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    Here Are Examples of Documents You Can Send

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    Curtis Savage
    This document provides examples of documents that can be submitted to the Department of Human Services (DHS) to provide information about an individual's earned income, unearned income, citizenship, liquid resources, residency, identity, psychological eligibility, expenses, relationships, date of birth, and burial resources. For each category, it lists the types of information needed and common examples of supporting documentation such as pay stubs, tax returns, bank statements, licenses, evaluation reports, and contracts.

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    Here Are Examples of Documents You Can Send

    Uploaded by

    Curtis Savage
    29 views2 pages
    This document provides examples of documents that can be submitted to the Department of Human Services (DHS) to provide information about an individual's earned income, unearned income, citizenship, liquid resources, residency, identity, psychological eligibility, expenses, relationships, date of birth, and burial resources. For each category, it lists the types of information needed and common examples of supporting documentation such as pay stubs, tax returns, bank statements, licenses, evaluation reports, and contracts.

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    This document provides examples of documents that can be submitted to the Department of Human Services (DHS) to provide information about an individual's earned income, unearned income, citizenship, liquid resources, residency, identity, psychological eligibility, expenses, relationships, date of birth, and burial resources. For each category, it lists the types of information needed and common examples of supporting documentation such as pay stubs, tax returns, bank statements, licenses, evaluation reports, and contracts.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    29 views2 pages

    Here Are Examples of Documents You Can Send

    Uploaded by

    Curtis Savage
    This document provides examples of documents that can be submitted to the Department of Human Services (DHS) to provide information about an individual's earned income, unearned income, citizenship, liquid resources, residency, identity, psychological eligibility, expenses, relationships, date of birth, and burial resources. For each category, it lists the types of information needed and common examples of supporting documentation such as pay stubs, tax returns, bank statements, licenses, evaluation reports, and contracts.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Here are examples of documents you can send.

    DHS may need more information to decide if you can get benefits.
    These are examples of the documents you can give DHS to provide that information.

    Information Needed Examples


    Earned Income Pay stubs, employment letter, wage form, tax return, completed
    verification of earnings form, farming/self-employment records.

    Unearned Income Social Security award letters, VA award letters (must include aid and
    attendance), retirement benefits letters (APERS, pension, railroad,
    OPM, etc.), rental property rental agreement, any monies received from
    insurance companies, trust documents (revocable, irrevocable, annuity,
    special needs, etc.), mineral rights/oil lease payments (including all
    checks received in last 12 months), any interest payments, worker’s
    compensation, cash contributions.

    Citizenship US passport, US citizen ID card (I-197), Social Security record, school


    record, birth certificate, Medicare card, certificate of naturalization,
    certificate of citizenship.

    Liquid Resources Bank account statement for all checking and savings accounts, Direct
    Express account, deeds to all real property, personal property
    assessments, trust documents, life estates, certificate of deposit,
    Individual Retirement Account (IRA), patient fund accounts, any
    inheritance or insurance settlements, copies of promissory notes, any
    stocks or bonds, dividends.
    If you own a home, no one is living in your home, and you would like
    to return home at some point in the future, please provide signed
    written statement stating your intent to return home. Proof of any
    resource that was sold, deeded, given away in the last 5 years (Bills of
    sale, receipts, bank statements, deeds, etc.)

    Residency Driver’s License, rent or mortgage statement, written statement from


    someone outside the home, other document showing name and
    address.

    Identity Driver’s License, adoption record, birth certificate, income tax return,
    law enforcement records (ex. sentencing order, release paperwork),
    federal, state, or local government issued ID.

    1
    Information Needed Examples
    Psychological Eligibility Child
    • Aged 5 – 18 or 21 if still in school; School records that include
    most recent psychological evaluation report (current within 3
    years). It should show the Intelligence Quotient (IQ) and
    adaptive behavior.
    • Current Individualized Education Plan (IEP) with conference
    decision form.
    • Other therapy evaluation reports that have related or support
    services (OT, PT, Speech, or Mental health reports as
    applicable).
    Adult
    • Signed and dated Psychological evaluation report. It should
    show the Intelligence Quotient (IQ) and adaptive behavior
    (current within 5 years).
    Expenses
    Household expenses such as real property tax (like for home or land)
    and personal property tax (like for vehicles, boats, campers,
    motorcycles), mortgage or rent, homeowner insurance premium, rental
    insurance premium.
    Relationship Marriage license or divorce decree, birth certificate, school records,
    adoption records or court order.
    Date of Birth US passport, US citizen ID card (I-197), school record, birth certificate,
    certificate of naturalization, certificate of citizenship, Driver’s License,
    adoption record, federal, state, or local government issued ID.
    Burial Resource
    Burial policies, deeds to burial plots, itemized burial contract, life
    insurance policies connected to burial contracts, burial annuity, burial
    association policy.

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