2019 RRP Application Form - Laserfiche WebLink

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PART 7: CHILD CARE PROVIDER ALLOWANCE: Check here if the following does not apply to your household. Un-reimbursed Child Care Expense If you pay ( and are not reimbursed) for a care provider to care for a child under the age of 13 who is a member of your family so that an adult member of your family may work or attend classes, enter the first name of the person who works or attends classes here ____________________________, and provide the following information: Name and Address of Care Provider for Verification: Name: _______________________________________ Address:__________________________________________ City: ________________________ State: _________ Zip_______________ Telephone:______________________ Date Child Care Began: ______________________________ Average Hours Per Week: ______________________ Total Child Care Cost: _________________________ Amount you Pay ($):_________________________ (circle one) per hour per week per bi-weekly per month Amount Reimbursed by an individual/ organization: $ ____________________ Name and Address of Organization: __________________________________________________________________ PART 8: DISABILITY ASSISTANCE EXPENSE: Check here if the following does not apply to your household. Un-reimbursed Disability Assistance Expense If you pay (and are not reimbursed) for care or equipment for a disabled member of your family so that either the disabled member or another member of your family may work, enter the first name of the person who works here ____________________________, and provide the following information: Name and Address of Care or Equipment Provider for Verification: Name: _______________________________________ Address:__________________________________________ City: ________________________ State: _________ Zip_______________ Telephone:______________________ PART 9: MEDICAL EXPENSE ALLOWANCE: Complete only if the Head of Household, Spouse, or Co-Head is disabled or age 62 or older. Check here if the following does not apply to your household. If you wish to claim an allowance for medical insurance premiums, medical, dental or optical expenses, or prescription or over-the-counter drug expenses, please provide the first name of any family member claiming each expense and the name and address of the provider of the service or product. YES NO \[ \] \[ \] Do you have Medicare (Social Security)? If YES, Monthly Premium Amount: $ _________ \[ \] \[ \] Do you have Medicaid (Welfare)? \[ \] \[ \] Do you have other Medical Insurance? If YES, Monthly Premium Amount: $ _________ \[ \] \[ \] Are you paying on any medical bills? If YES, Monthly Premium Amount: $ _________ Balance Amount: $ _________ Family Member First Name : ____________________ Family Member First Name : ____________________ Expense Claimed: $ __________________________ Expense Claimed: $ __________________________ Provider: ____________________________________ Provider: ____________________________________ Address: ____________________________________ Address: ____________________________________ City: _______________ State: _______ Zip: _______ City: _______________ State: _______ Zip: _______