:

Full-time student? Yes No

Is this person pregnant? Yes No If yes, due date? How many babies are expected? Answer the questions below if you are applying for this person. You do not

need to

answer these

questions

if you are

applying only

for SNAP.

Yes No

If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only?

Yes No

Is this person a U.S. citizen or national? Yes No

If this person is not

a U.S. citizen or

national, answer the

following questions:

Does this person have

eligible immigration

status?

Yes

If yes, fill in the

document type

and ID number:

Document type: Document ID number:

Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes No RACE (Optional)

(Check all that apply)

Person 4 CAO Use Only Line #:

Name (Include first, middle initial, last, suffix-Jr./Sr./etc.) Are you applying for this person? Yes No

Social Security number:

Birthdate (MM/DD/YYYY): Sex

M F

Driver’s license or state ID number

if this person has one: Marital

Status

Single Separated Married

Divorced Widowed

How is this person related to you?

Spouse Child Stepchild Not Related

Other Does this person live with you?

Yes No

Is this person in school?

Yes No

If yes, what grade? Name of school:

Full-time student? Yes No

Is this person pregnant? Yes No If yes, due date? How many babies are expected? Answer the questions below if you are applying for this person. You do not

need to

answer these

questions

if you are

applying only

for SNAP.

Yes No

If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only?

Yes No

Is this person a U.S. citizen or national? Yes No

If this person is not

a U.S. citizen or

national, answer the

following questions:

Does this person have

eligible immigration

status?

Yes

If yes, fill in the

document type

and ID number:

Document type: Document ID number:

Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes No RACE (Optional)

(Check all that apply)

Name (Include first, middle initial, last, suffix-Jr./Sr./etc.) Are you applying for this person? Yes No

Social Security number:

Birthdate (MM/DD/YYYY): Sex

M F

Driver’s license or state ID number

if this person has one: Marital

Status

Single Separated Married

Divorced Widowed

How is this person related to you?

Spouse Child Stepchild Not Related

Other Does this person live with you?

Yes No

Is this person in school?

Yes No

If yes, what grade? Name of school:

Full-time student? Yes No

Is this person pregnant? Yes No If yes, due date? How many babies are expected? Answer the questions below if you are applying for this person. You do not

need to

answer these

questions

if you are

applying only

for SNAP.

Yes No

If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only?

Yes No

Is this person a U.S. citizen or national? Yes No

If this person is not

a U.S. citizen or

national, answer the

following questions:

Does this person have

eligible immigration

status?

Yes

If yes, fill in the

document type

and ID number:

Document type: Document ID number:

Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes No RACE (Optional)

(Check all that apply)

Person 6 CAO Use Only Line #:

Name (Include first, middle initial, last, suffix-Jr./Sr./etc.) Are you applying for this person? Yes No

Social Security number:

Birthdate (MM/DD/YYYY): Sex

M F

Driver’s license or state ID number

if this person has one: Marital

Status

Single Separated Married

Divorced Widowed

How is this person related to you?

Spouse Child Stepchild Not Related

Other Does this person live with you?

Yes No

Is this person in school?

Yes No

If yes, what grade? Name of school:

Full-time student? Yes No

Is this person pregnant? Yes No If yes, due date? How many babies are expected? Answer the questions below if you are applying for this person. You do not

need to

answer these

questions

if you are

applying only

for SNAP.

Yes No

If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only?

Yes No

Is this person a U.S. citizen or national? Yes No

If this person is not

a U.S. citizen or

national, answer the

following questions:

Does this person have

eligible immigration

status?

Yes

If yes, fill in the

document type

and ID number:

Document type: Document ID number:

Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes No RACE (Optional)

(Check all that apply)

Name (Include first, middle initial, last, suffix-Jr./Sr./etc.) Are you applying for this person? Yes No

Social Security number:

Birthdate (MM/DD/YYYY): Sex

M F

Driver’s license or state ID number

if this person has one: Marital

Status

Single Separated Married

Divorced Widowed

How is this person related to you?

Spouse Child Stepchild Not Related

Other Does this person live with you?

Yes No

Is this person in school?

Yes No

If yes, what grade? Name of school:

Full-time student? Yes No

Is this person pregnant? Yes No If yes, due date? How many babies are expected? Answer the questions below if you are applying for this person. You do not

need to

answer these

questions

if you are

applying only

for SNAP.

Yes No

If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only?

Yes No

Is this person a U.S. citizen or national? Yes No

If this person is not

a U.S. citizen or

national, answer the

following questions:

Does this person have

eligible immigration

status?

Yes

If yes, fill in the

document type

and ID number:

Document type: Document ID number:

Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes No RACE (Optional)

(Check all that apply)

Other questions about people in your home:

Please answer these questions about you or anyone in your home who is applying for benefits. Does anyone get cash assistance, Medical

Assistance or SNAP in another state now? Yes No

If yes, what state and county?

Have you or anyone in your household been

disqualified or agreed to be disqualified for

food stamps or SNAP benefits in another state?

Yes No

If yes, tell us who:

Has anyone ever applied for any benefits using

a different name or Social Security number? Yes No If yes, please tell us the name and Social Security number: Is anyone in the U.S. military, or has anyone

been in the U.S. military? Yes No

Is anyone a widow, spouse, or child (under age 18) of anyone in the U.S. military, or anyone who has been in the U.S. military? Yes No Was anyone in foster care at age 18 or older? Yes No If yes, who? State:

Is anyone disabled, seriously ill, or in need of

medical attention? Yes No

If yes, who? What is the disability?

Does anyone have a medical condition that

requires health sustaining medication? Yes No

If yes, who?

Does anyone live in a medical or long term care facility or have a physical, mental or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.)? Yes No Does anyone have paid or unpaid medical bills

this month or the last three months? Yes No Has anyone been a victim of domestic abuse? Yes No Is anyone in treatment for drug or alcohol

abuse? Yes No

If yes, who?

Absent relatives: This section is for cash applicants. If anyone is applying for a child who has parents not living in your home or if anyone applying has a spouse not living in your home, please answer these questions so that we can try to get support. You do not need to fill out this section if providing this information or seeking support would put you or family members at risk of domestic violence or make it more difficult to escape domestic violence, or if your child was born as a result of rape or incest, or if you are considering adoption. If it would be a problem for you to provide this information or seek support because of domestic violence, rape or incest or because you are considering putting a child up for adoption, check this box: Name of person with an absent relative: Name of absent relative: Absent relative is a: Parent Spouse

Name of person with an absent relative: Name of absent

Contact this candidate