Application for Public Assistance

State of Colorado Departments of Health Care Policy and Financing and Human Services
Please remove pages A-F to keep for your records
You have the option to answer only those questions relevant to the program for which you are applying.
Food Assistance- Known federally as the Supplemental Nutrition Assistance Program (SNAP)
(Questions marked with a  are NOT required for Food Assistance.)
 You have the right to file your application today. You can start the process by filling out your name, address
and signature or that of an authorized representative on this form and turning it in to a county office. You
can give us your application in person, by fax, through the mail or you can apply through PEAK. An interview
will be required before receiving Food Assistance and you may be required to provide proof of some
information given on the application. Benefits will begin from the date any county office receives your
signed application.
 You may receive Food Assistance within 7 days if the household has less than $100 in assets and less than $150
income per month; OR if your monthly shelter costs are more than your monthly income plus any cash on hand or in
the bank; OR if anyone in the home is a migrant or seasonal farm worker and the household has less than $100 in
cash on hand and in the bank.
 If you do not qualify for expedited Food Assistance, benefits can begin within 30 days if all requested proof of
information that was given on your application was provided. If expedited assistance is denied, you may ask for
an informal hearing.
Cash Programs (Questions marked with a  are NOT required for Cash Assistance.)
 Colorado Works (CW), known federally as Temporary Assistance for Needy Families (TANF) – For households with
a child or a pregnant mother. Provides a cash benefit to families in need. With a few exceptions, parents must
participate in work activities. A referral may be made to Child Support Services based on your household
circumstances. If you feel this could cause hardship to you or your child(ren), you may request good cause for waiving
this referral.
 Colorado Supplement to SSI – Provides an additional cash supplement to eligible persons not receiving the full SSI
grant from the Social Security Administration.
 Aid to the Needy Disabled (State AND)– Provides a cash benefit for persons ages 18-59 who have been
determined totally disabled for at least six months or persons under the age 59 who meet the definition of a person
who is blind.
 Old Age Pension (OAP) – Provides a cash benefit for low income persons age 60 or over.
 Home Care Allowance (HCA)- For persons who need help on a regular basis with some or all of their daily self-care
(such as bathing, dressing, eating, getting around, and using the bathroom). Provides a cash benefit that used must
be to pay the provider for services. A functional assessment is required.
Medical Assistance (Questions marked with a  are NOT required for Medical Assistance.)
Medical Assistance includes free or low-cost insurance from Health First Colorado (Colorado’s Medicaid
Program) or the Child Health Plan Plus Program (CHP+). It also includes affordable private health insurance
plans that offer you comprehensive coverage through Connect for Health Colorado (the Marketplace). This
includes tax credits that can immediately lower your premiums for health coverage. It also includes assistance for
paying your Medicare Premiums.
Instructions:
List EVERYONE in your home and on your federal tax return, even if you are not applying for them. Use more
paper if necessary. If you are a non-citizen who has a sponsor, you will list the sponsor’s information in a question later
in this application.

If you are applying for benefits and you have a Social Security Number (SSN), we need this information. If you
provide your SSN, it may speed up the application process. We use SSNs to check income and other information to
see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or
visit socialsecurity.gov. TTY users should call 1-800-325-0778. Providing a SSN or immigration status is optional for
Food Assistance. If a SSN or immigration status is not provided for a person, that person will not receive benefits.
Even though the person’s SSN or proof of immigration status was not provided, they must provide any income and
resource they have as well as any expenses they pay because that information will be used to determine eligibility and
benefits for eligible household members.
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 What I Should Know
By completing and signing the State of Colorado Application for Public Assistance and other documents required to determine
whether I’m eligible for public assistance benefits AND by accepting benefits that I am eligible to receive, I understand the
following information and agree to the following requirements:

 I must tell the truth; it is a crime to lie on this application.

 I may have to give papers that show what I’ve told you is true.
 I may have to tell you of any changes to the information I gave you on my application. If I think you made a mistake, I can
ask for an appeal or fair hearing.
 The department will not discriminate.
 The department will confirm citizenship and immigration status for everyone applying for benefits.
 The department will tell you if your benefits change.
 The department or relevant federal agency will take back any benefits you should not have received.

