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) 0 0 8 ( OTHER HEALTH INCOME SUPPORT SERVICES PROGRAM FEES/CO-PAYMENT Required Documents Birth Certificate (for each applicant) Resident Alien Card (If not a US Citizen) or other residency documents Proof of California Residency: Driver’s License, State ID Card or current letter mailed to you at your address Social Security Card Medicare Card or other health insurance card Marriage Certificate School Enrollment/Attendance Papers If pregnant or applying for unborn child, Proof of Pregnancy Proof of Income If unearned income: child support and/or spousal support award letter, copies of check received or statement from Child Support Services Department for last month Proof of Resources: all current bank statements, property statements, auto registrations, life and/or burial insurance policies, life estate agreement Proof of Expenses/Proof of Deductions: work clothing and transportation costs, current taxes, medical insurance, etc. PROOF OF INCOME & EXPENSES: If you have any of the documents listed in the two sections below bring them with you. ACCESSING HEALTH AND HUMAN SERVICES PROGRAMS MOST COMMONLY REQUESTED DOCUMENTS
INCOME EXPENSES If employed: copy of most recent pay stub with name of employer and For care of a child or disabled adult: receipts, bill or cancelled checks that show person who worked OR name of the person cared for, cost of care, and the name of the person who paid Signed statement from employer with gross monthly income stated and for the care dates received If self-employed: copy of last year’s federal income tax return (with For housing and utility costs: receipts or bills that show user’s name and amount due Schedule C) or last 3 months’ profit and loss statements If disabled or retired: copies of award letters or bank statements showing For medical costs for the disabled or persons age 60 or older: bills, receipts, or direct deposits cancelled checks that show the name of the person who incurred the expense, cost and name of person who paid for the care If currently receiving benefits: proof of the amount (i.e. unemployment For court ordered support payments: receipts, cancelled checks or money orders insurance, Social Security, workers compensation, veteran income checks or that show who the payment was for and the amount paid disability insurance) If income from a loan: copy of loan papers with the name of person who is For self employed: signed receipts, cancelled checks or statements from whom you receiving the loan, the amount and current balance get your supplies
*For copies of this form, please log on to the Chief Executive Office at http://ceo.lacounty.gov/SIB/cust_serv.htm rev. 8/07 WHERE TO ACCESS THE MOST COMMONLY REQUESTED DOCUMENTS
DOCUMENT DEPARTMENT PHONE NO. & WEBSITE Birth, Death, and Marriage Registrar Recorder/County Clerk 1-800-201-8999 Certificates Department Headquarters www.lavote.net 12400 Imperial Highway Norwalk, CA 90650 Resident Alien Cards or other U.S. Citizenship and Immigration 1-800-375-5283 Residency Documents Services www.uscis.gov Proof of California Residency: California Department of Motor Vehicles 1-800-777-0133 Driver’s License, State ID (DMV) www.dmv.ca.gov Social Security Card Social Security Administration (SSA) 1-800-772-1213 www.ssa.gov Copies of Income Tax Return Internal Revenue Service (IRS) 1-800-829-1040 www.irs.gov Child Support Documents Child Support Services Department 1-800-615-8858 or (323) 890-9800 in LA County http://childsupport.co.la.ca.us
KEY COUNTY OF LOS ANGELES HEALTH & HUMAN SERVICES PROGRAMS . CALIFORNIA CHILDREN’S SERVICES (CCS) . IN-HOME SUPPORTIVE SERVICES (800) 288-4584 (888) 944-IHSS (944-4477) www.dhs.ca.gov/pcfh/cms/ccs http://dpss.lacounty.gov/dpss/ihss
. CHILD HEALTH & DISABILITY PREVENTION PROGRAM (CHDP) . WOMEN, INFANTS AND CHILDREN (800) 993-2437 (888) WIC-BABY (942-2229) www.dhs.ca.gov/pcfh/cms/chdp www.fns.usda.gov/wic
. HEALTHY KIDS . CHILD SUPPORT SERVICES (888) 4LA-KIDS (452-5437) (800) 615-8858 OR (323) 890-9800 http://www.first5la.org/ourprojects/healthykids.php4 http://childsupport.co.la.ca.us
. HEALTHY FAMILIES . MENTAL HEALTH (888) 747-1222 (800) 854-7771 www.healthyfamilies.ca.gov http://dmhconnection.lacounty.info
. MEDI-CAL OTHER NUMBERS OF INTEREST (877) 597-4777 www.dhs.ca.gov/mcs/medi-calhome . 211 LA COUNTY http://www.211lacounty.org . MEDICARE (800) MEDICARE (633-4227) . ACCESS FOR INFANTS AND MOTHERS www.medicare.gov (800) 433-2611 www.mrmib.ca.gov/MRMIB/AIM.html . CALWORKS (877) 481-1044 . COUNTY OF LOS ANGELES JOB HOTLINE www.dss.cahwnet.gov/cdssweb (800) 970-5478 http://dhr.lacounty.info/ . CASH ASSISTANCE PROGRAM FOR IMMIGRANTS (CAPI) (877) 481-1044 . LOW INCOME HOUSING INFORMATION http://dpss.lacounty.gov/dpss/capi (800) 731-HOME (731-4663) www.hacola.org . FOOD STAMPS (877) 597-4777 . LACOUNTYHELPS! http://dpss.lacounty.gov/dpss/food_stamps http://www.lacountyhelps.org
. GENERAL RELIEF . SUPPLEMENTAL SECURITY INCOME (877) 481-1044 (800) 772-1213 http://dpss.lacounty.gov/dpss/general_relief www.ssa.gov/notices/supplemental-security-income *For copies of this form, please log on to the Chief Executive Office at http://ceo.lacounty.gov/SIB/cust_serv.htm