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Help: If this person is eligible for more than one type of medical program, what would be the preference? Tell me more 
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Medical ProgramSummary
Aid to Aged, Blind and Disabled (AABD) Medical Covers seniors, persons who are blind and persons with disabilities with income up to 100% of the federal poverty level (FPL) and resources below the allowable limit. If income or resources are over the limit, the person may be eligible for spenddown. Please see HFS 591SP Medicaid Spend-down for more info on AABD spenddown.
FamilyCare/All Kids Covers children 18 years of age and younger, and their parents or caretaker relatives. To be eligible, children must live in families with countable family income within 318 % of the federal poverty level (FPL). The parents/caretaker relatives are eligible for coverage if the countable income is up to 138% FPL.
ACA Adults Covers adults 19-64, who are not parents or caretakers of minor children, with income up to 138% of the federal poverty level.
NOTE: All the above mentioned programs provide the same medical coverage.For medical program information, visit: www2.illinois.gov/hfs/MedicalClients/Pages/medicalprograms.aspx
Aid to the Aged, Blind and Disabled (AABD)     Family Care or ACA     No Preference

Help: Does this person want to backdate their medical application three months? Tell me more 
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Backdating your medical application could help pay for unpaid medical bills during that time. If you would like to backdate your medical application you must answer 'YES' to Healthcare Coverage.
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Household Composition

Person-Personal Information








Help: Social Security #: Tell me more 
Tell me more

Providing a Social Security Number is required by law for applicants seeking benefits. It will be used to help the State agency determine eligibility and benefit level. You do not have to give us the number for any person for whom you are not requesting benefits, but if you do, it may speed up the application process.

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Person-Program Selection


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Help: If this person is eligible for more than one type of medical program, what would be the preference? Tell me more 
Tell me more

Medical ProgramSummary
Aid to Aged, Blind and Disabled (AABD) Medical Covers seniors, persons who are blind and persons with disabilities with income up to 100% of the federal poverty level (FPL) and resources below the allowable limit. If income or resources are over the limit, the person may be eligible for spenddown. Please see HFS 591SP Medicaid Spend-down for more info on AABD spenddown.
FamilyCare/All Kids Covers children 18 years of age and younger, and their parents or caretaker relatives. To be eligible, children must live in families with countable family income within 318 % of the federal poverty level (FPL). The parents/caretaker relatives are eligible for coverage if the countable income is up to 138% FPL.
ACA Adults Covers adults 19-64, who are not parents or caretakers of minor children, with income up to 138% of the federal poverty level.
NOTE: All the above mentioned programs provide the same medical coverage.For medical program information, visit: www2.illinois.gov/hfs/MedicalClients/Pages/medicalprograms.aspx
Aid to the Aged, Blind and Disabled (AABD)     Family Care or ACA     No Preference

Help: Do you want to backdate your medical application three months? Tell me more 
Tell me more

Backdating your medical application could help pay for unpaid medical bills during that time. If you would like to backdate your medical application you must answer 'YES' to Healthcare Coverage.
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Person-Additional Medical Questions
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Person-Citizenship
Help: Citizenship Tell me more 
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Is the person applying a U.S. Citizen?
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Person-Race/Ethnicity
Help: Race/ Ethnicity Tell me more 
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Select this person's race/ethnicity. You may select more than one Race. You do not have to answer these questions if you do not want to. Your answers will not be used to make a decision about your benefits.
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Click the "Add Person" button to add and complete person information for additional people in your home.

SNAP Questions



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Benefit Information
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SNAP and Cash Applicants:
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SNAP Coverage - Client Rights and Responsibilities:


 

 


 


 

 


 

 
To file a program discrimination complaint, a Complainant should complete a Form AD -3027, the USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office by calling (833) 620-1071, or by writing a letter to USDA. The letter must contain the Complainant's name, address, telephone number, and a written description of the alleged discriminatory action in sufficient details to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:
 
  1. (1) Mail: Food and Nutrition Service, USDA
    1320 Braddock Place, Room 334
    Alexandria, VA 22314; or
  2. (2) Fax: (833) 256-1665; or
  3. (3) Email: FNSCIVILRIGHTSCOMPLAINTS@usda.gov

This institution is an equal opportunity provider.

Additional Illinois Nondiscrimination Information

You may also write the Illinois Department of Human Services (IDHS) at Illinois Department of Human Services, Bureau of Civil Affairs, 401 South Clinton St., 6th Floor, Chicago, Illinois, 60607 or call the IDHS Helpline Number at 1-800-843-6154 or 866-324-5553 TTY/Nextalk or 711 Relay.

IDHS, HHS, and USDA are equal opportunity providers and employers.

The State of Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.