1. The Department of Health Care Policy and Financing residence in order to obtain assistance in two states at the
(HCPF) is the state agency responsible for Medical Assistance same time will have their Colorado Works assistance
Programs in Colorado. The Department of Human Services is denied for ten (10) years.
the state agency responsible for the other public assistance 6. The department will notify me in writing of how and when
programs. The County Departments of Human/Social Services to tell the department of any changes. If I am receiving
and Medical Assistance Sites are the agencies that receive and financial assistance, I know that I must tell the organization
process applications for all public assistance programs. In this providing the assistance if information I listed on this application
statement, the term “department” is used to refer to all agencies. changes. I am aware I have 10 calendar days to report any
2. I must give the department all needed proof and documents changes if I am enrolled in Health First Colorado or Child
before qualifying for benefits. Health Plan Plus (CHP+). Changes are to be reported to my
3. The information I give on the application and in the local county office for Health First Colorado or to CHP+. I am
application interview is confidential. However, the responsible for paying fees, premiums and co-payments for
department can use or share the information with other myself and my family if they are required for Medical Assistance
program(s) that any of my family and/or household benefits. I know I have 30 calendar days to report any change
members are getting or are applying for. The information to Connect for Health Colorado if I am receiving Advance
can only be used for purposes of treatment, payment, Premium Tax Credits, Reduced Co-Pays or Deductibles, or I
determining eligibility, and other program and am enrolled in a Qualified Health Plan. If my family is enrolled
administrative operations, or other purposes permitted by in multiple insurance affordability programs, I must report
law for my family and/or household members or me. changes to each organization in the appropriate time frame. I
Additionally, this information may be disclosed to other understand that a change in information could affect my
Federal and State agencies for official examination and to eligibility and eligibility of member(s) of my household.
law enforcement officials for the purpose of apprehending 7. If I do not tell the truth on my application or if information is left
persons fleeing to avoid the law. It will also be determined off of the application, or if I do not report changes to the
if the information is factual. If any information is incorrect, department, as required, I may lose my assistance, and I may
Food Assistance may be denied and the applicant may be have to pay back the department for the assistance received
subject to criminal prosecution for knowingly providing when I was not eligible. If I have to pay back money to the
incorrect information. department, I understand that state or federal salaries, rebates,
4. It is a crime to lie on the application or to take benefits or tax refunds that would be received by me or another person
that I know that my family and I are not eligible to receive on this application may be taken.
and I may be subject to criminal prosecution for knowingly 8. The law says the department must check the immigration
providing false information. Giving false information may status and citizenship for anyone who is applying. They will not
be punished by a fine of up to $250,000 or a jail term of up check immigration status of family members who are not
to 20 years, or both. applying for benefits. I may be requested to give proof of non-
5. A person found to have intentionally given false citizen registration documentation received from the United
information cannot get Food Assistance and/or Colorado States Citizen and Immigration Service (USCIS) for every non-
Works/TANF for 12 months for the first offense, 24 months citizen member in my house who is applying for benefits. The
for the second offense, and permanently for the third department will confirm information with USCIS and any
offense. A court can also stop a person from getting Food information received from USCIS may affect my eligibility and
Assistance for another eighteen months. This crime is benefits. Federal law (Public Law 97-98) requires me to give the
subject to prosecution under other state and federal laws. department the Social Security number and/or alien registration
Receiving duplicate benefits of Food Assistance by lying number of all persons who are applying for public assistance. I
about identity or residence will result in a ten (10) year must also provide the Social Security number and/or alien
disqualification for the first offense, a ten (10) year registration number for all sponsors. For Adult Financial and
disqualification for the second offense and a permanent Colorado Works programs, sponsor information will be
disqualification for the third offense. If I omit or provide confirmed with USCIS and the information received from
any information (other than lying about identity or USCIS may affect sponsor repayment for my eligibility and
residence) that leads to duplicate benefits being issued, I benefits. My sponsor and I may be responsible for
can be disqualified for 12 months for the 1st offense, 24 reimbursing the state for benefits that I receive.
months for the 2nd offense and permanently for the 3rd 9. The following applies to all qualified non-citizens
offense. A person convicted by a court or whose applying for Adult Financial and/or Colorado Works: As a
disqualification was obtained through an Intentional condition of my eligibility for financial assistance programs I
Program Violation (IPV) waiver for misrepresenting their agree that, during the time I am receiving such assistance, I will
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not sign an Affidavit of Support to sponsor a non-citizen who is with all of these tasks.
seeking permission to enter or remain in the United States. I 16. If I think the department made a mistake, I can ask for a Fair
understand that any Affidavit of Support signed prior to July 1, Hearing. The department will tell me in writing how to make an
1997 does not affect my eligibility for assistance. If I do not appeal. I can ask for a Fair Hearing either verbally or in writing.
agree, I will no longer be eligible for financial assistance from My case may be presented by a member of my household or my
the State of Colorado. representative, such as legal counsel, friend, or relative. I may
10. I do not have to be a U.S. citizen to apply for assistance. request an appeal for any action on any program except for the
Please do not let the fear about immigration status stop you CHP+ program
from seeking benefits for your family. 17. If I think the CHP+ program made a mistake, I can ask for an
11. If I am a resident of an institution and jointly applying for SSI appeal. CHP+ tells me about how to make an appeal in writing.
and Food Assistance prior to leaving the institution, the filing 18. Colorado Works is not an entitlement program and benefits
date of the application is my date of release from the institution. are not guaranteed. Each county has the authority to determine
Processing time will begin from the date the application is eligibility requirements and benefit levels. To remain eligible, I
received in the Food Assistance office. may be required to complete an assessment and develop a
12. Privacy Act Information: The department is authorized to plan. Unless exempted, I will be required to participate in work
collect information on the application, including Social Security readiness activities
numbers and will confirm information that may affect initial or 19. As an applicant for Colorado Works, if I refuse to cooperate
ongoing eligibility and payments for all persons listed on my with Child Support Services at the time I apply or while
application. I am allowing the department to use Social receiving cash assistance through Colorado Works, without
Security numbers (SSN) and other information from my good cause, I will not receive assistance or a basic cash
application to request and receive information or records to assistance grant for my family. Good cause for not working
confirm the information in my application. Food Assistance with Child Support can be, but is not limited to; potential
will be denied to individuals that do not provide a Social Security physical or emotional harm to a child(ren), parent or caretaker
number, and Social Security numbers will be used and disclosed relative; pregnancy or birth of a child related to incest or forcible
in the same manner for both eligible and ineligible members. I rape; legal adoption before court or a parent receiving pre-
release the department from all liability for sharing this adoption services; or other reasons determined to be in the
information with other agencies for this purpose. For best interest of the child. In order to cooperate with Child
example, the department may get and share information with Support Services, I will be required to complete additional
any of the following agencies: Social Security Administration; documentation concerning the child(ren), parentage of the
Internal Revenue Service; United States Customs and child(ren) and provide all court documents that concern the
Immigration Services; Colorado Department of Labor and child(ren).
Employment; financial institutions (banks, savings and loans, 20. If I am an adult between the ages of 18 and 49, with no
credit unions, insurance companies, landlords, leasing agents, children under the age of 18 in my Food Assistance house, I
etc.); child support services; employers; courts; and other federal will only be eligible to receive Food Assistance benefits for
or state agencies; and for Food Assistance, law enforcement three months, unless one of the following applies: I work in a
officials for the purposes of apprehending persons fleeing to job 80 hours each month and report my hours worked to my
avoid the law. local Employment First office, or I meet the Workfare program
13. If a Food Assistance, Colorado Works, and/or Adult requirements or work program requirements set by the
Financial over-payment occurs against my household, the Employment First office. Additionally, I may continue to receive
information on this application, including all Social Security my Food Assistance benefits if I am determined to be physically
numbers, may be referred to Federal and State agencies, as well or mentally unable to work or if the Food Assistance office
as private claims collection agencies for claims collection action. identifies other applicable exemptions. If I meet any of these
14. The EBT (or Quest) card is used to pay me most of my criteria, I will be able to continue receiving Food Assistance as
public assistance benefits. I cannot trade or sell EBT cards. The long as I remain eligible.
only people allowed to use my household’s EBT card are 21. I understand and agree that to receive Food Assistance,
members of my household, my authorized representative(s), and certain members of the household need to register for work.
individuals outside my household that have my permission to use This means that certain members of the household must: A)
my EBT card to access benefits for the people in my household. Report to the Employment First (work program) when the Food
I cannot use my EBT card to access my cash benefits at Assistance office schedules an appointment. B) Comply with the
locations identified as prohibited locations including licensed instructions the Employment First (work program) gives including
gaming establishments, in-state simulcast facilities, tracks for reporting for all scheduled appointments and following through
racing, commercial bingo facilities, stores or establishments in on the written agreements signed. C) Provide information to the
which the principal business is the sale of firearms, retail Food Assistance office or the Employment First (work program)
establishment licensed to sell malt, vinous, or spirituous liquors, about any jobs me or my household member(s) get while on
establishments licensed to sell medical marijuana or medical Food Assistance. D) Tell the Food Assistance office or the
marijuana-infused products, or retail marijuana or retail Employment First (work program) if me or my household
marijuana products, establishments that provide adult-oriented member(s) are not able to work – I will be asked to provide
entertainment in which performers disrobe or perform in an verification; work any workfare hours assigned; go to job
unclothed state for entertainment. Continued misuse of my interviews arranged for me or my household member(s). Anyone
EBT card at prohibited locations will cause my cash who does not follow the work requirements may be disqualified
benefits to be suspended on my EBT card and/or my cash from receiving Food Assistance.
benefits to be terminated for a period of 30 days requiring 22. I must cooperate fully with state and federal staff if my case
a new application. is reviewed. My information on this application may be reviewed
15. I can name someone or an organization to be my and confirmed by the department, or its representatives. My
representative. I must do this in writing. The person and/or household will not be eligible for Food Assistance if I refuse to
organization I designate to be my authorized representative may cooperate with any review of my case, including a quality control
help me apply for assistance, get my benefits, and use my review.
benefits to buy food for me. I may name one person to help me 23. I cannot use Food Assistance benefits to buy nonfood
with each separate task or I may name one person to help me items, such as alcohol or cigarettes. I can be disqualified for

