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Printable Applications
 
 

The following Application Forms are available for completion and printing.

Medicaid and Insurance Affordability Programs: (MILTC-53) This application is utilized to determine eligibility for Medicaid and Insurance Affordability Programs (tax credits) through the Healthcare Marketplace.

Additional Person Form used with Medicaid and Insurance Affordability Programs Application: (MILTC-51) This form is utilized for each additional person in the household who were not included in the Medicaid and Insurance Affordability Application. A separate form will be required for each person over a household of 2.

Supplemental Application for Medicaid and Insurance Affordability Programs:(MILTC-63) This form is needed to determine eligibility for those over 65 or disabled and/or applying for a disability determination who are also in the household as someone using the MILTC-53.

Application for Nebraska Medicaid for Aged and Disabled:(MILTC-64)  This form is needed to determine eligibility for those over 65 or disabled and/or applying for a disability determination.

Application for Benefits: (EA-117) This form is utilized for any of the following programs: Supplemental Nutrition Assistance Program (SNAP), Aid to Dependent Children (ADC), Low Income Home Energy Assistance Program (LIHEAP), Child Care (CC), Assistance to the Aged, Blind and Disabled payment (AABD), and Social Services Aged and Disabled (SSAD).