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APPLICATION FOR LONG-TERM CARE SERVICES
Medicaid Benets for People Needing Long-Term Care
• Fill out this application to see if you qualify for long-term care services coverage through Medicaid. is program
is only for those who are planning to live or now live in a nursing facility, group home, or developmental center in
Louisiana, or who have been oered an opportunity through Home and Community-Based Services (HCBS) or the
Program of All-Inclusive Care for the Elderly (PACE).
• If you need extra space, use a separate sheet of paper or the space provided for you on page 13.
• If you have any questions, call 1-800-230-0690 from Monday–Friday to speak with a Medicaid representative. TTY
Text Telephone users call 1-800-220-5404.
• Complete and mail this application to the Medicaid Application Oce, 6069 I-49 Service Rd, Suite B, Opelousas, LA
70570 or fax it to 225-389-8019.
What long-term care benets are you applying for? (you may mark one or more)
□ Nursing facility services (Applicant Only) □ Nursing facility services (Applicant and Spouse)
□ HCBS Waiver □ PACE □ Intermediate Care Facility for the Intellectually Disabled (ICF/ID) or other group home
What is your preferred language?
□ English □ Spanish □ Vietnamese □ Other:
► Please PRINT clearly in black ink.
1 — Applicant’s Personal Information
First name Middle initial Last name Sux (Sr., Jr., etc.)
Social Security number Date of birth
Sex
□ Male □ Female
Marital Status: □ Single □ Married
□ Widowed □ Divorced □ Separated
If Hispanic/Latino, ethnicity (optional – you may mark one or more)
□ Mexican □ Mexican American □ Chicano/a □ Puerto Rican □ Cuban □ Other:
Race (optional – you may mark one or more)
□ White □ Asian Indian □ Japanese □ Other Asian □ Samoan
□ Black or African □ Chinese □ Korean □ Native Hawaiian □ Other Pacic
American □ Filipino □ Vietnamese □ Guamanian or Chamorro Islander
□ American Indian or Alaska Native – Tribe: □ Other:
Mailing Address Home Address (if dierent)
P.O. box or street address Apt/Lot # Street address Apt/Lot #
City State Zip City State Zip
E-mail address (if you have one) Home parish (where you live)
Cell phone
( )
Home phone
( )
Other phone
( )
Are you a Louisiana resident? □ Yes □ No Do you plan to stay in Louisiana? □ Yes □ No
BHSF Form 1-L
Rev. 1/2021
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2 — Application Assistance
Do you have someone helping you with this application? □ Yes □ No (If NO, skip to section 3)
Name of Assistant Relationship to Applicant
Mailing address
Do you want your mail to be sent to the address listed above? □ Yes □ No
Daytime phone
( )
Other phone
( )
E-mail address (if they have one)
3 — Legal Assistance
Do you have someone legally appointed to act on your behalf? □ Yes □ No (If NO, skip to section 4)
What kind of appointment does this person have? □ Power of Attorney □ Curator □ Other
Name of Appointee Relationship to Applicant
Mailing address
Do you want your mail to be sent to the address listed above? □ Yes □ No
Daytime phone
( )
Other phone
( )
E-mail address (if they have one)
4 — Citizenship
Are you a veteran or an active-duty member of the U.S. military? □ Yes □ No
Are you a U.S. Citizen or U.S. National? □ Yes □ No
If YES, were you born in the U.S. or a U.S. territory? □ Yes □ No (If NO, ll in your information below if it applies to you)
Alien number Certicate type Certicate number
If NO, do you have eligible immigration status? □ Yes □ No (If YES, ll in your information below if it applies to you)
Document type Document expiration date
Alien, I-94, or SEVIS ID number Card or Passport number Have you lived in the U.S. since 1996?
□ Yes □ No
5 — Long-Term Care
Do you currently live at or are planning to enter a long-term care facility?
□ Yes □ No (If NO, skip to section 6)
Facility name
Date you entered or plan to enter this facility Are you planning to stay at this facility for at least 30 days?
□ Yes □ No
Were you living with a legal spouse prior to entering this facility?
□ Yes □ No
If NO, were you living apart from a legal spouse for medical reasons? □ Yes □ No
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6 — Home and Community Based Services
Have you been oered a HCBS waiver slot?
□ Yes □ No (If NO, skip to section 7)
What type of HCBS waiver are you applying for?
□ Adult Day Health Care □ Children’s Choice □ New Opportunities □ Community Choices □ Other
Name of Support Coordination Agency
Are you expected to get waiver services for at least 30 days?
□ Yes □ No
7 — Disability
Do you have a disability?
□ Yes □ No (If NO, skip to section 8)
(NOTE: A disability is a physical, mental, or emotional health condition that causes limitations in daily activities like
bathing, dressing, chores, etc.)