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using Food Assistance to pay for items purchased on credit. If paid by people in my household who are elderly or who have a
a court of law finds a person guilty of using Food disability, I am stating that I do not want that specific deduction
Assistance benefits to illegally purchase or receive used to determine my Food Assistance benefit amount.
controlled substances that individual shall be disqualified 26. I can ask for Food Assistance apart from asking for benefits
for two years for a first offense and permanently for a from other programs. My eligibility for Food Assistance will be
second offense. Individuals found by a Federal, State, or determined apart from any other programs. The Food Assistance
local court to have used or received benefits in a office shall process all Food Assistance applications in
transaction involving the sale of firearms, ammunition, or accordance with Food Assistance timeliness, noticing, and fair
explosives shall be permanently ineligible to receive Food hearing requirements, even if I am applying for other programs.
Assistance upon the first occasion of such violation. If a 27. Colorado residents who have a qualifying disability, such as
court of law finds a person guilty of having trafficked persons receiving SSI or SSDI benefits, or residents who are at
benefits for an aggregate amount of $500 or more, that least 65 years of age (or a surviving spouse age 58 or older)
individual will be permanently ineligible to receive Food might also qualify for a Property Tax/Rent/Heat Rebate from the
Assistance upon the first occasion of such violation. Department of Revenue. Visit www.TaxColorado.com and click
24. The trafficking of benefits means: on the PTC button at the top of the page or call 303-238-7378 for
a. The buying, selling, stealing, or otherwise effecting an details.
exchange of Food Assistance benefits issued and accessed 28. IEVS refers to the Income Eligibility Verification System. IEVS
via Electronic Benefit Transfer (EBT) cards, card numbers reports discrepancies between the information you provide and
and personal identification numbers (PINs), or by manual information in the Department of Labor's system as well as Social
voucher and signature, for cash or consideration other than Security Administration's various systems. Information available
eligible food, either directly, indirectly, in complicity or through IEVS will be requested, used, and may be verified
collusion with others, or acting alone ; or, through collateral contacts when discrepancies are found. This
b. The exchange of Food Assistance benefits or EBT cards information may affect your eligibility and benefit level.
for firearms, ammunition, explosives, or controlled 29. I will immediately notify the State of any medical claim or
substances; or, lawsuit I have. I will cooperate with the State in collecting the
c. A Food Assistance participant, including the participant’s medical bills the State has paid. The state may collect from any
designated authorized representative, who knowingly insurance company or court settlement for medical bills that the
transfers Food Assistance benefit to another who does not, State has paid. If I am on Medical Assistance and receive
or does not intend to, use the Food Assistance benefits for money for the same medical bills that the State has paid, I will
the Food Assistance household for whom the Food give the money to the State. I assign to the State all rights to
Assistance benefits were intended; or payment for medical expenses and treatment. I also assign my
d. The reselling of food that was purchased with Food right to appeal a denial of benefits by another party responsible
Assistance benefits for cash; or for payment for the benefits to the State.
e. Obtaining a cash deposit when returning water or other 30. Federal and Colorado state law require the Department of
containers that were purchased with Food Assistance Health Care Policy and Financing to recover all medical
benefits. Purchasing water containers is an eligible food assistance benefits, including capitation payments, paid on
item that can be paid for with Food Assistance benefits; behalf of Health First Colorado clients from the estates of
however, when the container is returned, the deposit should deceased Health First Colorado clients who were permanently
be returned to the client’s EBT card and not given to the institutionalized. For Health First Colorado clients who were
client in cash. over the age of 55 when benefits were provided, the
f. Attempting to buy, sell, steal, or otherwise affect an Department recovers payments for nursing facility services,
exchange of SNAP benefits issued and accessed via home and community-based services, and related hospital and
Electronic Benefit Transfer (EBT) cards, card numbers and prescription drug services. There are certain exemptions to
personal identification numbers (PINs), or by manual estate recovery. For further information, please contact your
voucher and signatures, for cash or consideration other county and request the “Medical Assistance Estate Recovery
than eligible food, either directly, indirectly, in complicity or Program” brochure.
collusion with others, or acting alone.
25. If I do not report and provide proof of mortgage, housing
fees, property insurance, property taxes, court ordered child
support payments, child or adult care, and medical expenses

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CDHS Nondiscrimination Policy
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex, and in
some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious
creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large
print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for
benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact the USDA through the
Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages
other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Compliant Form, (AD-
3027), found online at:
http://www.ascr.usda.gov/compliant_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and
provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866)
632-9992. Submit your completed form or letter to USDA by:

(1) mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights
1400 Independence Ave, SW
Washington, D.C. 20250-9410

(2) fax: (202) 690-7442; or

(3) email: [email protected].

