Eligibility Factors and Suggested Documentation Guide

Form W-119D (page 1) LLF

Rev. 5/7/14

Note:

For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash Assistance (CA) and

Medical Assistance (MA), original documents are needed to verify identity and citizenship/alien status. Copies of documents

for all Eligibility Factors other than identity and citizenship/alien status are acceptable.

Eligibility Factor

To prove this factor,

provide: ONE of the

following  OR

TWO* of the following:

 Identity

You must establish identity for each person listed.

 Photo I.D.

 Driver’s license

 U.S. passport

 Naturalization certificate

 Hospital/Doctor’s records

 Adoption papers

 Statement from another person

 Birth/baptismal certificate

 Validated Social Security Number

(SSN)

 Marital Status

You must prove if you are married, divorced, separated

or widowed (not required for the Supplemental Nutrition

Assistance Program [SNAP]).

 Marriage/Death certificates

 Separation agreement

 Divorce decree

 Social Security records

 Veterans Administration (VA) records

 Statement from clergy

 Census records

 Newspaper notice

 Statement from another person

 Relationship

If you are related to a child in the household, you must

prove the relationship.

 Birth certificate (long form)

 Adoption papers/records

 Court records

 Medical records

 Applicant’s statement

 Newspaper notice

 Statement from clergy

 Statement from another person

 Residence

You must verify your place of residence

(if applicable).

 Statement from landlord/primary

tenant

 Current rent receipt or lease

 Mortgage records

 Statement from another person

 Current mail

 School records

 Household Composition/Size

You must prove who is living with you.

 Statement from nonrelative landlord

 School records

 Statements from other persons

 Age

You must prove the age of each person applying for

assistance, where appropriate.

 Birth certificate

 Baptismal records/certificate

 Hospital records

 Adoption papers/records

 Naturalization certificate

 Driver’s license

 Insurance policy

 Census records

 School records

 Statement from another person

 Physician statement

 Official correspondence from Social

Security Administration (SSA)

 Absence/Death of Parent(s)

If the parent(s) of any child in your home is not living with

you, you must prove this (not required for SNAP).

 Death certificate

 Survivor’s benefit records

 Hospital records

 VA or military records

 Divorce papers

 Proof of remarriage

 Newspaper notice

 Insurance company records

 Institutional records

 Agency case records and burial

payment files

 Statement from another person

 Absent Parent Information

If the parent(s) of any child in your home is not living with

you, you must provide information you have about the

individual’s: name, address, SSN, birth date, and

employment (not required for SNAP).

 Pay stubs

 Tax returns

 Social Security or VA records

 Monetary determination letters

 ID cards (health insurance)

 Driver’s license or registration

 Social Security Number

For Temporary Assistance, SNAP Benefits and Medical

Assistance only, you do not have to provide proof of

your SSN unless the SSN you give does not match the

SSA’s records or cannot be verified by the Agency.

 Social Security card

 Official correspondence from SSA

A Social Security number is not required

for aliens who are seeking Medical

Assistance for emergency treatment only

or are Medical Assistance – only

applicants who are pregnant.

*If you are applying for Supplementary Nutrition Assistance Program (SNAP) benefits or Medical Assistance only, you need to

bring one form for each Eligibility Factor checked.

Form W-119D (page 2) LLF Human Resources Administration

Rev. 5/7/14 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Note:

For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash Assistance (CA) and Medical

Assistance (MA), original documents are needed to verify identity and citizenship/alien status. Copies of documents for all Eligibility

Factors other than identity and citizenship/alien status are acceptable.

Eligibility Factor

To prove this factor,

provide ONE of the following:

 Citizenship or Current Alien Status

Status – U.S. citizens are eligible for Temporary Assistance, the

Supplemental Nutrition Assistance Program and medical assistance.

Aliens must be in satisfactory immigration status in order to be eligible

for Temporary Assistance, the Supplemental Nutrition Assistance

Program and medical assistance. Immigration status is not an

eligibility factor for pregnant women or immigrant children applying for

Child Health Plus B. Undocumented immigrants and temporary

nonimmigrants are eligible only for the treatment of an emergency

medical condition.

 Birth certificate

 Baptismal certificate/records

 Hospital records

 U.S. passport

 Military service records

 Naturalization certificate

 USCIS documentation

 Evidence of continuous U.S. residence since prior to 1/1/72

 Earned Income

 From employer

 Current wage stubs and statements of tips

 Pay envelopes

 Contact with employer

 On letterhead, rate of pay per hour, hours worked per week, first pay

date, if new and employer’s phone number

 From self-employment

 Business records

 Tax records

 Records and related materials concerning self-employment earnings

and expenses

 Current income tax return

 Income from rent or room/board

 Current contribution check

 Statement from roomer, boarder, tenant

 Income tax record

 Unearned Income

 Child Support

 Statement from Family Court

 Statement from person paying support

 Check stubs

 Official correspondence from the Child Support Enforcement Unit

 Unemployment Insurance Benefits (UIB)

 Current award certificate

 Official correspondence with New York State Department of Labor

 Social Security benefits (including SSI)

 Current award certificate/letter

 Current benefit check

 Official correspondence from SSA

 Veteran’s benefits

 Veterans Administration official correspondence

 Current award certificate/letter

 Current benefit check

 Worker’s Compensation

 Award certificate/letter

 Check stub

 Education grants and loans

 Statement from school

 Statement from bank

 Statement from agency administering grant/award letter

 Interest/dividends/royalties

 Statement from bank or credit union

 Statement from broker/financial institution/agent

Form W-119D (page 3) LLF Human Resources Administration

Rev. 5/7/14 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Note:

For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash Assistance (CA) and Medical

Assistance (MA), original documents are needed to verify identity and citizenship/alien status. Copies of documents for all Eligibility

Factors other than identity and citizenship/alien status are acceptable.

