This is a generic Affidavit to accompany a Motion to amend or strike alimony provisions of a divorce decree because of cohabitation by dependent spouse. This form is a generic example that may be referred to when preparing such a form for your particular state. It is for illustrative purposes only. Local laws should be consulted to determine any specific requirements for such a form in a particular jurisdiction.
Spousal Support Form For Medicaid In Harris
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Multi-State
County:
Harris
Control #:
US-00003BG-I
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If you recieve Medicaid through your local department of social service (LDSS), you may fill out form DOH-5247 and submit this with your renewal. This application can be used to apply for Medicaid, the.Family Planning Benefit Program, or for assistance paying your health insurance premiums. Under the Medicaid spousal impoverishment provisions, a certain amount of the couple's combined resources is protected for the spouse living in the community. The following are required to file your petition: ! Since the nonapplicant spouse has refused to "support" their spouse, this form assigns the right to support to the state. Who needs the Harris Health System Statement of Support Form? You may continue to call the HRA Medicaid Helpline at 1- if you have any questions about your Renewal Form. If you are asked for money to fill out or approve your application, do not send any money. Include your spouse and tax dependents even if they don't need health coverage.