Medical e form

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-1- Summary of e-Form # R402229455 Department of Social Services Signature Page e-Form Number R402229455 e-Form Date 9/18/2023 Primary Applicant XUAN H NGUYEN Address 1819 6th Street, Brookings, SOUTH DAKOTA 570061606 County Brookings Application Type Renewal Application Submitted Language English You are applying Benefits for the following Individuals: BENTLEY NGUYEN Rights and Responsibilities Summary Statement and Certification of Citizenship or Alien Status - I have agreed to submit an application by electronic means. - I understand the questions on this application and the penalty for giving false or misleading information or breaking any of the rules listed in the penalty warning below. I understand that I can be prosecuted if I provide false or misleading information or documentation or hide or omit information or documentation. - I understand and agree to provide information and documentation to prove what I have said as a condition of program eligibility. - I understand and agree that DSS may contact other persons, employers, financial institutions or organizations to obtain the necessary proof of my eligibility and to determine my level of benefits. - I certify, under penalty of perjury, that all my answers are true, correct and complete to the best of my knowledge, including information about the citizenship or alien status of each household member applying for benefits. - I understand that an electronic signature has the same legal effect and enforceability as a written signature on an application. Signature of applicant or person applying for applicant X Xuan Nguyen 9/18/2023 __________________________ __________________________ Signature Date
-2- Application Information e-Form Number R402229455 Application Submitted Date/Time 09-18-2023 08:22:34 PM CST Application Type Renewal Household Information Mailing Address Mailing Street Address or P.O. Box: 1819 6th Street Mailing City: Brookings Mailing State: SOUTH DAKOTA Mailing County: Brookings Mailing Zip Code: 570061606 Residence Address Is the Mailing address different than the residence Address? Yes Residence Street Address Line 1: 1819 6th Street Residence City: Brookings Residence State: SOUTH DAKOTA Residence Zip Code: 57006 What county do you live in? Brookings Contact Information Would you like to name a person to help give information at your interview, and speak with your Benefits Specialist for you? No Is there anyone in the household applying for coverage with at least one child under the age of 19 for which they are the main person taking care of this child? If yes, choose these adults. No Does any child on this application have a parent living outside of the home? No Were any individuals in the household applying for coverage in foster care at age 18 or older? No Are you or any other family members pregnant? Unborn children may be counted in the family. Yes Individual(s): XUAN H NGUYEN Does any individual in the household applying for coverage want help paying for medical bills from the last three months? No Has any individual in the household ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program or through a referral from one of these programs? No If no, is any individual in the household eligible to get services from the Indian Health service, tribal health programs, or urban Indian health programs, or through a referral from one of these programs? No Is any individual in the hosuehold applying for health insurance on this application incarcerated (detained or jailed)? No Cell Phone Number: (605) 520-9300 E-Mail Address: [email protected] What is your primary language? Other If other, please describe. VIETNAMESE
-3- Individual Information - XUAN H NGUYEN General Information Please tell us about this individual's relationship to other household members: is Spouse of PHU T NGUYEN is Parent (father or mother) of BENTLEY NGUYEN Social Security Number: 310-89-8403 Date of Birth: 07-30-1994 Sex: Female Will this individual plan to file a federal income tax return NEXT YEAR? (they can still apply for health insurance even if they don't file a federal income tax return.) Yes Will this individual claim any dependents on their tax return? No Will this individual be claimed as a dependent on someone's tax return? No What is this individual's marital status? Married What is this individual's Race? Asian Will XUAN H NGUYEN and PHU T NGUYEN file taxes jointly? Yes Is this individual a member of a federally recognized tribe? No When did this individual enter the US? 10/6/2017 Is this individual a US citizen? No Choose Immigration Document Type: Certificate of Citizen What is this individual's Alien Registration Number? 064798750 Has this individual lived in the US since 1996? No Does this individual have a physical, mental, or emotional health condition that causes limitations in activities that are expected to last more than a year (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? No Benefits None Citizenship When did this individual enter the US? 10-06-2017 What is this individual's Alien Registration Number? 064798750 Individual Information - PHU T NGUYEN General Information Please tell us about this individual's relationship to other household members: is Spouse of XUAN H NGUYEN is Parent (father or mother) of BENTLEY NGUYEN Social Security Number: 376-45-8922 Date of Birth: 11-11-1992 Sex: Male Check here if this person does not live in the same home as you. Yes
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