Summary of e-Form # W6853451

Health and Human Services Signature Page

Do not complete - For the County Assistance Office Use
e-Form Number e-Form Date Primary Applicant Address W6853451 02-14-2012 09:07:27 PM Matthew A Sweeney RR2 BOX 405A, Canadensis, PENNSYLVANIA, 18325 App Reg # Date Stamp Caseload Record #

Do not complete - For your Provider

County Organization Name Type of Community Based Organization Community Organization Provider Number Type of Medical Service Date of First Admission or Treatment You are applying for Health and Human Service Benefits for the following individuals: Matthew A Sweeney Monroe Provider Name Provider Number Inpatient Outpatient Emergency Non-applicable

Rights & Responsibilities Summary Statement and Certification of Citizenship or Alien Status
- I certify to the best of my knowledge that I understand my rights and responsibilities. - I authorize the release of my personal, financial, and medical information for the purpose of determining eligibility. - I understand that my situation is subject to verification from employers, financial sources and other third parties. - I understand I am required to report changes as stated on the Rights and Responsibilities page. - I certify that all information in this application is true and correct under penalty of perjury. - I certify that the person(s) that I am applying for are U.S. citizens or aliens in satisfactory immigration status. (This certification does not apply to an alien who is applying only for Medicaid emergency health care benefits.).

Signature of applicant or person applying for applicant

X Matthew A Sweeney Signature

02-14-2012 09:07:27 PM Date

Summary of e-Form # W6853451

Application Information
Application Submitted Date 02-14-2012 09:07:27 PM

Household Information
Address
Street Address RR2 BOX 405A

City State Zip County

Canadensis PENNSYLVANIA 18325 Monroe

Head of Household
Name Birth Date Gender Matthew A Sweeney 10-27-1989 Male

Household Individuals
Name Matthew A Sweeney Birth Date 10-27-1989 Gender Male

Benefits
Health Care Coverage Matthew A Sweeney SNAP (Food Stamps) Benefit Matthew A Sweeney Cash Assistance Matthew A Sweeney

Individual Details
Household
Has anyone been issued a summons or warrant to appear as a defendant at a criminal court proceeding? Does anyone owe fines, costs or restitution for a felony or misdemeanor offense? No No

Has anyone been convicted of welfare fraud? Is anyone currently on probation or parole? Is anyone currently fleeing from law enforcement officials? Has anyone in the household ever applied for benefits with a different name or social security number? Has anyone in the home ever been disqualified or agreed to be disqualified from receiving SNAP (Food Stamps) benefit or Cash Assistance in another state? Is everyone in your household living in a certified shelter for battered women?

No No No No No

No

Address
How long have you lived at this address? 2 Years i 570-269-8289 570-269-8289 570-269-8289 msweeney2789@gmail.com any P.O. Box 43, Cresco, PENNSYLVANIA, 18326

Contact Information
Home or Contact Phone Number Work Phone Number Mobile Phone Number E-mail Address When is the best time to call? What was your previous address?

Other Information
How long have you lived in Pennsylvania? Has anyone in the household ever received benefits in Pennsylvania? Have you ever applied for or received benefits while in another U.S. state? 22 Years, 5 Months No No No

Will your household's total income for this month be less than $150 before taxes are taken out? Include money you have already received this month, as well as money you expect to receive later this month. Has your household received (or will it receive) SNAP (Food Stamps) this month from any state? Does your household have $100 or less in cash, checking accounts, or savings accounts? What school district does the household live in? City/Township/Borough Would you like to allow someone else to obtain your SNAP (Food Stamps) Benefits for you? This person will also be able to use the SNAP (Food Stamps) to buy food for you. Does anyone in the household who is 21 or younger have a parent who does not live in the house or who has died? Does anyone in the household have a spouse who is not living in the house or has died? Does anyone in the household need help applying for child support or health insurance from an absent parent?

No

Yes Pocono Mountain BARRETT TWP. No

No

No

No

Is your monthly rent or mortgage and utilities (such as gas, electric, water, and telephone) MORE than your total monthly income before taxes are taken out?

Yes

Individual Information - Matthew A Sweeney General Details

What is this individual's citizenship status? US Citizen No Non-veteran No No Single/Never Married 204-70-7197 White or Caucasian No No High School Diploma, GED No

Is this individual currently a student? Is this individual a veteran? Is this individual a spouse, widow(er), parent, or minor child of a veteran? Has he/she applied for any benefits that they have not received yet? What is this individual's marital status? What is this individual's Social Security Number? What is this individual's race? Is this individual of Hispanic origin? Has this individual ever been known by another name? What is the highest grade level completed by this individual? Is this individual a migrant or seasonal farm worker?

Voter Registration
Is this individual interested in registering to vote? Yes

Income Details
Household Income
Does anyone currently have one or more jobs? Who has current employment? Has anyone stopped working at one or more jobs in the past 30 days? Does anyone receive money from one or more sources other than a job? Yes Matthew A Sweeney No No

Income Information - Matthew A Sweeney

C

Current Income
Employer Name Employer Street Address City State Zip Employer Phone Number When did this individual begin working at this job? Is this individual on strike for this job? How many hours does this individual work at this job each week? When does this individual get paid? What is this individual's gross income on each paycheck? This is the money he/she gets before paying for taxes and other deductions. CLUCK U UNIVERSITY 107 Brown Street East Stroudsburg PENNSYLVANIA 18301 570-431-0198 02-04-2012 No 15 Every Two Weeks $96.00

What is this individual's hourly pay rate? When did he/she last receive a paycheck for this job?

