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:(MLTC-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).
Developmental Disabilities Application: (DD-10) This application is needed to determine eligibility for developmental disabilities services funded through the Division of Developmental Disabilities.
The following Forms are available for completion and printing.
Earned Income Verification Form: This form is used to verify income that is received from a job in detail. This form is to be completed by an employer. Please call to request an Earned Income Verification Form for your employer to complete. Please call 800-383-4278 for Economic Assistance or 855-632-7633 for Medicaid.
FSP 1040 Supplement: This document is used to list payments on the principal of the purchase price of income – producing real estate and capital assets, equipment, machinery and other durable goods considered as an allowable cost of doing business.
Landlord Emergency Assistance Form: This form is used to request Emergency Assistance and is to be completed by a landlord.
Release of Information ASD-46: This form is used to release case information to another person.
Request for Fair Hearing DA-6: This form is used to appeal decisions by DHHS.
Self-Employment Ledger: This form is used to track monthly income received and the monthly expenses to run a business.
Tip Ledger: This form is used to track the amount of tips that are received.
Voluntary Child Support Form: This form is used to track child support payments that are voluntary
Work Verification Request (Volunteer Verification for ABAWD): This form is used to verify that a person is either working or volunteering.
Authorization for Disclosure Form MLTC-EA-34: By the completion and signing of this form, you are giving permission for DHHS to share otherwise private, protected information to the person(s) and/or agency you have indicated within this document.
Designation of Authorized Representative MLTC-35: By completion and signing of this form, you are giving permission for DHHS to discuss your application and renewal of eligibility and other ongoing communications with the authorized representative listed on the form.