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Financial Information Form

Applying for financial assistance is completely optional. If you are unable to pay your entire balance owed to Oneida County Human Services and would like to apply for a reduction or suspension of payments, complete the following form. Upon receipt of a completed application, Human Services will determine your monthly payment obligation per the WI administrative code DHS1 maximum monthly payment schedule.

In order to successfully apply for assistance you must complete the entire form. If you are insured by Medicaid it should only take 2 minutes to complete this form, if you have any insurance other than Medicaid or are uninsured please allow 15-20 minutes to complete this form. To complete the form please make sure to have employment and income information for all adults in the household.

All information requested in this form is REQUIRED. Incomplete applications are unable to be considered for payment suspension or reduction, so please complete the application as completely as possible.

For the purpose of completing this form, the CLIENT is the individual receiving services from Oneida County Human Services.

Financial Info Form Steps

Client Information
Insurance
Household Income - Client
Household Income - Spouse
Household Income - Others
Unearned Income
Obligations
Proof of Income
Attestation

First Name

Last Name

Social Security Number

Date of Birth

Type of Insurance client is covered by:

Medicaid/BadgerCare

Medicare

VA/Champus/Tricare

Commercial Company

None

What is the Medicaid/BadgerCare member ID?

Relationship of the client to the Medicaid/BadgerCare policy holder?

Self

Spouse

Parent/Guardian

What is the name of the Medicaid/Badgercare policy holder?

What is the Medicare member ID?

Relationship of the client to the Medicare policy holder?

Self

Spouse

Parent/Guardian

What is the name of the Medicare policy holder?

What is the VA/Champus/Tricare member ID?

Relationship of the client to the VA/Champus/Tricare policy holder?

Self

Spouse

Parent/Guardian

What is the name of the VA/Champus/Tricare policy holder?

Name of the commercial health insurance company?

What is the group number of the commercial health insurance policy?

What is the Member ID of the commercial health insurance policy?

Relationship of the client to the commercial insurance policy holder?

Self

Spouse

Parent/Guardian

What is the name of the commercial insurance policy holder?

The client is:

Age 0-17

Age 18+

Is the client employed? If the client is self-employed please respond "No".

Yes

Name and location of the CLIENT'S employer? If employed by more than one company, list ALL employers and locations.

How is the client paid and how much does the client earn from these employer? If you work for more than one company, list wages and terms from all employers.

Is the client self employed?

Yes

Company name(s)

Is the client married? (Report legally separated as married)

Yes

Is the spouse of the client employed? If the spouse of the client is self-employed please respond "No".

Yes

Name and location of the spouse of the client's employer? If employed by more than once company, list ALL employers and locations.

How is the spouse of the client paid and how much does the spouse earn from these employer? If you work for more than one company, list wages and terms from all employers.

Is the spouse of the client self employed?

Yes

Company name(s)

Are there any other relatives living in the home who meet all 3 of the following criteria: 1-ARE federal tax exemptions 2-ARE NOT attending school 3-Earn income. Most common examples include step-parents or multi-generational homes.

Yes

Please enter the name of all persons, their date of birth and their relationship to the client.

Do any of the relatives listed in the previous question have a job that they earn income from? Do NOT report self-employment wages here.

Yes

List the names of all relatives from the previous question who are employed. If anyone is employed by more than once company, list ALL employers and locations.

For the relatives identified in the previous question, list the names of each person employed, the types of wages they receive and how much they earn from these employer? If you work for more than one company, list wages and terms from all employers.

Are any relatives identified in the previous question self-employed?

Yes

Company name(s)

Does anyone living in the home receive one or more of the following payment options?

DISABILITY payments (SSI, SSDI, VA, Aetna, etc)

VA benefit payments (disability, pension, etc)

ALIMONY, CHILD SUPPORT or SEPARATE MAINTENANCE

UNEMPLOYMENT COMPENSATION

SOCIAL SECURITY retirement, PENSION or other RETIREMENT type payments

Other Payment Option

Other Payment Information

Report the name of each family member, type of payment(s)and the amount received PER MONTH

Report the name of each family member and the amount received PER WEEK for UNEMPLOYMENT

Does the client or any other household member have court ordered OBLIGATIONS (typically child support, alimony, etc)

Yes

What is the total amount of court ordered obligations paid MONTHLY by household members reporting income? (typically child support, alimony, restitution, etc)

What is the total number of persons dependent on family income for support (exclude persons for whom court ordered support is paid and persons living in care facilities).

Is the family currently being billed for STATE OR COUNTY FUNDED services related to the mental hygiene, alcohol and other drug abuse, developmental disabilities, social services, youth corrections services NOT provided by Oneida County Human Services?

Yes

List the name of any agencies paid and the total amount paid per month.

What is your current living situation?

Renting a home/apartment

Living with family/friends rent free

Homeless

Home owned - No mortgage

Home owned - with a mortgage

Other

Other Living Situation

Please list any additional information you would like considered when reviewing your application below.

In order for an application to be complete, proof of income is required. Please submit the following documentation for all applicants:

Employment income - Pay stubs for most recent 60 days. If overtime, tips or commissions are common, also include the prior years W-2.

Self-employment income - 2 most recent tax returns (Form(s) 1040/1065/1120 with all schedules)

Other income - Award letter OR 2 most recent bank statements with direct deposits circled/highlighted. Entire bank statement is not necessary, just the deposit portion.

How will you be submitting the required information?

I will encrypt and email the required documentation to [email protected]

I will drop proof of income off at The Human Service Center (no originals please)

I will mail proof of income to PO Box 897, ATTN: Billing, Rhinelander, WI 54501

I reported that I have no household income, no documentation is required.

You noted that you do not have any income, please indicate how you sustain yourself (ie food, shelter, etc.)

Please provide the best contact information to reach you at if we have questions regarding this application (phone, email, etc)

Statements made in this application must be true and correct to the best of the applicants knowledge. Making false statements, failing to report ALL income or intentional misrepresentation of any information is considered non-compliance which will result in full liability for all debts.

I attest that all statements in this application are true and correct to the best of my knowledge (TYPE NAME OF PERSON COMPLETING APPLICATION).

Signature

Date