$7.25 02-10-2012

Transportation Expenses
For which employer does he/she have to pay for transportation to get to work? If this individual drives with another person or takes the bus/subway/trolley, how much does it cost each week? If this individual drives to work, how many miles are driven each week? If this individual owns or leases a car, what is the monthly payment? CLUCK U UNIVERSITY

$20.00

60 $300.00

Expenses
Household Expenses
Does the household currently receive housing assistance? Does anyone in the household pay any shelter, utility, or other household expenses? Does the household share any shelter expenses with someone who does not live in the household? Does anyone pay for child care or care for an adult with a disability so that they can go to work? Does anyone pay for child care or adult care so that they can attend training or pursue education in order to prepare for employment? Does anyone pay legal fees to collect any income? Does anyone pay child support to a person who does not live in the house? In the last 90 days, has anyone in the household had any medical expenses that they had to pay themselves? In other words, has anyone had any medical expenses that were not covered by health insurance? Has the household received any LIHEAP payments since October 1st? No Housing Subsidy No No No No No No No

No

Insurance
Household
Does anyone have health (or medical) insurance (including Medicare or Long Term Care Insurance) Has anyone lost health insurance within the last 6 months? No No

Health Insurance - Employer

Could anyone get health insurance through their job? No

Ways To Qualify
Household
Does anyone have a medical condition (including a disability), a chronic condition (such as arthritis), an ongoing special health care need, or ongoing medication prescribed by a doctor? Who? Has anyone received Supplemental Security Income in the past? Yes

Matthew A Sweeney No

Has anyone received Social Security Disability in the past? Does anyone have unpaid medical bills or ongoing medical expenses? Who? Has anyone paid medical bills this month or within the past 3 months? Is anyone disabled, blind, seriously ill, or in need of help to overcome a drug or alcohol problem? Is anyone receiving treatment for a drug or alcohol problem? Is anyone receiving protective services as a victim of domestic violence?

No Yes Matthew A Sweeney No No

No No

Ways to Qualify - Matthew A Sweeney Medical Condition

Please describe the medical condition Seizures

Is the parent able to care for his or her child(ren)?

No

Resources
Household
Does anyone have cash or other financial holdings, such as a checking or savings account? Does anyone own non-residential property? Is anyone expecting to receive any money, such as an inheritance, accident settlement, or trust fund? Does anyone own any vehicles, such as a car, truck, or motorcycle? Does anyone own a burial space? Does anyone have a burial or trust agreement with a bank or funeral home? Does anyone own a life insurance policy? No No No Yes No No No

Vehicle
Who in the household owns a vehicle? What model year is the vehicle? What make is the vehicle? What model is the vehicle? Is the vehicle licensed? Is money still owed for this vehicle? Matthew A Sweeney 2001 Saturn SL1 Yes $2500.00

Additional Information
What language do the applicants most easily understand? If an interview is necessary, do you want an interpreter? English No

Rights & Responsibilities

I understand that the information entered in this application will be kept confidential and used only to administer benefits. I authorize the release of personal, financial and medical information for the purpose of determining eligibility. I understand that any changes I am required to report must be reported within the first 10 days of the month following the month of change. For reporting changes to a child care agency, please see the Child Care Works Rights & Responsibilities. I understand that I will receive a written notice explaining the benefits. If benefits are denied, changed, suspended, or stopped, the written notice will explain why. I understand that I will have 30 days (90 days for SNAP (Food Stamps) Benefit) from the date of the notice to request a hearing if I do not agree with the decision made on this application. I understand that my situation is subject to verification from employers, financial sources and other third parties. I understand that applicants must provide their Social Security Number or apply for one if they do not have one. This number may be used to check the information on this application. I understand that I must use the Electronic Benefit Transfer (EBT) or the PA ACCESS Card only during the period I am eligible. I must use the EBT or the PA ACCESS Card only for the person who is eligible and I may get only the benefits that are needed and reasonable. I understand that I do not have to provide a Social Security Number for anyone who is not applying for Medical Assistance. If I do provide their Social Security Number, it may be used to check the information on this application. I certify that all information that has been entered is true under penalty of perjury. I understand that I have the right to a certificate of creditable coverage to verify my medical coverage. Federal law limits when health care coverage may be denied or limited for a pre-existing condition. If I enroll in a group health plan that has a pre-existing condition clause, I can get credit for the time I received Medical Assistance. I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for CHIP. If this is the case, I authorize the Department of Public Welfare to give my name and information on this application to the Insurance Department or the CHIP contractor. I understand my rights and responsibilities under CHIP. If I receive cash benefits, I will cooperate with the requirements of the child support enforcement program as directed by the Department. I give the Department and the Domestic Relations Section the right to pursue and collect cash and/or medical support for me and others for whom I am applying.
d