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should
either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State
Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S.
Department of Health and Human Services (HHS), write HHS Director, Office for Civil Rights, Room 515-F, 200
Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

Medical Assistance Nondiscrimination Policy

The Department of Health Care Policy and Financing and Connect for Health Colorado do not discriminate on the basis
of race, color, ethnic or national origin and expression, marital status, religion, creed, political beliefs, or disability in any
of its programs, services and activities. For further information about the Department’s policy, to request free disability
and/or language aids and services, or to file a discriminating complain, contact: 504/ADA Coordinator, 1570 Grant St.,
Denver, CO 80203, Phone: 303-866-6010, Fax: 303-866-2828, State Relay: 711, Email: [email protected]. For
information about Connect for Health Colorado’s policy, aids and services or to file a discrimination complaint, contact:
General Counsel, 3773 Cherry Creek N. Dr., Suite 1005, Phone: 303-590-9640, Fax: 303-322-4217. Complaints can
also be filed with the U.S Department of Health and Human Services Office for Civil Rights at
http://www.hhs.gov/ocr/filing-with-ocr/index.html.

For Other Programs: For information about the Colorado Department of Human Services policies, to request free
disability and/or language aids and services, or to file a discrimination complaint, contact: 504/ADA Coordinator, 1575
Sherman St Denver, CO 80203, Phone: 303-866-7129, Fax: 303-866-6080, State Relay: 711, Email:
[email protected]. For additional information please visit www.colorado.gov/cdhs.

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Civil rights complaints can also be filed with the U.S. Department of Health and Human Services Office for Civil Rights
electronically through the Office for Civil Rights Complaint Portal available at
https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf or by mail, phone, or fax at: 1961 Stout Street Room 08-148
Denver, CO 80294, Telephone: 800-368-1019, Fax: 202-619-3818, TDD: 800-537-7697. Complaint forms are available
at http://www.hhs.gov/civil-rights/filing-a-complaint/index.html.

Domestic violence information and services are available to me. If I ever feel I am in immediate danger I should
call 911. If I would like to receive information regarding safety and services in Colorado, I will call the Colorado
Coalition Against Domestic Violence at 303-831-9632 or toll free at 1-888-778-7091. I may also find the location of
services near me by going to www.colorado.gov/cdhs/dvp. The National Domestic Violence Hotline at
1−800−799−SAFE (7233) or TTY 1−800−787−3224 or www.thehotline.org can also provide information. If I am a
survivor of domestic violence, sexual assault, or stalking, the Address Confidentiality Program (ACP) can provide me
with a legal substitute address to use instead of my physical address for use with state and local government
agencies. I can find out more about the ACP at acp.colorado.gov. If I need or receive either of these services, I should
tell my department worker.

F
 Application for Public Assistance
State of Colorado Departments of Health Care Policy and Financing and Human Services

Check the box for each program you would like to apply for.
 Food Assistance- Known federally as the Supplemental Nutrition Assistance Program (SNAP)
Questions marked with a  are NOT required for Food Assistance.

 Cash Programs- Questions marked with a  are NOT required for Cash Assistance.
 Colorado Works- Known federally as Temporary Assistance for Needy Families (TANF)
 Adult Financial – Includes Colorado Supplement to SSI, Aid to the Needy Disabled (State AND),
Old Age Pension (OAP), and Home Care Allowance (HCA)

 Medical Assistance- Including Health First Colorado (Colorado’s Medicaid Program), Child Health Plan
Plus (CHP+), Tax Credits, and Cost Sharing Reductions
Questions marked with a  are NOT required for Medical Assistance.
Your Legal Name (First, Middle Initial, Last) Maiden Name 1 Date of Birth
Social Security Number

Home address (Number, Street) City State Zip Phone number

Mailing address (if different) City State Zip Other phone number

Do you speak and read English?

Yes No If no, what language do you speak?
Are you homeless?
Yes No
Are you a resident of Are you currently residing in a
nursing home?
Colorado? Yes No
Yes No
1
If you are applying for any program and have an SSN, we need this information. Even if you are not applying for benefits, providing your SSN
will help us to quickly process your application. We use SSNs to check income and other information to see what you and your household may
qualify for.

Under penalties of perjury, I state that I have examined this application, and to the best of my knowledge and belief, my answers
are true, including household composition, citizenship and non-citizenship information. I have listed all amounts and sources of
income and property I receive/own. I have the right to declare an Authorized Representative. If I am declaring an Authorized
Representative, by signing below, I allow this person to sign my application, get official information about this application , and
act for me on all future matters with this agency. I read, understand, and agree to “What I Should Know.”
Your signature Date  Spouse’s/Co-Applicants signature, if applying Date
(optional)

Authorized Representative, Conservator, Guardian Printed Name Authorized Representative, Conservator, Guardian Printed Name:

Authorized Representative Signature Date Authorized Representative Signature Date

Name, address and phone number of person who helped completed application

We can send links that allow you to view electronic notices about your case. You may choose more than one option, but if you do not
choose, you will receive paper notices by standard mail. I would prefer:
Paper notices An email with a link to view your notices sent to ____________________@___________________
(For Medical, if you would like to receive notices electronically, please see Instruction Booklet at Colorado.gov/HCPF/Apply or
ConnectforHealthCO.com/About-Us/Customer-Resources)

1
 Household Demographics
Legal Name (First,
Middle, Last)
Relation
to you
Birth Date Male/ Does
this
Married,    US
Citizen
Female Civil Union, Hispanic 1 Social Security
person Race or US
(M/F) Domestic or 2
want Number Nation
Partnership, 1
benefits Latino? al
Single,
?
Divorced,
Separated,
Widowed
SELF Page 1 Yes Yes Page 1 Yes
No No No
Yes Yes Yes
__/___/___ No No No
Yes Yes Yes
__/___/___ No No No
Yes Yes Yes
__/___/___ No No No
Yes Yes Yes
__/___/___ No No No
1
Race and ethnicity information is optional, and will not affect eligibility; rather it is collected to ensure that benefits are provided to all eligible
applicants regardless of race/color/national origin. Race options include: American Indian/Alaskan Native- AI; Asian - A; Black/African
American- B; Native Hawaiian/ Other Pacific Islander- NH; White- W
2
If you are applying for any program and have an SSN, we need this information. Even if you are not applying for benefits, providing your SSN
will help us to quickly process your application. We use SSNs to check income and other information to see what you and your household may
qualify for.