 

 

 

 

 

 
  • Hide or give wrong information on purpose to get SNAP benefits.
  • Trade, steal or sell SNAP benefits, or resell food bought with SNAP benefits.
  • Use SNAP benefits to buy non-food items like alcohol or tobacco.
  • Use someone else's SNAP benefits for yourself or someone else.
  • Throw away beverages purchased with SNAP benefits just to get money back from a container deposit.
  • 12 months the first time
  • 24 months the second time
  • permanently the third time

  • Trade SNAP benefits for controlled substances, such as drugs.
  • 24 months the first time
  • permanently the second time

  • Trade SNAP benefits for firearms, ammunition or explosives.
  • permanently

  • Buy, sell or trade SNAP benefits of more than $500.00.
  • permanently
  • Give false information about who you are and where you live so you can get extra SNAP benefits.
  • 10 years

 

 

Cash / Healthcare Coverage - Client Rights and Responsibilities:

 

 
  • The SSN will be used in computer matching and program reviews or audits and to make sure the household is eligible for assistance, other federal assistance programs, and federally assisted state programs, such as school lunch, TANF, and Medicaid.
  • Statements you provide as well as information from other verification systems is used; this includes such information as receipt of social security benefits, unemployment insurance, unearned income and wages from employment.
  • Any information obtained will be used in determining eligibility for assistance and the amount of assistance provided for all programs.
  • When discrepancies are found, verification of this information may be obtained through contacts with a third party, such as employers, claims representatives, or financial institutions. This information may affect your eligibility for assistance and the amount of assistance provided.
  • Your SSN will only be used for the purpose for which it was collected.
  • Your SSN will not be: sold, leased, loaned, traded, or rented to a third party for any purpose; it will not be publicly posted or publicly displayed. We will not require you to transmit your SSN over the Internet, unless the connection is secure or your SSN is encrypted. We will not print your SSN on any materials that are mailed to you, unless State or Federal law requires that number be on documents mailed to you, or unless we are confirming the accuracy of your SSN.
 
  • Cooperation includes establishment of paternity and/or support enforcement and modification of child support orders.
  • I assign and give all my rights, title and interest of child support and medical support to the Healthcare and Family Services (IHFS) as long as I receive Cash/or Healthcare Coverage.
  • I understand and agree that any child support payments paid through the clerk of the circuit court and through the State Disbursement Unit (SDU) may be forwarded to the HFS as long as I receive Cash.
  • I understand that if I apply for Cash and/or Healthcare Coverage for my children only, I am not required to cooperate with child support enforcement, but I may request services.
  • Income, resources, or property ;
  • The number of people in household ;
  • Address or phone number ;
  • Someone moves out of Illinois, dies, goes to jail or prison ;
  • Someone becomes covered by other insurance
Right to Appeal I understand that if I am not satisfied with the action taken on my application that I have the right to a fair hearing. I understand that I can ask for a fair hearing by getting in touch with the office where I applied or by writing to: Illinois Department of Human Services, Bureau of Assistance Hearings, 401 South Clinton Street, 6th Floor, Chicago, Illinois 60607, by emailing Department of Human Services Bureau of Hearings email address or by calling 1-800-435-0774. If you use a TTY, call 1-877-734-7429.

 

To file a complaint of discrimination for yourself or someone else regarding a program receiving federal financial assistance through HHS, complete the form on line through OCR's Complaint Portal at https://ocrportal.hhs.gov/ocr/. You may also contact OCR via mail at: Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201; fax: (202) 619-3818; or email: OCRMail@hhs.gov. For faster processing, we encourage you to use the OCR online portal to file complaints rather than filing via mail. Persons who need assistance with filing a civil rights complaint can email OCR at OCRMail@hhs.gov or call OCR toll-free at 1-800-368-1019, TDD 1-800-537-7697. For persons who are deaf, hard of hearing, or have speech difficulties, please dial 7-1-1 to access telecommunications relay services. We also provide alternative formats (such as Braille and large print), auxiliary aids and language assistance services free of charge for filing a complaint.

Fraud Penalty Affidavit


 

Report fraud for Cash, SNAP & Healthcare Coverage

Electronic Attestation

I have agreed to submit this application by electronic means. By signing this application electronically, I declare under penalties of perjury that my answers are correct and complete to the best of any knowledge and belief. I declare under penalties of perjury, that the citizenship or alien status of each person applying for assistance is true and correct. I also declare the following:

  • I understand the questions and statements on this application.
  • I have read and understand my Rights and Responsibilities in the box above.
  • I understand the penalties for giving false information.
  • I understand that upon verification of my information, this attestation will have the same legal effect and can be enforced in the same way as a written signature.
 


Official Site of The State of Illinois