Describe your disability
When did this disability start?
Was the disability caused by an accident? □ Yes □ No
Have you ever applied for disability benets? □ Yes □ No
If YES, has a decision been made regarding your application
for disability benets?
□ Yes □ No
Name of doctor, hospital, or other medical provider with records that can support your disability claim
Medical provider’s address Medical provider’s phone number
( )
8 — Health Insurance (other than Medicaid)
Do you want help paying for medical bills (paid or unpaid) for medical care received in the past 3 months? □ Yes □ No
Do you have health insurance? □ Yes □ No (If NO, skip to section 9)
What type of insurance coverage do you have?
□ Private Health Insurance □ Medicare Supplement □ Medicare Drug Plan □ Medicare Advantage
Name of policyholder
Insurance company name
Group/Policy number Medicare Claim Number (if you have one)
How much is the premium for this insurance? Do you have a Long-Term Care or Partnership Insurance policy?
□ Yes □ No
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9 — Members of your Household
Provide information about your spouse, parents, children, and anyone else living with you or who lived with you before you
entered a long-term care facility. If no one lives with you or had lived with you, leave blanks empty.
Person 1 Person 2 Person 3
Name
Relationship to you
Social Security number
Date of birth
Sex
□ Male □ Female □ Male □ Female □ Male □ Female
Does this person want to
apply for Medicaid?
□ Yes □ No □ Yes □ No □ Yes □ No
Is this person a veteran?
□ Yes □ No □ Yes □ No □ Yes □ No
Do you want to give a portion of your income to a spouse or dependent listed above? □ Yes □ No
If YES, who do you want to give it to?
Provide information about your former or deceased spouse(s).
If you do not have a former or deceased spouse, leave blanks empty and skip to section 10.
Former Spouse 1 Former Spouse 2
Name
Social Security number
Date of birth
Sex
□ Male □ Female □ Male □ Female
Did you divorce this person?
□ Yes □ No □ Yes □ No
If YES, date of divorce
Has community property been settled?
□ Yes □ No □ Yes □ No
Is this person deceased?
□ Yes □ No □ Yes □ No
If YES, date of death
Has succession been opened?
□ Yes □ No □ Yes □ No
Is this person a veteran?
□ Yes □ No □ Yes □ No
10 — Lump Sum Payments
Have you or anyone in your household received or are expecting to receive a lump sum of money, such as from an insurance/
lawsuit/worker’s comp settlement, an inheritance, or Social Security backpay?
□ Yes □ No (If NO, skip to section 11)
Who received or is receiving the lump sum? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
When was or will it be received? Who was it received from? How much is it worth?
Explain the reason the lump sum was paid out
Give the name, address, and phone number of any attorney involved in this payment
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11 — Income from Jobs (examples: cash, checks, tips, etc.)
Do you or anyone in your household work? □ Yes □ No (If NO, skip to section 12)
Job 1 Job 2 Job 3
Worker’s name
Is this person self-employed?
□ Yes □ No □ Yes □ No □ Yes □ No
Employer name
Employer address
Employer phone number
( ) ( ) ( )
How often paid? (weekly,
biweekly, monthly, etc.)
How much are they paid?
(gross income before taxes)
$ $ $
12 — Other Income
Do you or anyone
in your household
receive:
Who receives
this money?
(you, spouse, parent, etc.)
Where does
it come from or
who pays it?
How often
are they paid?
(weekly, monthly, etc.)
How much
are they paid?
(before taxes)
Social Security
□ Yes □ No
$
SSI
□ Yes □ No
$
Veteran’s Benets
□ Yes □ No
VA le #:
$
Railroad Retirement
□ Yes □ No
Claim #:
$
Retirement/Pension
□ Yes □ No
$
Annuities
□ Yes □ No
$
Royalties
□ Yes □ No
$
Rental Income
□ Yes □ No
$
Worker’s Comp
□ Yes □ No
$
Unemployment
□ Yes □ No
$
Alimony/Child Support
□ Yes □ No
$
Other:
□ Yes □ No
$
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13 — Bank Accounts
Do you or anyone in your household have any bank accounts or Certicates of Deposit (CDs)?
□ Yes □ No (If NO, skip to section 14)
Type of Account:
(check only one per row)
Who does
it belong to?
Name of Bank/
Credit Union
Account Number
How much is
it worth?
□ Checking □ Savings
□ Christmas Club
□ Direct Express Card Acct
□ Certicate of Deposit
$
□ Checking □ Savings
□ Christmas Club
□ Direct Express Card Acct
□ Certicate of Deposit
$
□ Checking □ Savings
□ Christmas Club
□ Direct Express Card Acct
□ Certicate of Deposit
$
14 — Retirement Accounts
Do you or anyone in your household have a pension or retirement account (IRA, Keogh, 401-K, etc.)?
