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Application Document Checklist

Please choose one of the four descriptions below that best describes you. After you choose a number, read which documents you must provide. The back of this page lists good documents you can provide for each type.

1. Are you a U.S. Citizen with a valid Social Security Number?
Each CountyCare application must include documents for each applicant that prove:
+ Income - A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source
+ Address - A document that shows the applicant’s name with a home address in Cook County

2. Are you a U.S. Citizen without a valid Social Security Number?
Each CountyCare application must include documents for each applicant that prove:
+ Income - A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source
+ Identity - A document that shows the applicant’s name
+ Citizenship - A different document from the identity document that shows the applicant is a U.S. citizen
+ Application for SSN - A document that shows the applicant recently applied to the Social Security Administration to get a Social Security Number
+ Address - A document that shows applicant’s name with a home address in Cook County

3. Are you a Non-Citizen with a valid Social Security Number?
Each CountyCare application must include documents for each applicant that prove:
+ Income - A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source
+ Identity - A document that shows the applicant’s name
+ Legal Status - A different document from the identity document that shows the applicant’s legal status in the U.S
+ Address - A document that shows the applicant’s name with a home address in Cook County

4. Are you a Non-Citizen without a valid Social Security Number?
Each CountyCare application must include documents for each applicant that prove:
+ Income - A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source.
+ Identity - A document that shows the applicant’s name
+ Legal Status - A different document from the identity document that shows the applicant’s legal status in the U.S
+ Application for SSN - A document that shows the applicant recently applied to the Social Security Administration to get a Social Security Number
+ Address - A document that shows applicant’s name with a home address in Cook County

ALL APPLICANTS MUST SEND A SIGNED SIGNATURE PAGE WITH THEIR DOCUMENTS

Acceptable Documents

Income - A document or set of documents for each income source that, when added together, shows the dollar amount each applicant currently receives in a month from each income source.

Note: Documentation is not required to verify amounts received from the Social Security Administration or from unemployment insurance benefits from the Illinois Department of Employment Security are not required.

+ Pay stubs or pay statements that the applicant receives from their employer each time they are paid
+ A statement on the applicant’s employer’s stationery, signed by the employer or the employer’s representative
+ A benefits award letter
+ Alimony payment records
+ Retirement benefits statement

Self-Employment Income -A document or set of documents for self-employment income that, when added together, shows the dollar amount of net income, after business expenses, that the applicant currently receives in a month.

To document self-employment income, applicants should submit a month’s worth of business records that list
+ income amounts received by source and date received and
+ business expense amounts incurred by type of expense and receipts for each expense paid

Address - A document that shows the applicant’s name with a home address in Cook County
+ A copy of a page from a medical provider’s electronic medical record showing the applicant’s name and address
+ An electric, water, cable or other utility bill
+ A current lease agreement or rent receipt
+ A mortgage document
+ An Illinois Driver’s License or State Identification Card
+ If the applicant is homeless, a letter from a local shelter, social services organization or religious organization where the applicant can receive mail about their CountyCare coverage

Identity - A document that shows the applicant’s name
+ Birth certificate
+ Work Identification Card
+ Illinois Driver’s License or State Identification Card
+ School Identification Card
+ Military Identification Card
+ Certificate of Citizenship or Certificate of Naturalization

Citizenship - A different document from the identity document that shows the applicant is a U.S. citizen. Only required if applicant does not have a valid social security number.

+ Birth certificate
+ Certificate of Naturalization
+ Certificate of Citizenship
+ U.S. passport

Legal Status - A different document from the identity document that shows the applicant’s legal status in the U.S
+ Form I-94 Arrival-Departure Form
+ Employment Authorization Card
+ Alien Registration Card
+ Permanent Resident Card
+ Immigration Status Filing (Green Card)
+ Foreign passport stamped with the applicants Alien Registration Number

Application for SSN - A document that shows the applicant recently applied to the Social Security Administration to get a Social Security Number.

 

If you have questions about your application documents, call 312.633.5841 between 8 a.m.-6 p.m., Monday-Friday.

Call 877-RES-INFO for Nurse Advice, Doctor Referrals or Class Registration Monday - Friday 8 am to 8 pm • Weekends 8 am to 4pm

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