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Page 1: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)� � � � � � � � � � �� � � � � � � � � �� � � � � � � � � � � � � � �

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a W T H W H T b M P M c W d d X U G P U Q O R P G [ [ d W S G U W O H ^ 8 � � � � � � & � # � & � 5 + " � ( � � � . � � � � � � ) � � � � ( � � � � � " � � � ( � � ,? � � � � 0 � � � � � � " � � ' *! � � � � � 0 � � � � � e 8 � � �7 � � � �$ � � � � � � � 0 � � � � f � � A � C � 0 � � �- $ g � ( � � � � � � � " � � �! � � � � �f 0 � � � � � � & � � � 0 � ) � � � � � � � � ) � � � � � � � � � � � � � ) � � � � � � � � � � & � ) � � � � � � � � � ( � � � 0 � � � � � � ' 5 * � � � & � � � � � � � � � � � � � � � � ( � �� � � / ' ` * � � � � � � � ) � � ( ( � � � � � � � ( � � � � � � � � � " � � � � 0 � � � � � � � � � � � � / � � � ' ; * � � � � � ( � � � � � � � � � � � � � � � � . � � 0 � 0 � � & � � � � ,8 � � �� � � � � ( � � � � � ) � � � � � � � � � � � � � ) � � � & � � � � � � � ( � � � � � � � � � � C � & � � � h � � � � � � � � � �# 0 � � � � � � " � � �$ � � � � . � � � � � � � � � � � � � � � � ) � � � � � � � � � � � � � ) � e - ( � � / � � � � � � � � � 0 � ( � � � � . � � & �

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Page 2: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

i j k k k l m n o p q r s l t u l v n w s x y z x { | } ~ � � � { � � { { � { | � � � x l � x � � � � � � { { � { | � � � x l � z � � � x � x � | � � � z | � � | � ~ � � { { � { | � � � x � � ~ � � � �� � � � | x � � � � z | � ~ � � | � ~ } | � x � | � | x ~ } i � � � � ~ � { � � � v k l t � m o v m t � t t t

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Page 3: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

State of Illinois

Department of Human Services

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  O c Z G H Q [ M O [ d M d W ¡ M c W U b Q O R ¢ W H S d R I M Q O R P X M d N £ �� � � � � � � � � 0 � ( � � � � . � � & ( � � � ) � � � � � � � � � 0 � 0 � � � 0 � � � , - � � � � � � � � � � � � . 0 � � � ) � . � � 0 � � � . 0 � � � � � � � � � B � � � � � & � � � � � � � , 8 � �� � � & � ) � � � 0 � � � � � � � � � � � � � � � � " � � ( � � � � � 0 � � � � � ( � � . 0 � � � � � � � � � � B � � � � � & " � � � ( � � , 8 � � I O H O U 0 � ) � � � & � ) � � � 0 �� � � " � � ( � � � � � � � � � � ( � � . 0 � � � � � � � � � � � � � B � � � � � & " � � � ( � � / " � � � ( � � � � � / � � � � � � � � � � � � 0 � � � � � � � � � � � � � � � � � ,% � � A � 0 � " � E ( � � � 0 � � � � & � � � � 0 � � � � � � � � � � � � � � & ( � � � � ! # % � � � � � � � � 0 � � � % , - , � � � � ( ( � E � � � � � � � � � / � ( � � �

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Page 4 of 18i j k k k l m n o p q r s l t u l v n w s x y z x { | } ~ � � � { � � { { � { | � � � x l � x � � � � � � { { � { | � � � x l � z � � � x � x � | � � � z | � � | � ~ � � { { � { | � � � x � � ~ � � � �� � � � | x � � � � z | � ~ � � | � ~ } | � x � | � | x ~ } i � � � � ~ � { � � � v k l t � m o v m t � t t t

Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

State of Illinois

Department of Human Services¼ ½ ¾ ¿ À Á ¿ Â Ã Ä Å

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% � � A � 0 � " � E ( � � � 0 � � � � & � � � � 0 � � � � � � � � � � � � � � & ( � � � � ! # % � � � � � � � � 0 � � � % , - , � � � � ( ( � E � � � � � � � � � / � ( � � � 2 � � � � � � � 0 � � � � � � � � � � � � � � � � � � � g % � E � � � � 0 $ � � � % � � � � � � � � � � # � � & � � � � e - ( � � / � � � � � � � 7 � . � � � � " � " � � � E � � � � � � e¤ N U b W X [ M P X O H W X G [ [ d Q W H T N O P ¥ M I W S G d G X X W X U G H S M G H X c M P � R M X U W O H \ ^ � �8 � 5 , $ � � � 0 � � � � � � � � � � � � ( � � � � � � � � � � ? � E 2 � � � � � � � E � � � � � e - ( � � / � � . � � ` 4 : " � � � .� �8 � ` , f � � � � 0 � � � � � � ( � � � ¦ � � � � � � . � � 0 � � � � � e - ( � � / � � � � � ( � � � � �� �8 � ; , $ � � � 0 � � � � � � 0 � ) � � � � � � � � � � � � � e - ( � � / � � � � � � � ' * �: , - � 0 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � § � � E � � � � � � e � �8 � - ( � � / � � � � 0 � � � � � � ( � 0 � � � E ( � � � � � 7 � . � � 0 � � � � � � � � � � � � � � � � 0 � � � E ( � � � � e¨ b M N O d d O c W H T � R M X U W O H X G P M N O P W H N O P Z G U W O H G d [ R P [ O X M X O H d Q © ¢ O [ U W O H G d £� �8 � - � 0 � � � � � � 7 � � � � � � � � � � � � � � ef 0 � � � � 0 � � � � � � § � � � � e ' � � � � � � � � � � � � � � * ª « � ¬ �� � ¬ � ­ � ® � ¯ � � � � � ° ± ² ¬ « � ± ³ � ´ � µ � ´ ¶ · � � � � ±¸ · � ´ ¹ ° ± º µ ± � ´ � � º � � ± � ´ � �º ¶ � � �º � � ± � ´ � � � � � � � » º · � ¶ ¹ � � � � ¬ � ­ �

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Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

State of Illinois

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Page 6: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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Page 7: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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Page 8: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

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Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

State of Illinois

Department of Human Services- � � � � � � � � � � � � 0 � � � 0 � � � � � � � � � � � � � � � � � � � � e 8 � � �- ( � � / � � � � � � � � � 0 � ( � � � � . � � & �Æ G Z M O N Ì M P X O H ©3 � � � � � � � ! � � � � �� � � " � � � ( 0 � � � . � � A � � . � � A � � � 3 � � � � � � � �3 � � � � � � � # 0 � � � �! � � � � � # � � � ' � � � � � � � � & � � � * " � ( � � � � � E � F7 � . � ( � � � � � � � � f � � A � � 3 ) � � � � . � . � � A ? . � � � � � � � � 0 % � � � 0 � �Æ G Z M O N Ì M P X O H ©3 � � � � � � � ! � � � � �� � � " � � � ( 0 � � � . � � A � � . � � A � � � 3 � � � � � � � �3 � � � � � � � # 0 � � � �! � � � � � # � � � ' � � � � � � � � & � � � * " � ( � � � � � E � F7 � . � ( � � � � � � � � f � � A � � 3 ) � � � � . � . � � A ? . � � � � � � � � 0 % � � � 0 � �- � � � � � � � � � � � � 0 � � � 0 � � � � � ( 4 � � � � � � � � e

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State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

State of Illinois

Department of Human Services� O Z [ d M U M O H d Q N O P [ M P X O H X c b O G P M V d W H I Y b G ¡ M G I W X G V W d W U Q O P G P M G T M Û Ü O P O d I M P ^ - ( � � � � � � � � � � � � ) � � & . � � 0 � � � � / � � �� � � � � � � � � � � � � � � � 0 � � � � � � . � , - ( � � � � � � � � ( � 0 � ( � � � � . � � & / � � � � � � 0 � � � � � � � " � � � . , ! � � � � 0 � � � � ( , ! � � � � 0 � � � � � � � � � � 0 � � � ' * � ( � � � � � � ,$ � � � � � � � � � . � � � � � � � � � � � � ' � � * � � 0 � � 0 � � � / ) � � � � � � � 0 � � � / � � � � 0 � � � / " � � � � � � & � � � � � � e 8 � � �C . � � � ! � � � � ? � � � 1 � � � � ! � � � � � C . � �F FF F$ � � � � � � � � � . � � � � � / � � � � A / � � � � � � � � � � / " � � � / � � � � � � � � � � � 0 � � ) � 0 � � � � e$ � � � � � � � � � . � � � � � � ( � � � � � � � � � e

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Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

State of Illinois

Department of Human Services� O Z [ d M U M O H d Q N O P M Z [ d O Q M I [ M P X O H X c b O G P M V d W H I Y b G ¡ M G I W X G V W d W U Q O P G P M G T M Û Ü O P O d I M P ^ ! � � � � � � � � 0 � � � � � � � � � � �� E � � � � ( � � � � � � � � � � � � � � � � � � � � � � � � � ( � � 0 � � � � � � � � � & � 5 + � ( � 0 � � � � ) � � � & � � 0 � � ,È Z [ d O Q M I [ M P X O H ë X H G Z M © ' 5 *

% � � � 0 � � � � � � � � � F8 � � �% � � � 0 � � � � � � � � � � � � � � � � � / & � � � � � � ( � � � � � � � � � � � � � � � � / & � � � � 0 � � � � 0 � � � � � � � � � � � � � � � / � � � � � � � � � � � � � � � �. � � 0 0 � � � � � & � � � � � � � � � � � � ( � � � � � � � � � � e- ( � � 0 � � � � � � � � � � � � � � � � � � � / � � � � � � � � � � � � � � � , ! � � � � 0 � � � � ( ,- ( � 0 � � � � � � � � � � � � � A � � 0 � " � / . 0 � � � � 0 � ( � � � � � � � � ( � � � . � � A e F- ( � 0 � � � � � � � � 0 � @ 0 � � � . � � � � / 0 � . � � � � � � � � � � � � � ( � � � . � � A e # � � � � � � � , � ( � � 0 � � �C � 0 � �� � C . � � � �8 � � �7 � . � � � � 0 � � � � � � & � � � � � � � ( � � � . � � A e$ � � � 0 � � � � � � " � � � � � ( � � � � � � � � � � � � � � � e$ � � � 0 � � � � � � " � � � � " � � � & � � � � 0 � � . � � A ef � � A � � 3 ) � � � � . � . � � A � � 4 % � � � 0 � � % � � � 0 � �� � � � & � � � � 0� � � � � � � 07 � . � ( � � � � � � � � � � � � � � � � � � � � � � E . � � 0 0 � � � � F- ( � � / � � � � � � 0 � � � � � " � � & 0 � / 0 � . � ( � � � / � � � � � � , ! � � � � 0 � � � � ( , � � � � � � / � � � � � � � � � � � � � E � . � � 0 0 � � � � F! � � � � � � � � � � ) � � " � ( � � � � � � � � � � � � ' & � � � � � � � � * � FÈ Z [ d O Q M I [ M P X O H ë X H G Z M © ' ` *

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Page 14: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

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Page 15: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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Page 16: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

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Page 17: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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Page 18: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

State of Illinois

Department of Human ServicesRequest for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)

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Page 19: State of Illinois Department of Human Services · 2015-12-08 · State of Illinois Department of Human Services Request for Cash Assistance - Medical Assistance - Supplemental Nutrition

FOR ILLINOIS RESIDENTS ONLY

TO VOTE YOU MUST:

· Be a United States citizen

· Be at least 18 years old

· Live in your election precinct at least 30 days

· Not be convicted and in jail

· Not claim the right to vote anywhere else

TO VOTE IN THE NEXT ELECTION:

Mail or deliver this application to your County Clerk or Board

of Election Commissioners no later than 28 days before the

next election. (click here for County Clerk/Election Board

listings) or go to www.elections.il.gov

IMPORTANT INFORMATION:

If you do not have a driver's license, State Identification Card or social security number,

and this form is submitted by mail, and you have never registered to vote in the

jurisdiction you are now registering in, then you must send, with this application, either (i)

a copy of a current and valid photo identification, or (ii) a copy of a current utility bill, bank

statement, government check, pay check, or other government document that shows the

name and address of the voter. If you do not provide the information required above,

then you will be required to provide election officials with either (i) or (ii) described above the

first time you vote at a voting place or by absentee ballot. If you change your name you must

re-register. If you register at a public service agency, any information regarding the agency

that assisted you will remain confidential as will any decision not to register. If you do not

receive a Notice within 2 weeks of mailing or delivering this application, call your County Clerk

or Board of Election Commissioners.

ILLINOIS VOTER REGISTRATION APPLICATION ù ú û û ü ý þ ü ÿ � � ú û ú ý þ � � � � � ù � �� �

S

N

EW� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ! � � � �" � � � # � � $ � � � � � � � � � � % & ' ( ) ( * & + , ' , ' � � % - ' & ) * ' , + . , , / % � �0 � � � � � � � � 1 � � � � � � � � � 2 � � 2 � � � ) 2 3 4 5 $ 6 7 5 7 � 8 3 9 : $ ; 7 : 4 � 8 " : ; 9 < 6 7 " : = $ � 8 <Are you a citizen of the United States of America? (check one)

Will you be 18 years of age on or before election day? (check one)

Yes No

NoYes

If you checked "No" in response to either of these questions, then do not complete this form.

You can use this form to: (check one) Change your addressapply to register to vote in Illinois Change your name

1. Last name First Name Middle Name or Initial Suffix (Jr. Sr. II III IV)

2. Address where you live (House No., Street Name, Apt No.) City/Village/Town Zip Code County Township

3. Mailing Address (P.O. Box) City/Village/Town Zip Code County Township

4. Former Registration Address: (include City and State and Zip Code) Former County 5. Former Name: (if changed)

6. Date of Birth: MM/DD/YYYY

7. Sex (check one)

FemaleMale

8. Home Telephone number

including area Code (optional)

9. ID Number-Check the applicable box and provide the appropriate

number IL Driver's License or, if none, Sec. of State ID or

Last 4 digits of SSN

I have none of the above-listed identification numbers

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