□ Yes □ No (If NO, skip to section 15)
Who does this account belong to? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Name of bank/company
Account number How much is it worth?
Do you currently receive regular payments from this account?
□ Yes □ No
If YES, how much are they and how often do you receive them? If NO, are regular payments available?
□ Yes □ No □ I’m Not Sure
Can a lump sum withdrawal of funds be made from this account?
□ Yes □ No □ I’m Not Sure
15 — Annuities
Do you or anyone in your household own annuities?
□ Yes □ No (If NO, skip to section 16)
Who owns the annuities? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Name of annuity beneciary Name of annuity remainder beneciary
Name of insurance company
Account number Date of purchase How much is it worth?
Do you currently receive regular payments from this account?
□ Yes □ No
If YES, how much are they and how often do you receive them? If NO, are regular payments available?
□ Yes □ No □ I’m Not Sure
Can a lump sum withdrawal of funds be made from this account?
□ Yes □ No □ I’m Not Sure
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16 — Patient Trust Fund
Do you have a patient trust fund account at a nursing facility?
□ Yes □ No (If NO, skip to section 17)
Facility name How much is it worth?
17 — Safe Deposit Box
Do you or anyone in your household own a safe deposit box?
□ Yes □ No (If NO, skip to section 18)
Who owns the safe deposit box? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Name of bank where box is located
List items that are kept in the box (any items that can be converted to cash)
How much are the items kept in the box worth?
18 — Stocks
Do you or anyone in your household own stocks?
□ Yes □ No (If NO, skip to section 19)
Who owns the stocks? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Name of company stock is held in
How many shares? How much are they worth?
19 — Bonds
Do you or anyone in your household own bonds?
□ Yes □ No (If NO, skip to section 20)
Who owns the bonds? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
How many bonds? How much are they worth?
What type of bonds?
Bond number(s)
20 — Mortgages, Loans, and Promissory Notes
Do you or anyone in your household own a mortgage, loan, or other promissory note?
□ Yes □ No (If NO, skip to section 21)
Who does the loan belong to? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Date of agreement Can this agreement be sold?
□ Yes □ No
How much is it worth?
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21 — Vehicles (examples: cars, trucks, boats, trailers, campers, motorcycles, ATVs, etc.)
Do you or anyone in your household own any vehicles? □ Yes □ No (If NO, skip to section 22)
Type of Vehicle:
(include make/model/year)
Who does
it belong to?
How much is
it worth?
How much is
owed on it?
$ $
$ $
$ $
$ $
22 — Primary Residential Real Estate
Do you or anyone in your household own property where they live, are in the process of buying property where they
intend to live, or have usufruct of a property in which they live?
□ Yes □ No (If NO, skip to section 23)
If YES
, which is it? □ Own/buying property □ Usufruct of property
Who does the property belong to? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Address of the property
Parish/county property is located Property lot size Number of buildings on property
How much is the property worth? How much is owed on it?
Who lives on the property?
Is the property for sale?
□ Yes □ No
Is the property rented/leased?
□ Yes □ No
If you are currently in a facility, do you intend to return to
this property? □ Yes □ No
23 — Secondary Real Estate
Do you or anyone in your household own or have usufruct of any additional property, including (but not limited to) a
second home, out-of-state property, or a share of other inherited property?
□ Yes □ No (If NO, skip to section 24)
Who does the property belong to? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Address of the property
Parish/county property is located Property lot size Number of buildings on property
How much is the property worth? How much is owed on it?
Who receives the tax notice for this property? What percentage of this property is owned/inherited?
Is the property for sale?
□ Yes □ No Is the property rented/leased? □ Yes □ No
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24 — Burial Funds
Do you or anyone in your household have any funds set aside for burial?
□ Yes □ No (If NO, skip to section 25)
Who owns the funds?
For whose burial
are they for?
Name of Bank or
Funeral Home
How much are
they worth?
$
$
$
25 — Burial Contracts
Do you or anyone in your household have a pre-paid/pre-need burial contract?
□ Yes □ No (If NO, skip to section 26)
Who owns the contract?
For whose
burial is it for?
Name of
Funeral Home
How much is
it worth?
$
$
$
26 — Life Insurance
Do you or anyone in your household have life or burial insurance?
□ Yes □ No (If NO, skip to section 27)
Who is
insured?
Who owns
the policy?
Name of
Insurance Co.
Policy
Number
Policy Type
What is the
face value?
Does this policy
have accumulated
dividends?
$
□ Yes
□ No
$
□ Yes
□ No
$
□ Yes
□ No
27 — Burial Space
Do you or anyone in your household own a cemetery plot, grave site, mausoleum, vault, casket, urn, headstone, or other
burial space/item?
