xx SM Proof for Eligibility - Oregon DHS Applications home

1 DHS 0223 (08/14), Replaces and can use MSC 0223 Page 1 More on Other SideProof for EligibilityThis form lists the required Proof for each program applied for. On page two (2) you will find some common examples of Proof you can give to the Department of Human Services (DHS). If you cannot get items, DHS may be able to help you get some of them. Please let us know if you need you are applying for more than one program, you will need to provide the Proof that is required for each program. Your worker may ask for more verification during your all persons applying for food benefits, you will need to provide Proof of: Identity of the head of household Income for each person Alien status for any person who is not a citizenExpenses - If you pay court ordered child support or have medical expenses, you may qualify for more benefits by providing Proof of those all persons applying for Temporary Assistance to Needy Families TANF benefits (cash assistance), you will need to provide Proof of: Income for each person Alien status for any person who is not a citizenIf you are applying for child care benefits, you will need to provide Proof of.

2 Income of the parents/caretakers in the household Alien status for any children needing care who are not citizensSMThis document can be provided upon request in an alternate format for individuals with disabilities or in a language other than English for people with limited English skills. To request this publication in another format or language, contact the Publications and Design Section at 503-378-3486, 711 for TTY, or email 0223 (08/14), Replaces and can use MSC 0223 Page 2 Expenses (if applying for food benefits):If you are paying child support: Court or administrative order (to prove legal obligation) Evidence of withholding from wages or unemployment Statement from custodial parent for payment of supportIncome:Examples of Proof of EligibilityYou do NOT have to give us all items listed. You only need to give one example from each section needed for the program you are applying for. Driver's license/photo identification card Work or school ID card (must have picture) Certificate of Indian blood military record If child applying for medical - parents may attest to identity Wage stubs (cannot be used for medical programs) Birth certificate (cannot be used for medical programs)Identity (ID): Pay stubs Employer's records/statement Self-employment bookkeeping records Tax records Award letter (veterans, financial aid, Bureau of Indian Affairs, ) Worker's compensation letter Statement of person giving you money (gifts/loans) Unemployment compensation letterAlien status: USCIS ID card or recordsCitizen.

3 Birth certificates Naturalization papers Passport Certificate of citizenship Proof of tribal membershipIn accordance with Federal law and Department of Agriculture (USDA), Department of Health and Human Services (HHS) and Oregon Department of Human Services (DHS) polity, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability or sexual orientation1. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political may file a complaint if you believe you have been treated differently for any of these reasons. To file a complaint of discrimination, contact USDA or HHS. USDA and HHS are equal opportunity providers and file a complaint with the state, you can contact the Governor s Advocacy Office at:USDA, Director Office of Civil Rights 1400 Independence Avenue, Washington 20250-9410 (800) 795-3272 (voice) or (202) 720-6382 (TTY) HHS, Director Office for Civil Rights, Room 506-F 200 Independence Avenue, Washington, 20201 (202) 619-0403 (voice) or (202) 619-3257 (TTY) Health insurance policy showing premium amount Billing statements Bill for visiting nurse, homemaker, home health aide, Itemized receipts Bill/receipt for prescribed equipment, medical supplies, Statement from pharmacyIf you have medical costs:Governor s Advocacy Office 500 Summer Street NE, E17 Salem, OR 97301 Phone: 1-800-442-5238 (TTY 711) Email: orientation is protected by the State of Oregon , but not federal laws.