Picture Identification (for ALL household members, includiing dependents)

Choose 1 of these:

• Driver's License or State ID Card
• Student ID Card
• Government ID
• Passport

Proof of U.S. Legal Status

(for EACH Health Plan Applicant)

Choose 1 of these:

• U.S. Birth Certificate
• U.S. Passport
• Certificate of Naturalization
• Certificate of Citizenship
• Green Card or Permanent Resident Card
• Form I-94 (Arrival-Departure Record) showing asylee or refugee status

Proof of Howard County Residency

(for EACH Health Plan applicant)

Choose 1 of these which include the applicant's name and address:

• Valid MD Driver's License
• Maryland vehicle registration card or title
• Voter registration card
• Additional federal, state or county correspondence
• A bill in the name of the applicant
• Checking or savings or retirement account statement
• Lease agreement or contract
• Mortgage account or proof of home ownership
• Installment loan contract from a bank or other lender

Applicants must copy:

• 2009 Federal Tax Return

Choose 1 of these to copy:

• 4 week's worth of recent pay stubs from each job held in your household
• Signed Statement of Income from the employer for each job held in your household, including verification that no medical insurance is provided
• Schedule C, D, or E from last year's Tax Return

If you receive regular financial support from a friend/family member, you should also submit a signed Statement of Support.

NOTE: If your tax return no longer represents your average household income, or if you did not file faxes last year, you  may substitute the HHAP Income Statement form for the tax return. You must provide documentation for each type of income that you list on this form.

• Valid marriage license
• Signed statement of marriage or domestic partnership
• Deed, mortgage or lease agreement listing both name
• Bank statement with both names
• Being listed as spouses on the previous year's federal tax return

• Layoff notice on company letterhead (The letter must include the applicant's name, date of layoff, and reason for layoff.)
• Proof of Unemployment Insurance Eligibility (Letter)
• Proof of Unemployment Insurance Eligibility (Check Stub)

• Letter from the provider containing: 1) date of termination of coverage and 2) reason for termination
• Letter from previous employer containing: 1) date of termination of coverage and 2) statement of retirement

• Letter from the provider containing: 1) date of termination of coverage and 2) reason for termination

• Letter from the provider containing: 1) date of termination of coverage and 2) reason for termination

•  Letter from the program office containing: 1) date of termination of coverage and 2) reason for termination