□ Yes □ No (If NO, skip to section 28)
Who does it belong to? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Describe the site/item
Whose burial is it for? How much is it worth? Is it paid for in full?
□ Yes □ No
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28 — Other Ownership and Cash on Hand
Do you or anyone in your household own anything else of value, including (but not limited to) a business or mineral
rights, or have access to any other cash on hand?
□ Yes □ No (If NO, skip to section 29)
Who does it belong to? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
Describe what is owned and give as much information about it as you can, including how much it is worth
29 — Other Bank Accounts
Do you or anyone in your household have their name on SOMEONE ELSE’S bank/credit union account?
□ Yes □ No
Does SOMEONE ELSE have a bank/credit union account with money in it that belongs to you or someone in your
household?
□ Yes □ No (If NO for both questions, skip to section 30)
Whose name is on
the account?
Whose money is in
the account?
Name of Bank/
Credit Union
Account Number
How much belongs
to you or your
household?
$
$
30 — Trusts
Have you or anyone in your household ever created a trust, placed items in a trust, or had a trust set up for them?
□ Yes □ No (If NO, skip to section 31)
Who does the trust belong to? □ You □ Spouse □ You and spouse □ Parent(s) □ Other:
What kind of a trust is it? Whose money/items/property were added to the trust?
Describe the money/items/property that are a part of the trust, including how much they are worth
31 — Transfer of Resources
Have you, anyone in your household, or anyone acting for them given away, sold, or transferred ownership of any item of value,
including (but not limited to) land, houses, life insurance, vehicles, or bank accounts, in the past 60 months?
□ Yes □ No
What was
transferred/
sold?
When was it
transferred/
sold?
Who was it
transferred/
sold to?
How much was
it worth?
Was anything
received in
return?
What happened
to what was
received?
$
$
$
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APPENDIX A
Choosing a Dental Plan
Most people on Medicaid or LaCHIP need to choose a Dental Plan. These plans are groups of dentists and other sta who work together
to provide dental care. You can look at information about the dierent Dental Plans at www.healthy.la.gov. If you know which Dental
Plan you want, please choose now. If you do not choose, and you need to be in a Dental Plan, we will choose for you.
Which Plan is Right for You?
All Dental Plans must oer the same dental coverage. Certain plans may oer extra benets. You can choose a dierent Dental Plan for
each person approved for full Medicaid.
Choosing a Plan
1. When choosing a plan the rst thing to consider is if your current provider is in that plan. Contact your dentists to nd out what
plans they accept.
2. For more information about the plans you can choose, visit www.healthy.la.gov or call 1-855-229-6848.
NOTE: If you chose a Dental Plan for anyone please include this appendix with your application.
I choose the following plans for each person applying:
NAME OF
PERSON APPLYING
SELECT A DENTAL PLAN FOR THE PERSON APPLYING
(Please select only ONE Dental Plan per person)
DENTAL PLANS
DentaQuest MCNA Dental
DENTAL PLANS
DentaQuest MCNA Dental
DENTAL PLANS
DentaQuest MCNA Dental
DENTAL PLANS
DentaQuest MCNA Dental
DENTAL PLANS
DentaQuest MCNA Dental
DENTAL PLANS
DentaQuest MCNA Dental
If you have more people to include, visit www.medicaid.la.gov to download and print additional pages
or make a copy of this page and complete.
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YOUR RIGHTS AND RESPONSIBILITIES
• By signing and submitting this application, you state that you have permission from all of the people listed on the application to both submit their
information to the Louisiana Department of Health (LDH), and receive any information about their eligibility and health coverage.
• You understand that LDH is authorized to gather the information requested in this application and any supporting documentation, including
social security numbers, under the Patient Protection and Aordable Care Act (Public Law No. 111-148), as amended by the Health Care and
Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act.
• You understand that providing the requested information (including social security numbers) is voluntary. However, failing to provide it may
delay or prevent you from getting health coverage through Medicaid or any other insurance aordability program.
• You understand that LDH will check the information you give us to make sure it is correct. You give LDH permission to contact any outside
source(s) necessary to check this information, process your application, determine eligibility, and otherwise operate the Medicaid program. ese
outside sources may include:
– Federal agencies (such as the Internal Revenue Service, Social
Security Administration, and Department of Homeland Security),
other state agencies, and/or local government agencies.
– Banks, nancial institutions, and consumer reporting agencies.
– Employers identied on applications for eligibility determinations.
– Doctors or other medical providers.
– Applicants/enrollees, and authorized representatives of applicants/
enrollees.
– LDH contractors engaged to perform a function for the Medicaid
program.
– Anyone else as required or allowed by law.
• You give these outside sources permission to give LDH any information about you, or any person necessary for this application, that it may request.