Is anyone in the home considered a roomer or boarder (they rent a Yes No If yes, list below
room from you)?
Name Amount paid for rent Are meals included with the rent?
$ Yes No
$ Yes No

Is there any household member temporarily out of Yes No If yes, list below. Examples of types of institutions are listed be at
the home in any type of facility or institution? the bottom of the table

Name Date Name of facility Type of facility Is this person pending Are meals provided?
entered disposition of
charges?
Yes No Yes No
Yes No Yes No
Examples: Nursing home• Hospital • Mental health institution • Incarceration

Emergency Details
Including yourself, how many people in your home do Is anyone in the home a migrant or  Yes No 
you buy and prepare food for? seasonal farm worker?
Total money my household expects to get this month $ Total cash on hand and money in your $
(before deductions) checking/savings account
Amount you pay for rent or mortgage $ Home insurance/Property Taxes/HOA $
fees
Utilities you pay for (check all that apply) Heating/Cooling  $______ Electricity  $______ Water  $______
Phone  $______ Trash  $______ Sewer  $______ Other $______

Did anyone in the home get any food or cash benefits in any other state in Yes No
If yes, list below
the last 30 days?
 If you are applying for Colorado Works, have you received benefits from Yes No
If yes, list below
any other state since 1996?
Name(s) Date of receipt City County State

Dependent Children
Do you live with at least one child under the age of 19, and are you the main person Yes No
taking care of this child?

2
  Do any of the children living in the home have a parent Yes
No
If yes, have you tried to get medical support
from the child’s parent living outside the
Yes
No
living outside the home?
home?
Name of Parent Address Phone For which child?

I would like to apply for good cause from pursuing Child Support Services Assistance allowable under the Family Violence Option Waiver (as
described in the What I Should Know section) Yes No
 Is anyone in the home currently in foster care or has ever been in foster care? Yes No
If yes, list below
Name Age Dates when in foster care

Pregnancy Details
 Is anyone in the home pregnant? Yes No If yes, list below
Name: Due date: Number of babies expected:
Name of the father, if known:
Would you like to pursue good cause from pursuing Child Support Services Assistance? Yes No

Disability Details
Does anyone in your home have a disability? Yes Name:
No
 If yes, does this person need help with self-care activities (bathing, Yes No
dressing, eating, using the bathroom, etc.)?
 Does anyone have a medical or developmental condition that has Yes No Name:
lasted, or is expected to last more than 12 months?
 Have you or anyone in the home applied for Supplemental Security Income (SSI) or Yes No
If yes, list below
other Social Security benefits?
Name What Date of Application Status Pending
Program? SSI Application ___/_____/___ Approved
______ Denied
Appealed
Name What Date of Application Status Pending
Program? SSI Application ___/_____/___ Approved
______ Denied
Appealed
If no, has anyone who is disabled ever received SSI or Yes No If yes, when did SSI or SSDI end? ___/_____/___
SSDI?

Non-Citizen Details
Is anyone who is applying for benefits a Yes No If yes, you may be asked to provide a copy of your U.S. Citizenship and
non-citizen? Immigration Services card.
Non-Citizen 1
Name of Non-Citizen 1: Non-Citizen Status:

Alien or I-94 Number: Card/Passport Number:

Document Expiration Date: Country of Issuance:

 Is the non-citizen’s spouse or parent a veteran Yes No  Has this person lived in the US since 1996? Yes No
or active-duty member of the US military?
Non-Citizen 2
Name of Non-Citizen 2: Non-Citizen Status:

Alien or I-94 Number: Card/Passport Number:

Document Expiration Date: Country of Issuance:

 Is the non-citizen’s spouse or parent a veteran Yes No  Has this person lived in the US since 1996? Yes No
or active-duty member of the US military?

3
Are any of the non-citizens listed above sponsored to remain in this Yes No
country? If yes, list below
Sponsor (please add additional pages if there is more than one sponsor)
Who is sponsored?

Name of sponsor: Name of sponsor’s spouse:

Sponsor’s Social
Security Number
 Sponsor’s spouse’s Social
Security Number
Sponsor’s address: Total number of people in
sponsor’s household?
Does the sponsored individual live with the sponsor? Yes No
Does the sponsored individual receive free room and board from the sponsor? Yes No
Does the sponsored individual receive any support from their sponsor? Yes No
Has the sponsored individual been abandoned, mistreated or abused by their sponsor? Yes No

Earned Income
Does anyone work or is anyone starting a new job? Yes No
If yes, list below
Job 1: Name of person who is or will be working:
Employer name and phone number:
Monthly wages/tips (before taxes): Hourly wage: Average hours worked each week:
How often is this person paid? Hourly Weekly Every 2 weeks Twice a month Monthly Yearly Daily
Is this job considered temporary and expected to last less than 3 months? Yes No
Is this income from?  Seasonal Employment  Commission-based Employment (including tip jobs)

Job 2: Name of person who is or will be working:

Employer name and phone number:
Monthly wages/tips (before taxes): Hourly wage: Average hours worked each week:
How often is this person paid? Hourly Weekly Every 2 weeks Twice a month Monthly Yearly Daily
Is this job considered temporary and expected to last less than 3 months? Yes No
 Is this income from?  Seasonal Employment  Commission-based Employment (including tip jobs)

Is anyone in the home considered self-employed? This includes, but is not limited to, earning money from babysitting, Yes No
selling goods such as make-up or kitchenware, selling goods on the internet or selling homemade/homegrown food If yes, list
products? below
Name of individual that is self-employed: Business name (if applicable):
One month’s gross income $ Month of this income:
Type of self-employment:  Sole Proprietor  LLC  S-Corp  Independent Contractor
Utilities paid for business: Business taxes paid: Interest paid for business: Gross business labor costs:
$_________ $_________ $_________ $_________
Cost of merchandise Other business cost: Other business cost Other business cost:
$_________ Type: Type: Type:
$_________ $_________ $_________
Total Net Income (Subtract your expenses from your gross income):

