Printable Application Forms

 
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​​​The following Application Forms are available for completion and printing.​​

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 two. en Español

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). en Español

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.​

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. en Español

Economic Assistance Authorization for Disclosure Form: (HHS-160) 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. en Español

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. en Español

Home and Community-Based Services Application: (DD-10) This application is needed to determine eligibility for any of the HCBS waivers: the Aged and Disabled (AD) Waiver, the Developmental Disabilities (DD) waivers, and the Traumatic Brain Injury (TBI) Waiver. en Español - Arabic - Karen - Swahili - Thai - Vietnamese

Landlord Emergency Assistance Form: This form is used to request Emergency Assistance and is to be completed by a landlord.

Medicaid Authorization for Disclosure Form: (MLTC-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. en Español

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. en Español 

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. en Español

Self-Employment Ledger: This form is used to track monthly income received and the monthly expenses to run a business. en Español

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. en Español

Tip Ledger: This form is used to track the amount of tips that are received. en Español

Voluntary Child Support Form: This form is used to track child support payments that are voluntary.  en Español

Work Verification Request (Volunteer Verification for ABAWD): This form is used to verify that a person is either working or volunteering. en Español