You understand that this permission will end when this application is denied, when your Medicaid eligibility ends, or when you submit a written
statement to LDH canceling this permission, whichever comes rst. A cancellation may prevent you from being found to be eligible for Medicaid.
• You understand the social security numbers will only be used to get information from these outside sources to verify income, make eligibility
determinations, or for other purposes directly connected to the administration of the Medicaid program.
• You must tell Medicaid if anything changes or is dierent than what you’ve written on this application. Call 1-888-342-6207 to report any
changes. You also understand that a change in your information could aect the eligibility for member(s) of your household. You agree to tell
Medicaid within 10 days if any of the following change: mailing or home addresses, things you own, health insurance coverage or premiums,
income, if anyone moves in or out of your home, or if anyone moves out of state.
• You state that answers you gave on this application are true and correct. If you purposely gave information that is not true or if you withheld
information, you have committed fraud. If you commit fraud, you may have to pay back money that Medicaid pays for care that you receive.
• You state that the information given in this application about your citizenship and immigration status is true and correct.
• By signing and submitting this application, you understand that if anyone on this application enrolls in Medicaid, you are giving LDH your
rights to any money owed to you by any other health insurance, legal settlement, a spouse or parent, or other third party.
• You understand that Medicaid will only send case information to Child Support Enforcement for medical support if you ask them to. LDH will
only make a referral if parents of children under age 19 receive Medicaid. You can request that Medicaid not refer you if you feel you have good
cause not to cooperate with Child Support Enforcement.
• You understand that Estate Recovery rules require LDH to recover the cost of certain Medicaid payments from your estate in the event of your
death. ese costs include the total amount of payments for facility services, hospital care, waiver services, payments to Home and Community
Based Services (HCBS) or Program for All-Inclusive Care for the Elderly (PACE) providers, and prescription drugs received at age 55 or
older. LDH will not make a claim against the estate while you or your legal spouse is still living. LDH will also not make a claim if you have a
dependent child who is under age 21, blind, or disabled. Collection may not be made if it is not cost eective for LDH to do so, or if your heirs
apply for a hardship waiver after your death. A hardship may exist if the estate property is the only source of income for the heirs, if that income
is limited, or if there are other extenuating circumstances.
• You agree that by accepting Medicaid, the State of Louisiana or its assignee will be named as the remainder beneciary of all annuities purchased on
or after Feb. 8, 2006 for the total amount of medical assistance paid on your behalf, unless you have a spouse, minor child, or a child with a disability.
In these cases, the State of Louisiana must be named as beneciary after these individuals. You agree to tell Medicaid about any annuity you and your
spouse own or co-own regardless if the annuity is irrevocable (cannot be changed) or Medicaid counts it. You understand that you must tell Medicaid
about changes made to any annuity which may aect when payments begin, the amount paid, frequency of payments, and additions to the principal.
• You can ask for a Fair Hearing if you think any decision made on the case is unfair, incorrect, or made too late.
• LDH cannot treat you dierently because of race, color, sex, age, disability, religion, nationality, or political belief. If you think it has, you can
call the U.S. DHHS Regional Oce for Civil Rights in Dallas, TX at 1-800-368-1019 or write to the Louisiana Department of Health, Human
Resources at P. O. Box 4818, Baton Rouge, LA 70821-4818.
After reading, please continue to the next page to complete your application.
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Use this space or an extra piece of paper for any comments or information that you could not t on your application.
Read and sign below
By signing this application I am giving my permission to the State of Louisiana and its agents to verify the information given
on this application. Under penalty of perjury, I certify that all information contained in this application, including U.S.
citizenship or lawful immigrant status of all persons applying for benets, is true and correct to the best of my knowledge.
I have read or someone has read to me the “Rights and Responsibilities” section of the application (located on page 12),
including fraud penalties.
Sign here: Date:
Spouse sign here (if applying): Date:
Application assistant sign here (if necessary): Date:
Witness One sign here
(if any applicant signs with an X or other mark): Date:
Witness Two sign here
(if any applicant signs with an X or other mark): Date:
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DOCUMENTS OF PROOF
We may ask you for documentation to prove what is reported on this application. Let us know if
you do not have or cannot obtain any of these documents and we may be able to assist you. We
are required by law to keep all information you provide to us private.
Use the checklist below to help keep track of what you may need to provide as proof.
Proof of applicant’s legal marriage such as a marriage certicate (not needed if applicant’s spouse has Long-Term
Care Medicaid or if spouse is deceased.)
Copy of Permanent Resident Card (green card) or other cards/forms from U.S. Citizenship and Immigration
Services. Only for applicants who are not U.S. citizens.
Copy of legal documents to show power of attorney, curator, or interdiction.