Supplemental Nutrition Assistance Program (Food Stamps) Rights & Responsibilities I understand that if I report and provide proof of the household expenses, I will get the maximum amount of SNAP (Food Stamps) benefits allowed. Failure to report or provide proof of the household expenses will be regarded as my statement that I do not want to receive a deduction for the unreported or unproved expense. (Authority: United States Department of Agriculture, Food and Nutrition Service, Mid-Atlantic Region, Administrative Note 6-99, issued January 4, 1999). I understand that I have the right to receive credit for the household expenses at the time I report and provide proof of them at any time during my SNAP (Food Stamps) certification period. I understand that I have the right to ask the County Assistance Office (CAO) for assistance in getting proof of expenses and that the CAO can contact other people for confirmation if I am having trouble getting proof of anything. In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. Children's Health Insurance Program (CHIP) Rights & Responsibilities You have a right to: Confidentiality All information on this application will be kept confidential. This application will be shared only with the programs for which you apply and/or may be eligible, such as the Medical Assistance program. Designate a Personal Representative You may select another person to receive health related information regarding you or your minor child(ren) by completing a Personal Representative Designation form. Certificate of Creditable Coverage When you leave the program, you will receive a certificate of creditable coverage to verify medical coverage, if you are eligible. Written Notice You will be given a written notice explaining your eligibility. Appeal You may request an impartial review if you do not agree with any decision made regarding this application, if the request is made within 30 days of the decision. You have a responsibility to: Read and fully understand this application. Provide true, correct and complete information, understanding that there are penalties for knowingly giving false information: it is a serious offense and considered criminal insurance fraud. Help with the review of this application, which may include interviews and reviewing health records. Be aware that certain information may be subject to verification from employers, financial sources and other third parties. Provide proof of identity and U.S. citizenship if that information is not obtained through this application process. Provide proof of legal immigration status by presenting documentation from the U.S. Citizenship and Immigration Services if you are applying for someone who is not a U.S. Citizen. Report all changes regarding your household including income, address and telephone number as soon as they occur.

Verification Documents Required for e-Form # W6853451

In order to finish processing this case, please obtain copies of the documents below:
Note: If information is missing or you have any questions please contact HELPLINE at 1-800-692-7462

Department of Public Welfare Individual

Provide Proof of
Disability

Individual
Matthew A Sweeney

Provide copy of one of the following

Medical information to verify disability and/or need for medication

Date of Birth

Matthew A Sweeney

Naturalization Certificate, Adoption Record, Hospital Records, School Records, Bureau of Vital Statistics Records, Driver's License, Passport

Identification

Matthew A Sweeney

Driver's License, Passport, Selective Service Card, State Identification Card, Voter Registration Card, Work or School Identification Card

Income
Provide Proof of
Current Income - Employer

Individual
Matthew A Sweeney

Provide copy of one of the following

Pay Stubs, Employee's W2, Income Producing Contract, Pay Envelope, Wage Tax Receipts, Self Employment Bookkeeping Records, Statement from Company

Expense
Provide Proof of
Expenses - Transportation Expenses - Medical

Individual
Matthew A Sweeney Matthew A Sweeney

Provide copy of one of the following

Current Receipt, Bills Statements or bills from physicians, pharmacists, or other certified providers, Bills from providers of health insurance, services, and products, Health Insurance Policies

Resource
Provide Proof of
Resources - Vehicles

Individual
Matthew A Sweeney

Provide copy of one of the following

Car Dealer Statement, Published Car Wholesale Book

Address Information
Please mail, fax, or hand-deliver the documents above as soon as possible, but no later than Mar-15-2012 :
Monroe County Assistance Office Business Route 209 South at Tanite Road P.O. Box 232 Stroudsburg, PA 18360-0232 Info Number: 570-424-3030 Fax Number: 570-424-3915 Toll Free Number: 1-877-905-1495 Email:C-MONROE@STATE.PA.US

Routing & Provider Information of e-Form # W6853451

Note: If information is missing or you have any questions please contact HELPLINE at 1-800-692-7462 Department of Public Welfare
Monroe County Assistance Office Business Route 209 South at Tanite Road P.O. Box 232 Stroudsburg, PA 18360-0232 Info Number: 570-424-3030 Fax Number: 570-424-3915 Toll Free Number: 1-877-905-1495 Email:C-MONROE@STATE.PA.US

The information on this application will be sent to the County Assistance Office for processing. Eligibility for the following program(s) will be evaluated.
Health Care Coverage SNAP (Food Stamps) Benefit Cash Assistance

Based upon the information you have given us, this application will be processed for Medical Assistance health care Health care coverage may include: - Checkups - Sick Visits and Prescription Drugs - Emergency Room Care - Hearing Testing and Hearing Aids - Immunizations - Vision Testing and Eyeglasses - Lab Tests and X-rays - Mental Health and Substance Abuse Treatment

If someone in the house no longer qualifies for CHIP, that person might be able to receive Medical Assistance. If this can happen, the Insurance Department will give the information on this application to the Department of Public Welfare.