Has anyone in the home quit a job, lost a job, or reduced their work hours in the Yes No
past 30 days? If yes, list below
Name of person: Employer name and phone number:

Start date of job: End date of job: Monthly wages/tips (before taxes):

Date and amount of last paycheck: How often was this person paid? Monthly Yearly Hourly
Weekly Every two weeks Twice a month

Unearned/Other Income
Does anyone have other types of income? Yes No If yes, list below. Examples of other
types of income are listed at the bottom of the table
Name Type of Money/Income Monthly Amount

4
Examples include but are not limited to: Unemployment benefits • SSI • Veterans’ benefits • Widow Benefits • Workers’ Comp • Railroad Retirement •
Child Support • Survivor’s Benefits • Dividends/Interest • Rental income • Money from a boarder • Disability benefits • Retirement/pension • SSDI •
Alimony • In-kind income (Working for rent) • Social Security benefits • Public Assistance • Plasma donations • Gifts • Loans • Foster Care payments •
Tribal Benefits

Has anyone who is applying received (or Yes No

expects to receive) a lump sum payment? If yes, list below. Examples of types of lump sums are
listed at the bottom of the table
Name Date Received Type of Lump Sum Amount

Examples: Lawsuit settlement • Insurance settlement • Social Security, SSI, SSDI Payment • Veterans • Inheritance • Surrender of Annuity • Life
Insurance payout • Lottery/gambling winnings

Is anyone in the home on strike? Yes No If yes, list below

Name: Date strike began:
Date of last check: Amount of last paycheck:

Expenses
 Does anyone pay child or adult daycare, legally-obligated child support, child Yes No
If yes, list
support arrears, medical expenses , student loan interest and/or alimony?
1
below
Expense Who Pays Is this person Who is this expense for? Month of Amount Legally Obligated
outside of the expense Paid Amount
home?
Yes No $ $
Yes No $ $
Yes No $ $
For Food Assistance, medical expenses are only allowed for persons disabled and/or 60 years old or over. Some examples of medical expenses
rd
include prescriptions, medical/dental/eye, co-pays, insurance premiums and in-patient care. Amounts which are reimbursed by a 3 party are not to
be claimed.

Student Details
Does anyone in the home attend high school, Yes No For Food Assistance, student information is only required for individuals
vocational, trade school or college? If yes, list between the ages of 18 and 49 unless a person under the age of 18 is the
below head of household.
Name Name of School Last Grade Start date Expected Are you a full-time
student?
Completed Graduation Date
Yes No
Yes No
Is anyone in the home receiving financial aid (grants or scholarships), work study income or income Yes No
through a GI Bill? If yes, list below
Who:
What is the amount ($) of Grants, Scholarships, and/or Work Study used for living expenses this month? $_____________
What is the taxable amount ($) of Grants, Scholarships, and/or Work Study this person received for the year? $_______________
- If you need Medical Assistance, you will need this information
Living Expenses Examples: Food • Clothing • Housing • Transportation • Utility Costs • Insurance • Other

Resources INFORMATION ABOUT RESOURCES IS NOT REQUIRED FOR COLORADO WORKS

Does anyone in the home have any Yes No If yes, list below. Examples of types of resources are listed at the
resources, including those that are jointly bottom of the table.
owned with someone else?
Name Type of Name of financial Account number Current value
resources institution
$
$

Examples: Cash on-hand • Checking and Savings accounts • Stocks • Bonds • Mutual funds • 401Ks • IRAs • Trusts • CDs • Annuities • College
funds • PASS accounts • IDAs • Promissory notes • Education accounts

5
 Does anyone own a vehicle, including cars, trucks, motorcycles, trailers, boats, Yes No
If yes, list below
snowmobiles, and other recreational vehicles?
Name Year, make and model Current value
$
$

Does anyone have life insurance policies or burial insurance policies? Yes No If yes,
list below
Who Company & Policy Number Type Revocable or Value
Irrevocable?
Burial policy Revocable $
Insurance policy Irrevocable
Burial policy Revocable $
Insurance policy Irrevocable

Does anyone in the home own any property (including your home)? Yes No
If yes, list below
Name/owner of property Property type Property address Value Primary use for this property (choose one)
$ Primary Home Rental income Business/self-
employment Other:
$ Primary Home Rental income Business/self-
employment Other:

Has anyone in the home sold, transferred or given away cash, property, Yes No
1 If yes, list below
or other assets within the last five years?
Name Date of Transfer What Asset? Amount Received Fair Market Value

$ $
$ $
1
If you are only applying for Food Assistance; you only need to declare for the last 3 months. For AND, OAP, HCA and CS-SSI, you only need to
declare for the last 36 months (3 years).

Prior Convictions
THESE QUESTIONS ARE ONLY REQUIRED FOR FOOD ASSISTANCE, COLORADO WORKS AND ADULT FINANCIAL
If you are applying for Medical Assistance, please skip to the next section.
Yes No
1. Have you or any member of your home been convicted of, or disqualified for, fraudulently receiving duplicate Food
Who:
Assistance benefits in any state after 9/22/1996?
Yes No
2. Are you or any member of your home hiding or running from the law to avoid prosecution, being taken into custody,
Who:
or going to jail, for a felony crime or attempted felony crime, or violating a condition of parole or probation?
3. Have you or any member of your home been convicted of a felony under federal or state law for possession, use, or Yes No
distribution of a controlled drug substance (felony drug conviction) or for a crime while under the influence of a controlled drug Who:
substance after 8/ 22/1996?
Yes No
4. Have you or any member of your home been convicted of, or disqualified for, buying or selling, or attempting to buy
Who:
or sell, Food Assistance benefits for more than $500 after 9/22/1996?
Yes No
5. Have you or any member of your home been convicted of trading Food Assistance benefits for guns, ammunitions,
Who:
explosives, or drugs after 9/22/1996?
Yes No
6. Have you or any member of your home applying for assistance ever been disqualified for an Intentional Program Violation or
Who:
been convicted of welfare fraud in a criminal case?
7. Have you or any member of your home been convicted of aggravated sexual abuse, murder, sexual exploitation and abuse of Yes No
children, sexual assault as defined in the Violence Against Women Act of 1994, or a similar state law, and is also not in Who:
compliance with the terms of their sentence?
IF YOU ARE ONLY APPLYING FOR FOOD ASSISTANCE YOU MAY STOP HERE.

Has anyone in the home been in the military? Yes No If yes, who?

If you need help to pay your burial/funeral costs, would you prefer: Cremation Burial No Preference

6
Lawful Presence Affidavit

AFFIDAVIT
for the Colorado Department of Human Services as Proof of Lawful Presence in the United States

I, _______________________, swear or affirm under penalty of or perjury under the laws of the State of Colorado that:

 I am a United States citizen, or

Check
only  I am not a United States Citizen but am a legal Permanent Resident of the United States, or
one
box  I am not a United States Citizen or a legal Permanent Resident but am lawfully present in the
United States pursuant to federal law.

I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide
proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent
statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised
Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
Signature: Date:

AFFIDAVIT
for the Colorado Department of Human Services as Proof of Lawful Presence in the United States

I, _______________________, swear or affirm under penalty of or perjury under the laws of the State of Colorado that:

 I am a United States citizen, or

Check
only  I am not a United States Citizen but am a legal Permanent Resident of the United States, or
one
box  I am not a United States Citizen or a legal Permanent Resident but am lawfully present in the
United States pursuant to federal law.

I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide
proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent
statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised
Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received
Signature: Date:
IF YOU ARE ONLY APPLYING FOR COLORADO WORKS OR ADULT FINANCIAL ASSISTANCE YOU MAY STOP HERE.

Retroactive Medical Coverage

Does anyone want help paying for medical bills from the last 3 months? Yes No
Who Month(s) Household income in that month(s)

Tax Filer Information

Instructions: Please complete for yourself, your spouse/partner, and children who live with you and/or anyone on the same federal income tax
return, if you file one. If you don’t file a tax return, remember to still add family members who live with you. Use more paper if necessary.
Do you plan to file a Federal Income Tax Return NEXT YEAR? Yes No
If yes, list below
Filing jointly with a spouse? Yes No Name of spouse:
Claiming dependent(s)? Yes No Name of dependent(s):
Expects to be claimed as a dependent on someone else’s tax return that does not live at your address? Yes No If yes, list below
Claimed as a dependent? Yes No Name of person claiming you:
Is this person listed on the Yes No Is this person a non-custodial parent? Yes No
application?
If you indicated that you are a tax filer and that you are Married, Filing Separately on your tax forms, do Exceptional Circumstances (that you
have been a victim of domestic violence) apply to your case? Yes No

Does anyone else in the home plan to file a Federal Income Tax Return NEXT YEAR? Yes No Name:
Filing jointly with a spouse? Yes No Name of spouse:
Claiming dependent(s)? Yes No Name of dependent(s):
Expects to be claimed as a dependent on someone else’s tax return that does not live at your address? Yes No If yes, list below
Claimed as a dependent? Yes No Name of person claiming them:
7
 Is this person listed on the application? Yes No Is this person a non-custodial parent? Yes No
If they indicated that they are a tax filer and that they are Married, Filing Separately on your tax forms, do Exceptional Circumstances (that you
have been a victim of domestic violence) apply to their case? Yes No

Does anyone else in the home plan to file a Federal Income Tax Return NEXT YEAR? Yes No Name:
Filing jointly with a spouse? Yes No Name of spouse:
Claiming dependent(s)? Yes No Name of dependent(s):
Expects to be claimed as a dependent on someone’s tax return that does not live at your address? Yes No If yes, list below:
Claimed as a dependent? Yes No Name of person claiming them:
Is this person listed on the Yes No Is this person a non-custodial parent? Yes No
application?
If you indicated that you are a tax filer and that you are Married, Filing Separately on your tax forms, do Exceptional Circumstances (that you
have been a victim of domestic violence) apply to your case? Yes No

Health Insurance Coverage

1 Yes No If yes, list below
Does anyone in your home qualify for or have health insurance/coverage?
Name(s) Type of Coverage Dates Is this person enrolled?
Coverage
Eligible Enrolled
Eligible Enrolled
Eligible Enrolled
Eligible Enrolled
1
Types of coverage: Medicare •TRICARE • VA Health Care • Peace Corps • COBRA • Retiree Health Plan •Current Employer Sponsored Health
Coverage • Railroad Retirement Insurance

If you listed that someone in your home is enrolled in TRICARE, Peace Corps, VA Health Care Program, or other state or Federal
Health Benefit Program, complete the table below.
Type/Name of Program:
Who is currently enrolled in this health coverage?
Insurance Company Name:
Policy number:

If you listed that someone in your home has access to health insurance from a job, complete the table below. This includes if the
coverage is from someone else’s job such as a parent or a spouse OR if you have COBRA or a Retiree Health Plan.
Employer Name: Employer Identification Number:
Employer Address:
Employer Phone: Who can we contact about your coverage?
Date you could start coverage: Date you lost coverage:
Who else in the Household had access to this coverage? Who else in the Household was enrolled in this coverage?

How much would you need to pay in premiums: $ I don’t know

How often would you pay them? Weekly Every 2 Weeks Twice a month Monthly Yearly
1
Do you have access to an employee-only health plan that meets the minimum value standard health plan? Yes No
If Yes, what is the name of the lowest-cost plan that meets the minimum value standard offered only to the employee?
 I don’t know No plans meet the minimum value standard
1
An employer-sponsored health plan meets the “minimum value standard” if the employer pays for 60% of the allowed health plan benefits. You
would pay 40%.

If you or anyone in your household is enrolled in Medicare, complete the table below. For Part C coverage, please complete if you will
be entitled or enrolled in the month in which you would like to purchase private health insurance.
Medicare Part A Medicare Part B Medicare Part C Medicare Part D
Are you entitled to or receiving Are you entitled to or receiving Are you entitled to or Are you entitled to or receiving Part
Part A? Yes No Part B? Yes No receiving Part C (Medicare D? Yes No
Advantage) Yes No
When did your Part A begin? When did your Part B begin? When did you part C begin? When did your Part D begin?

Are you currently enrolled How much is your Part B How much is your Part D Premium
Yes No premium:$___________ $_______________
Who pays for your Part A Who pays for your Part B Who pays for your Part D Premium?
premium? _______________ premium? _______________ _______________
Is your Part A Premium Free?
Yes No

Are you or anyone in your home being treated for an injury that you have brought or may bring a legal claim? Yes No
Name:

8
 Individuals that are 18 years or older can get their own mail about their health coverage at a Yes No If yes, list below
different address. Do any individuals that are over 18 want to receive their own mail?
Name Address

Expected Income Change

Does the income in your household change from month to month? Yes No If yes, list below
Name Annual income from your job and Will the Annual income be the
employer name same or lower in the next
calendar year?
$ Yes No
$ Yes No

Reasons for Income Differences

After you submit your application, we will verify your income. Please tell us, if any of the following have happened to you in the past
few months to help us with the verification process:
Name What Happened?
Stopped working a job Hours changed at a job
Change in employment Married, legal separation, or divorce
Other
Stopped working a job Hours changed at a job
Change in employment Married, legal separation, or divorce
Other
Does anyone in your household have any job or non-job related deductions? Check all that apply. Provide the amount and how often
you pay it. Telling us about these deductions could make the cost of your health insurance lower. You should not include a cost that
you already considered in your previous answer to job income and net self-employment.
Do the deductions change month to month? Yes No If yes, fill out both the current amount and the
actual annual amount
Deduction Type and How Often Current Amount Actual Annual Amount
Type_____________________________________ $ $
One Time only Weekly Every 2 weeks Twice a month Monthly Yearly
Type_____________________________________ $ $
One Time only Weekly Every 2 weeks Twice a month Monthly Yearly
Type_____________________________________ $ $
One Time only Weekly Every 2 weeks Twice a month Monthly Yearly
Example: • Alimony Paid • Capital Losses • Penalty on Early Withdrawal of Savings •Student Loan Interest • Domestic Production Activities •
Reimbursement of Expenses • HSA deduction • Moving Expenses •Contribution made to your Traditional IRA •Certain Business Expenses of
Reservists, Performing Artists, or Fee based Government Officials

Did anyone in your household have income and deductions from a past job, self-employment, or other sources
during the coverage year which is not listed as current income that you will need to include on your tax return? Yes No

If yes, tell us the amount of the past income and deductions. Do not include any ongoing or future income or deductions.

Amount of past Income: $ _________

Amount of past Deductions: $ __________

American Indian or Alaska Native Information

American Indians and Alaska Natives can get services from the Indian Health Service, tribal health programs, urban Indian health program, or
through a referral from one of these programs. They also may not have to pay cost sharing and may get special monthly enrollment periods.
Answer the following questions to make sure your family gets the most help possible. Certain money received may not be counted as income for
receiving insurance affordability programs. List any income that includes money from these sources:
•Per capital payments from a Tribe that come from natural resources, usage rights, leases or royalties
•Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of
Interior (including reservations and former reservations)
•Money from selling things that have cultural significance
Is anyone in your home an American Indian or Alaska Native? Yes No If yes, list
below
Name Tribe Name Tribe State Type of Income Received Frequency and Amount

9
 Has anyone in the household ever received a service from the Indian Health Service, a Tribal health Yes No If yes, list
program, Urban Indian Health program or through a referral from one of these programs? below
Name:
Name:

If none, who in the household is eligible to receive services from Indian Health Service, Tribal health Yes No If yes, list
programs, Urban Indian Health Programs or through a referral from one of these programs? below
Name:
Name:

Permission to Validate Income

As part of the eligibility process, we are required to verify information that you have provided to us for this application. By checking the box below,
you indicate that Connect for Health Colorado DOES NOT have permission to verify income information from tax returns. By not allowing the use
of this data, you understand that Connect for Health Colorado will send you a letter requesting that you provide proof of information for your
household, including your annual income. If you do not provide the requested proof of your household’s income tax return information
within 90 days of the request, you will be determined ineligible for Advance Premium Tax Credits/Cost Sharing Reductions (APTC/CSR).
 I DO NOT give Connect for Health Colorado permission to validate my income data against federal sources.

AUTHORIZED REPRESENTATIVE INFORMATION FOR MEDICAL ASSISTANCE

For Medical only you can choose an Authorized Representative. An Authorized Representative is a trusted person or organization who you
choose to help you with your application. We need your permission in order for your Authorized Representative to talk with us about this
application, see your information, and act for you on all issues related to your health coverage. If you ever want to change your Authorized
Representative, or no longer want an Authorized Representative, contact Health First Colorado & CHP+ or Connect for Health Colorado.

Is your Authorized Representative an:  Individual  Organization:

Authorized Individual/Organization Name:

Company/Organization ID Number (is applicable):

Authorized Individual/Organization’s Address:

In Care Of (If applicable):

City, State, Zip Code, County:

Telephone Number: Email Address:

Do you want your Authorized Representative to receive copies of your Yes No
notices/communications?

By signing, you allow the Authorized Representative to sign your application, get information about the application, and act for you on all future
matters with this agency and/or Connect for Health Colorado.
Applicant’s Signature Date: (mm/dd/yyyy)

By signing, I agree to fulfill all responsibilities within the scope of the authorized representation that the individual who I represent is required to
fulfill. I agree to maintain the confidentiality of any information regarding the applicant or client provided by the agency or Connect for Health
Colorado in compliance with state, federal, and all other applicable laws.
If an Authorized Representative is an organization, the signature of an organizational contact who is either a provider, staff member, or volunteer of
the organization is required.
As a provider, staff member or volunteer of an organizations which is an Authorized Representative, I affirm that I will adhere to the regulations in
42 CFR §431, Subpart F and to 45 CFR §155.260(f), and 42 CFR §447.10, as well as all other relevant state and federal laws concerning conflicts
of interests and confidentiality of information.
If you have been given the legal authority to act as an Authorized Representative on the applicant or client’s behalf through some means other
than assignment through this Worksheet, you will need to affirm that you have that authority and provide the appropriate documents verifying that
you have that authority.
I, affirm that I have legal authority to act on behalf of the applicant or client. (Please provide a copy of the following documents with this application
when it is submitted: a power of attorney, court order establishing legal guardianship, or other legal document explicitly stating that you may legally
act on behalf of the applicant or client.)

Authorized Representative/Organizational Contact Signature Date: (mm/dd/yyyy)

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