If applicant is widowed, copy of the succession. If the succession has not been completed, then a copy of the will.
Proof of income, such as a check stub or award letter showing amount of gross income (before deductions), from
retirement, pension, Veteran’s benets, annuities, mineral rights, worker’s compensation, child support, reverse
annuity mortgages, and royalties. Provide for applicant, applicant’s spouse, applicant’s parents (if applicant is
under 18), and applicant’s dependents under age 18.
If the applicant, applicant’s spouse, or applicant’s parents (if applicant is under 18) own property that is rented out,
send proof of the amount of rental income received (letter from renters or canceled check) and proof of expenses of
rental property.
Statement from friends and/or relatives who have given money to the applicant and/or their spouse.
For anyone who works, send pay stubs or a letter from employer showing gross pay (before deductions) for the
last month. If self-employed, send copies of their most recent tax return and all schedule attachments. Provide for
applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s dependents under
age 18.
Proof of any lump sum payments received in the last ve years from an insurance or lawsuit settlement, inheritance,
worker’s compensation settlement, or Social Security. Provide for applicant, applicant’s spouse, applicant’s
parents (if applicant is under 18), and applicant’s dependents under age 18.
Copies of bank statements for the last three months. Send ALL pages showing the check images, account numbers,
names and addresses of banks, all deposits and withdrawals, and all names on the accounts. Provide for applicant,
applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s dependents under age 18.
Copy of annuity and statements for the last three months. Provide for applicant, applicant’s spouse, applicant’s
parents (if applicant is under 18), and applicant’s dependents under age 18.
Account statements for certicates of deposit (CDs), IRAs, 401-Ks, Keoghs, and retirement accounts for the last
three months. Provide for applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and
applicant’s dependents under age 18.
A list of what is inside any safe-deposit boxes and a sworn statement from the person who accessed them. Provide
for applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s dependents
under age 18.
Copies of stocks and bonds, including any account statements. Provide for applicant, applicant’s spouse,
applicant’s parents (if applicant is under 18), and applicant’s dependents under age 18.
CONTINUED ON NEXT PAGE
Questions? 1-800-230-0690 Page
|
15
DOCUMENTS OF PROOF (continued)
If you own more than one vehicle, copies of vehicle registrations/titles and proof of what is owed on each vehicle,
like a statement from creditor. Provide for applicant, applicant’s spouse, applicant’s parents (if applicant is
under 18), and applicant’s dependents under age 18.
For property that is owned (not counting the applicant’s home) or property that has been inherited (can be
undivided), send proof to show what the property is worth and how much of a share the applicant and their family
have. Provide for applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s
dependents under age 18.
Copy of the last bank statement for burial or funeral accounts. Provide for applicant, applicant’s spouse,
applicant’s parents (if applicant is under 18), and applicant’s dependents under age 18.
Copies of pre-arranged burial contracts with funeral homes with included list of services. Provide for applicant,
applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s dependents under age 18.
Copies of life or burial insurance policies if the face value for all is more than $10,000 for each person. Provide for
applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s dependents under
age 18.
For any burial space items, such as a mausoleum or cemetery plot that is not already paid in full, send proof of how
much is owed and how much the items are worth. Provide for applicant, applicant’s spouse, applicant’s parents
(if applicant is under 18), and applicant’s dependents under age 18.
Copies of trust documents, including schedule of assets and current values of the items in trust. Provide for
applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s dependents under
age 18.
Copies of paid or unpaid medical bills for services received in the last 3 months (if applying for Medicaid for
those months). Provide for applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and
applicant’s dependents under age 18.
Copies of the Act of Donation, Bill of Sale, bank statements, or other documents showing items that were given
away, sold, or a deed that was changed. Include fair market values of these items at the time the transaction
occurred. Provide for applicant, applicant’s spouse, applicant’s parents (if applicant is under 18), and
applicant’s dependents under age 18.
Copies of all health insurance cards (front AND back), including Medicare, long-term care insurance, Medicare
prescription drug plans, and Medicare supplements. Include verication of premium amounts. Provide for applicant,
applicant’s spouse, applicant’s parents (if applicant is under 18), and applicant’s dependents under age 18.
LONG
-
TERM
CARE
SERVICES
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LEFT BLANK.
STATE OF LOUISIANA
VOTER REGISTRATION AGENCIES
DECLARATION FORM
If you are not registered to vote where you live now, would you like to apply
to register to vote here today? (Check one)
I want to register to vote. I do not want to register to vote.
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE
DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
Applying to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency. Voter eligibility requirements are found on the voter registration application form.
Note: If you do register to vote, the location where your application was submitted will remain confidential.
If you decline to register to vote, this fact will remain confidential. Applying to register or declining to
register to vote will be used only for voter registration purposes.
If you would like help in filling out the voter registration application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the application form in private.
(Check one)
Yes, I would like help. No, I do not want help.
For assistance in completing the voter registration application form outside our office, contact Louisiana
Department of Health and hospitals at 1-888-342-6207.
If completed outside our office, this declaration form and your completed voter registration application
form (if you filled one out) should be returned to P.O. Box 91278 Baton Rouge, LA 70821-9278.
Signature or Mark Name Typed or Printed Date
Signatures of Two Witnesses If Signed With Mark:
1) ____________________________________ 2) _______________________________________
COMPLAINTS
If you believe that someone has interfered with your right to register or to decline to register to vote, your
right to privacy in deciding whether to register or in applying to register to vote, or your right to choose
your own political party or other political preference, you may file a complaint with the Louisiana Secretary
of State, Commissioner of Elections, P.O. Box 94125, Baton Rouge, LA 70804-9125 or by calling (225)
922-0900 or 1-800-883-2805.
Comments/Remarks (for official use only):
NVRADF Rev. 6/14
THIS PAGE INTENTIONALLY
LEFT BLANK.
Louisiana Voter Registration Application
(LA-VRA - Rev. 6/19)
SEE THE OTHER SIDE OF THIS PAGE FOR INSTRUCTIONS
QUESTIONS? - Call your parish Registrar of Voters Office or call the
Secretary of State at 1-800-883-2805 or (225) 922-0900.
OFFICIAL USE ONLY:
WD: ___________________ PCT: ___________________ REG. TYPE: ___________________ IN/OUT: ___________________ REG # ___________________
Provided by the Louisiana Secretary of State
Approved by the Louisiana Attorney General
LA-VRA - Rev. 6/19
Please print clearly in ink, preferably black.
Reason for Application:
New Voter Registration
Updating Voter Registration
* If you do not have a LA driver’s license or LA special ID, the last four digits of your social security number are required if you have one. Full SSN is preferred but optional.
Note: If you decline to register to vote, this fact will remain confidential and will be used only for voter registration purposes. If you register to vote, the office where your application was submitted
will remain confidential and will be used only for voter registration purposes. You may request a copy of your voter registration form at any time from the registrar of voters.
Eligibility 1.
Are you a citizen of the United States of America?
Yes
No
If you checked ‘No’ in response to either of these questions, do not complete this form. You
are not eligible to vote at this time.
(Please see application instructions for information regarding eligibility to register
prior to age 18.)
Will you be 18 years of age on or before election day?
Yes
No
Name 2.
LAST NAME:
FIRST NAME:
FULL MIDDLE OR
MAIDEN NAME:
SUFFIX (Sr., Jr., II):
Residence
Address
(Where you live and
claim homestead
exemption, if any)
3.
HOUSE # &
STREET (NO P.O. BOX):
UNIT/APT #:
Give Location (If Necessary)
CITY/TOWN:
STATE
LA
ZIP CODE:
Mailing
Address
(If different from
Residence Address)
Check if no postal service at your residence address above and supply mailing address here.
HOUSE # &
STREET/P.O. BOX:
UNIT/APT #:
CITY/TOWN:
STATE:
ZIP CODE:
Date of Birth 4.
_______/_______/_________
MM DD YYYY
5.
*SSN
___________ - ________ - ____________
XXX XX XXXX
6.
Sex
M
F
7.
Race
(Optional)
WHITE BLACK ASIAN
HISPANIC AMERICAN INDIAN
OTHER ________________________
Party
Affiliation
8.
DEMOCRAT GREEN INDEPENDENT
LIBERTARIAN REPUBLICAN NO PARTY
OTHER
(Specify) ____________________________
9.
Place
of Birth
CITY/TOWN:
STATE:
PARISH/COUNTY:
COUNTRY:
Mother’s
Maiden Name
10.
____________________________
11.
Email
_______________________________
12.
Phone
Home: (________) _________ - ___________
Other: (________) _________ - ___________
LA DL/ID
Card #
13.
_________________________________________
I do not have a LA DL/ID card.
14.
Do you need
assistance in
voting?
No
Yes, Reason: _____________________________________________
Last
Residence
Address
15.
HOUSE #
& STREET:
16.
Place
of Last
Registration
STATE:
17.
Former
Registered
Name, if any
CITY:
STATE:
PARISH/
COUNTY:
Affirmation
and Signature
(Read and sign or
make your mark.)
18.
I do hereby solemnly swear or affirm that I am a United States citizen, that I am of eligible age to register to vote, that I have not been incarcerated pursuant to an order of
imprisonment for conviction of a felony within the past five years, nor am I under an order of imprisonment for a felony offense of election fraud or other election offense
pursuant to R.S. 18:1461.2, that I am not currently under a judgment of full interdiction or limited interdiction where my right to vote has been suspended, that I am a bona
fide resident of this state and parish, and that the facts given by me on this application are true to the best of my knowledge and belief. If I have provided false information,
I may be subject to a fine of not more than $2,000 ($5,000 for subsequent offense) or imprisonment for not more than 2 years (5 years for subsequent offense), or both.
Applicant
Signature:
Date:
Witnesses
(If your signature is
a mark, you must
have two witnesses
sign.)
19.
Witness #1
Signature:
Witness #1
Print Name:
Witness #2
Signature:
Witness #2
Print Name:
OFFICIAL USE ONLY
New Registration Updated Registration: Address Change Name Change Party Change Change to Assistance in Voting Other
REMARKS:
CIRCLE ONE:
PA MV RG SDA SS (Disability) Received by: __________________________________________________ Date: _________________________
Louisiana Voter Registration Application
(LA-VRA - Rev. 6/19)
QUESTIONS? - Call your parish Registrar of Voters Office or call
the Secretary of State at 1-800-883-2805 or (225) 922-0900.
Provided by the Louisiana Secretary of State
Approved by the Louisiana Attorney General
LA-VRA - Rev. 6/19
APPLICATION INSTRUCTIONS
USE THIS LOUISIANA VOTER REGISTRATION APPLICATION TO: 1) register to vote; 2) change your address; 3) request a name change; 4) change party affiliation; or
5) request assistance in voting.
TO REGISTER AND BE ELIGIBLE TO VOTE, AN APPLICANT MUST: 1) be a U.S. citizen; 2) be at least 17 years old (16 years old if registering to vote in person at the
Registrar’s Office or with an application for a Louisiana driver’s license) but must be 18 years old before actually voting; 3) not be under an order of imprisonment for
conviction of a felony or, if under such an order, not have been incarcerated pursuant to the order within the last five years and not be under an order of imprisonment related
to a felony conviction for election fraud or any other election offense pursuant to R.S. 18:1461.2; 4) not be under a judgment of full interdiction or limited interdiction where
your right to vote has been suspended; 5) reside in the state and parish in which you seek to register and vote.
Instructions: the gray section numbers on this page correspond to the gray section numbers on the application.
Reason for Application: Check “New Voter Registration” if this is a first time registration or if a new registration in a new parish after moving. Check “Updating Voter
Registration” if you are making any change to your present registration. If new registration, fill out the form completely.
1.
Eligibility - Federal law requires you to affirm that you are a citizen of the United States of America and that you will be 18 years of age on or before the election day in
which you are eligible to vote. If you checked ‘No’ in response to either of these questions, do not complete this form. You are not eligible to vote at this time. If you are
registering as a 16 or 17 year old, you may check “Yes” because you will not be allowed to vote until you are 18.
2.
Name - You must provide your full name. Do not use nicknames or initials for middle or maiden name. If this application is for a change of name, please also complete
section 17: “Former Registered Name.”
3.
Residence Address - “Residence Address” means the address (number, street, city, state, and zip) where you live and are registering to vote. Residence address must be
the address where you claim homestead exemption, if any, except for a resident in a nursing home or veterans’ home who may choose
to use the address of the nursing
home or veterans’ home or the home where they have a homestead exemption. A college student may elect to use their home address or their address at school
while
attending. Do not use a post office box for your “Residence Address.” If you use a rural route and box number, you may draw a map in box labeled “Give Location”
to
provide the exact location. Write in the names of the crossroads (streets) nearest to residence. Draw an X to show residence. Use a dot to show any scho
ols, churches,
stores, or landmarks near residence and write the name of the landmark.
Mailing Address - If you check that you do not receive postal service at your residence address, you must provide your mailing address (number, street, city, state, and
zip). Otherwise, a mailing address may be provided and you may use a post office box for a mailing address.
4.
Birthdate - Print your date of birth. The month and day of your birth remains confidential by law.
5.
Social Security Number - If you do not have a LA driver's license or LA special identification card, you must provide the last four digits of your social security number, if
issued. The full social security number is preferred and may be provided on a voluntary basis and will be kept confidential. If you were not issued a social security number
or a LA DL or ID and this form is submitted by mail, and you are registering to vote for the first time, in order to avoid additional identification requirements for first time
voters you must attach one or more documents to prove your identity, residence, and date of birth. Documents may be: a) a copy of current and valid photo identification
and/or b) a copy of a current utility bill, bank statement, government check, paycheck, or other government document.
Your SSN remains confidential and is only used for
registration purposes.
6.
Sex - Check male or female (for statistical purposes only).
7.
Race - Race/Ethnic origin is optional (for statistical purposes only).
8.
Party Affiliation - If you are registering for the first time, you may choose a party affiliation of Democrat, Green, Independent, