Free Caretaker Supplement (CTS) Instructions for Application - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-22571A (Rev. 07/2008)

STATE OF WISCONSIN WI Statutes s. 49.775

CARETAKER SUPPLEMENT (CTS) INSTRUCTIONS FOR APPLICATION
This application is to be used by parents who receive Supplemental Security Income who are living with and caring for their minor children, and who have limited income and assets. This is not an application for food stamps, child care, Medicaid, or W-2. If you are interested in applying for these assistance programs you must contact your local county / tribal social or human services agency or your W-2 agency. These programs provide persons or families help with the costs of food, the costs of child care health care or finding a job as part of W-2. If you need help filling out this application or wish to answer the questions in person or over the telephone, contact your local county / tribal social or human services agency. If you have a disability and need to access the instructions and application in an alternate format, or need it translated to another language, contact (608) 266-3356 or (608) 266-2555 TTY. All translation services are free of charge.

HOW TO USE THIS FORM
1. Read the instructions completely before completing application. 2. Print clearly. Use blue or black ink. 3. Fill out the application completely. Answer all the questions. There may be a delay in Caretaker Supplement (CTS) benefits if the application is not complete. If your application is not complete or you requested retroactive eligibility, your county / tribal social or human services agency will contact you for more information. 4. Enter information about all the people that live in your household. If you need more space add a second sheet. 5. If you are pregnant, include with your application a signed and dated note from your doctor or another health care professional saying that you are pregnant and identifying your expected due date. 6. You may authorize a representative to apply for you. Complete and send the Authorized Representative form (F-10126) with your application. You can get this form by calling Recipient Services at 1-800-362-3002. This form authorizes a representative to complete and sign the application for you. A legal guardian, conservator, or power of attorney / durable power of attorney authorized to act on these types of matters may apply for an individual without separate authorization by the individual. 7. Write all dates using the mm/dd/yyyy format. Example: 08/31/2004. 8. Attach an additional sheet of paper if you need more space to provide the required information.

IMPORTANT INFORMATION
The following is important information regarding Caretaker Supplement eligibility. · Your application date is the date your application is received by your county / tribal social or human services agency. The application must include at least your name, address and signature. A decision regarding your eligibility for CTS will be mailed to you within 30 days of the application date. Unsigned forms will not be processed and will be returned. Your rights and responsibilities are provided in Section XI. If you have any questions about your rights and responsibilities contact your local county / tribal social or human services agency. If you are found eligible for CTS you will need to complete a review every 6 months to determine eligibility. Changes in your income or household composition need to be reported to your county / tribal social or human services agency within 10 days of the change.

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CARETAKER SUPPLEMENT APPLICATION INSTRUCTIONS F-22571A (Rev. 07/2008)

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SECTION I ­ Client Information
Name of Person Applying for CTS Enter your last name, first name and middle initial. Telephone Number Enter your 10-digit telephone number (include area code, for example (608) 292-4021). Address Enter your street address, city, state and zip code. Mailing Address Enter the mailing address where you would like information sent regarding your CTS. This may be your current address or the current address of your authorized representative.

SECTION II ­ General Information
Eligibility for Caretaker Supplement will be based on family members living in your household. Complete this section of the application for all family members living in your household. Name Enter the last name, first name and middle initial of all family members living in your household. This may include yourself, your spouse, father, mother, children or stepchildren, etc. Social Security Number Enter a Social Security Number (SSN) for all members of your household who are applying for CTS. If someone in your household is not applying for CTS you do not need to provide SSN information for that person. Providing or applying for a SSN is voluntary; however any person who wants CTS but does not want to provide their SSN or apply for one will not be eligible for benefits. Social Security Number information will be used for the direct administration of the CTS program. Your SSN permits a computer check of your information with government agencies such as the Internal Revenue Service (IRS), Social Security Administration (SSA) and the Department of Workforce Development. Your SSN will not be shared with the U.S. Citizenship and Immigration Service (USCIS). Date of Birth Enter the birth date of all members of your household. Gender Circle "M" for each male member of your household. Circle "F" for each female member of your household. Marital Status Enter the code in the space provided that best describes each household member's marital status. · · · · · · · A D LS M S N W = = = = = = = Annulled Divorced Legally Separated Married Separated Never Married Widowed

CARETAKER SUPPLEMENT APPLICATION INSTRUCTIONS F-22571A (Rev. 07/2008)

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Are you a U.S. Citizen? Check "Yes" for each member of your household that is a U.S. citizen. Check "No" for each member of your household that is not a U.S. citizen. If you checked "No" for any household member applying for CTS, submit a copy of both sides of the immigration documentation with this application. Information may be submitted to the USCIS for verification for those applying for these programs. If someone in your household is not applying for CTS you do not need to provide proof of immigration status for that person. What is your race or ethnic background? (Optional) Enter the code or codes that best describe the race or ethnic background of each member of your household. This information is voluntary and will not be used to determine eligibility. · · · · · · · A = Asian B = Black H = Hispanic origin I = American Indian / Eskimo P = Native Hawaiian or Pacific Islander S = Southeast Asian W = White

Relationship to Applicant Enter the relationship to the applicant of each person listed.

SECTION III ­ Absent Parent Information
A CTS eligibility requirement is cooperation with identifying parents who are absent from the home. Complete this section as accurately as you can for each parent absent from the home. If there is a reason you do not want to provide information for an absent parent, leave this section blank. If this section is left blank, you will be contacted by your local / tribal social or human service department for additional information. Do any children have a natural or adoptive mother or father who is not living at home? Check "Yes" if any of the children living in your household have either a natural or adoptive parent who is not living in the home. If you checked "Yes", complete all of Section III. Check "No" if the children living in the home have both natural or adoptive parents living in the home. If you checked "No", skip to Section IV. Name Enter the last name, first name and middle initial of any parent who is absent from the home. Social Security Number Enter the Social Security Number (SSN) of the absent parent, if you know it. If this field is left blank, you may be contacted by your local / tribal social or human service agency for additional information. Date of Birth Enter the birth date of the absent parent, if known. When entering the birth date, use the number for the month, day and year. Name(s) of Child(ren) Enter the last name, first name and middle initial of the child(ren) of this absent parent. Relationship to Child Check "Mother" or "Father" to indicate the absent parent's relationship to the children listed.

CARETAKER SUPPLEMENT APPLICATION INSTRUCTIONS F-22571A (Rev. 07/2008)

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Reason for Parent's Absence List the reason why the parent does not live in the household. (For example, divorced, separated, not married, unable to locate.) Date Parent Left the Household Enter the date that the absent parent left the household, if known. Date of Last Contact with Parent Enter the date of last contact with the absent parent. Court Order of Divorce or Paternity If there is a court order of divorce or paternity, enter the case number, county, and state for the order that was issued.

SECTION IV ­ Employment
CTS will be based on your total family income (including minor children). Enter the expected gross monthly earnings for the current month and next month for each member of your household. Are you or any household member working? Check "Yes" if any member of your household is working and complete the rest of the Section IV. Check "No" if no one in your household is working, and skip to Section V. Is anyone listed in Section IV a migrant worker? Check "Yes" if any member of your household is a migrant worker and complete the rest of Section IV. Check "No" if no one in your household is a migrant worker. Name Each Working Person Enter the last and first name of each member of your household that is employed. Employer's Name, Address and Telephone Number Enter the employer's name, address and telephone number for each member of your household who is employed. Date Employment Began Enter the beginning date of employment for each member of your household who is employed. Gross Monthly Earnings Expected this Month Enter the expected monthly gross earnings (before taxes and deductions) for this month for each member in your household who is employed. Gross Monthly Earnings Expected Next Month Enter the expected monthly gross earnings (before taxes and deductions) for next month for each member in your household who is employed.

SECTION V ­ Self-Employment
Are you or any household member self-employed? Check "Yes" if you or any member of your household is self-employed. If you checked "Yes" complete the rest of Section V. List amounts you reported to the IRS on your tax forms. If you did not file taxes last year, leave the net annual income and depreciation boxes blank. Your county / tribal agency will contact you for more information. If no one in your household is self-employed, check "No" and continue on to Section VI. Self-Employed Person Enter the last name, first name and middle initial of each person in the household who is self-employed.