Eligibility Factor

To prove this factor,

provide ONE of the following:

Unearned Income (continued)

 Private pension/annuity

 Current award letter

 Current benefit check

 Official correspondence from source of income

 Contact with source of income

 Current contribution check

 Other unearned income

 Resources

(For Medical Assistance only, resource information is not requested

from pregnant women, children under the age of 19 and persons

eligible for Family Health Plus.)

 Bank Accounts: Checking, savings, retirement (IRA and

Keogh), credit union

 Current bank records

 Current credit card records

 Stocks, bonds, certificates and mutual funds

 Stock/bond certificate

 Statement from financial institution

 Life insurance

 Insurance policy

 Statement from insurance company

 Burial trust or fund, burial plot or funeral agreement

 Bank records

 Burial agreement

 Burial plot deed

 Statement from funeral director

 Income tax refund or Earned Income Tax Credit (EITC)

 Refund of EITC check

 Statement from tax office

 Real estate other than residence

 Deed

 Statement from real estate broker

 Broker’s appraisal/estimate of current value by broker

 Motor vehicle

 Registration (older models)

 Title of ownership

 Appraisal of current value by dealer

 Financing data

 Lump sum payment

 Statement from the source of payment

 Lump sum check

 Other resources

 Statement from household

 Statement from nursing home

 Household statement of current value

 Sales slips

 Insurance appraisal

Form W-119D (page 4) LLF Human Resources Administration

Rev. 5/7/14 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Note:

For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash Assistance (CA) and Medical

Assistance (MA), original documents are needed to verify identity and citizenship/alien status. Copies of documents for all Eligibility

Factors other than identity and citizenship/alien status are acceptable.

Eligibility Factor

To prove this factor,

provide ONE of the following:

 Shelter Expenses

You must prove how much it costs you to live where you do. (You

may need to provide separate documentation for each item of shelter

expense.)

Medical Assistance does not require documentation of shelter

expenses.

 Current rent receipt/lease/mortgage book/records

 Property and school tax records

 Landlord statement

 Sewer and water bills

 Garbage/trash collection bills or receipts

 Homeowner’s insurance records

 Fuel bills/shut-off notice

 Nonheating utility bills

 Telephone bills (or a statement from the household that the expense is

incurred)

 Medical Expenses

For SNAP, for aged/disabled individuals only

 Statement from provider of health insurance premiums

 Copies of medical bills (paid and unpaid)

 Medicare prescription drug card

 Health Insurance

If you or anyone applying has health insurance coverage (even if paid

for by someone else), you must prove this.

 Insurance policy/card

 Statement from provider of coverage

 Medicare card

 Separation or divorce agreement with court-ordered health coverage

 Disabled/Incapacitated/Pregnant

If you or anyone living with you is sick or pregnant, you must provide

proof. (For MA only, resource information is not requested from

pregnant women, children and persons eligible for Family Health

Plus).

 Statement from doctor, clinic or hospital verifying pregnancy, expected

date of birth

 Statement from medical professional

 Proof of SSA/SSI benefits for disability/blindness

 Unpaid Bills

Rent, utility

 Copy of each bill showing amount owed, period of

services and provider

 Referral

 Drug/alcohol treatment program

 Statement from provider of treatment

 Employment service

 Statement from employment service

 Other Expenses/Dependent Care Cost

You must provide proof if you pay court-ordered support, child care,

recurring loans or for the services of a home health aide or attendant.

 Court order

 Statement from day care center or other child care provider

 Statement from aide or attendant

 Canceled checks or receipts

 School Attendance

You must prove who is in school.

 School records (current report card)

 Statement from school or higher education institution

Form W-119D (page 5) LLF Human Resources Administration

Rev. 5/7/14 Family Independence Administration

Eligibility Factors and Suggested Documentation Guide

Note:

For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash Assistance (CA) and Medical

Assistance (MA), original documents are needed to verify identity and citizenship/alien status. Copies of documents for all Eligibility

Factors other than identity and citizenship/alien status are acceptable.

Eligibility Factor

To prove this factor,

provide ONE of the following:

 Past Management

(For Safety Net Assistance)

 Earned Income

 Letter from employer giving dates of employment, amount earned and

reason(s) for leaving

 Other

(For cash assistance only)

If you were not supporting yourself from employment/earned income,

please bring verification of how you were able to support yourself in the

past such as:

 Bankbook/bank statement

 Verification of expiration of benefits (workers’ compensation, disability,

Social Security, UIB, etc.)

 Statement from person(s) who provided support

 Potential Benefits

Statement from person(s) who provided support

 If you or anyone in the household has applied for and been denied or

has been accepted for benefits from any of the following sources, bring

the award letter, check or other correspondence: Social Security, court

payments, SSI, veteran’s benefits, workers’ compensation, union

benefits, pension, military allotment, railroad retirement, NYS disability

or other source

 Other