CARETAKER SUPPLEMENT APPLICATION INSTRUCTIONS F-22571A (Rev. 07/2008)

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Business Name and Address Enter the name and address of the business for each person in the household who is self-employed. Type of Business Enter the type of business for each person in the household who is self-employed. Net Annual Income Enter the net annual income for each person in the household who is self-employed. List the amounts reported to the IRS on your tax forms. If you did not file taxes last year, leave this box blank. Your county / tribal social or human services agency will contact you for more information. Depreciation Amount Claimed List the amounts reported to the IRS on your tax forms. If you did not file taxes last year, leave this box blank. Your county/tribal social or human services agency will contact you for more information. Income you Expect to Earn this Year Enter the amount of gross annual income (before taxes and deductions) for each person in the household who is selfemployed.

SECTION VI ­ Unearned Income
Other Type of Income Check "Yes" if anyone in your household receives unearned income. Check "No" if those in your household do not receive unearned income. If you answer "Yes" complete Section VI for each income type. Name Enter the name of the person for the income types that were checked "Yes". Gross Monthly Amount Enter the gross monthly amount received for each income type for the ones checked "Yes".

SECTION VII ­ Assets
Name Enter the name of the person who owns the asset type listed. Current Value Enter the current value of the asset. Description Give a description of the asset. Example; for a checking account, the bank or financial institution's name, the account numbers, etc.

SECTION VIII ­ Vehicles
Type of Vehicle Enter the type of vehicle. Include all vehicles that are owned jointly with another person. Year, Make and Model of the Vehicle Enter the year, make and the model of the vehicle. Name of the Owner Enter the name of the owner of the vehicle. If the vehicle is jointly owned, list name's of all owners.

CARETAKER SUPPLEMENT APPLICATION INSTRUCTIONS F-22571A (Rev. 07/2008)

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How much is still owed on the vehicle? If you still owe money on this vehicle, list the amount that is still owed. Is this vehicle used to get to medical appointments? Check "Yes" if this vehicle is used to get to medical appointments. Check "No" if you do not use the vehicle to get to medical appointments. Is this vehicle for employment, training, school, or farming? Check "Yes" if this vehicle is used for employment, training, school, or farming. Check "No" if it is not used for employment, training, school, or farming.

SECTION IX ­ Child Support
Does anyone pay child support? Check "Yes" if someone in your household pays child support. Check "No" if no one in your household pays child support. If you checked "Yes" answer the questions to the right of the YES / NO box. If you checked "No" go to Section XI. Who pays the child support? Enter the name of the person in your household who pays the child support. Who receives the child support payments? Enter the name of the person who receives the child support payment. (This should not be the name of the absent parent.) Monthly Amount Enter the monthly amount that is paid or received for child support.

SECTION X - Pregnancy
Are any members of your household pregnant? Check "Yes" if anyone is pregnant in your household. Check "No" if there are no pregnant women in your household. If you checked "Yes" answer the questions to the right of the YES / NO box. If you checked "No" go to Section XI. Name of Pregnant Woman Enter the first and last name of the pregnant woman / women in your household. Due Date Enter the due date(s) of the pregnant woman / women in your household. (For example, if the due date is April 3, 2003 you would enter 04/03/03 in the space provided.) You will need to provide verification from a medical professional of your / their pregnancy(s) and the due date(s) to your county / tribal social or human services department. Multiple births expected? Enter "Yes" if multiple births are expected. Enter "No" if multiple births are not expected. If you checked "Yes" enter the number of expected babies.

SECTION XI ­ Rights and Responsibilities
Read all of your Rights and Responsibilities. Check each box indicating that you have read and understand them. Your signature on the application means that you understand and acknowledge that the county / tribal social or human services agency, W-2 agency and the state Department of Health Services is authorized to request any information that is appropriate and necessary for the proper administration of the Caretaker Supplement Program authorized under Wisconsin law. You have the right to apply for CTS benefits for any month in which you receive SSI and did not receive W-2 benefits.

CARETAKER SUPPLEMENT APPLICATION INSTRUCTIONS F-22571A (Rev. 07/2008)

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YOUR RESPONSIBILITIES:
· · · You must cooperate with the child support agency. You are responsible for obtaining a Social Security Number for your child or children. You are responsible for reporting to your agency worker, within 10 days, any change in income, assets or other household circumstances that may affect your eligibility. If a child(ren) included in your Caretaker Supplement Group is (are) no longer under your care and custody, you must report it in five (5) days.

Use the "Change Report" form that you get when you apply, call your worker, or report the change in person.

You must also report:
· · · · · · · · · · · Whenever anyone in your household starts receiving SSI or stops receiving SSI. When any member of your household turns 18 years old, graduates from high school, obtains a GED, or quits school. When the source of your income changes. When anyone moves into or out of your household. If a child(ren) included in your Caretaker Supplement Group is (are) no longer under your care and custody, you must report it in five (5) days. When anyone in your household has a change in earnings from work. When your household's unearned income, cash-in-hand, checking or savings accounts, stocks, bonds or other assets change. When the total assets of your children exceed $1000. When anyone in your household gets married, divorced, becomes pregnant or gives birth. When your child care or dependent care expenses change. When your address changes. When you or anyone in your household receives a lump sum payment such as a personal injury award, inheritance, windfall payment, retroactive benefits such as Social Security or Unemployment Insurance. You may be ineligible for CTS for a period of time if you receive lump sum payment. Do not spend this money until you have contacted your worker to find out if there will be a period of time for which you must use this money to meet current living expenses. Any other change that affects your eligibility or the amount of your benefits.

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You have the right to appeal any action taken concerning your Caretaker Supplement application or ongoing benefits that you do not agree with by requesting a Fair Hearing. You may request a Fair Hearing by writing to: Wisconsin Department of Administration Division of Hearings and Appeals P.O. Box 7875 Madison, WI 53707-7875 OR calling: (608) 266-7709 You may also contact your local county / tribal social or human services agency and ask for a Fair Hearing verbally or in writing. The Department of Health Services (DHS) is an equal opportunity employer and service provider. For civil rights questions, call (608) 266-3465 (voice) or (608) 266-2555 (TTY).

CARETAKER SUPPLEMENT APPLICATION INSTRUCTIONS F-22571A (Rev. 07/2008)

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To file a complaint of discrimination by contacting either the: · Wisconsin Department of Health Services (DHS) Affirmative Action and Civil Rights Compliance Office 1 W. Wilson Street, Room 555 Madison, WI 53707-7850 Telephone: (608) 266-9372 (Voice); (608) 266-5555 (TTY) Fax: (608) 267-2147

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U.S. Department of Health and Human Services Office for Civil Rights ­ Region V 233 N. Michigan Avenue Suite 240 Chicago, IL 60601 Telephone: (312) 886-5077 (voice) or (312) 353-5693 (TTY)

CHECKLIST
Is the application complete? If you are not a U.S. citizen, did you include a copy of both sides of your immigration status documents? If you are pregnant, did you include a signed and dated note from a doctor or other health care professional saying that you are pregnant and stating the due date? Did you read the Rights and Responsibilities section? Did you sign and date the application form? Did you include the Authorized Representative form (F-10126) if you are acting on behalf of an applicant? Send the completed application to your local county / tribal social or human services agency, W-2 agency or Medicaid outstation site. Addresses for county / tribal agencies can be found at: http://dhs.wisconsin.gov/em/imagencies/index.htm or by contacting Medicaid Recipient Services at 1-800-362-3002.

OTHER PROGRAM INFORMATION
If you are interested in services for veterans, call 1-800-947-8347 (WIS-VETS), or contact your county Veteran Service Officer. For information about the Women, Infants, and Children (WIC) Nutrition Program, call 1-800-722-2295. For information about services for women, children and families, contact the Wisconsin Maternal Child Health Hotline at 1-800-722-2295.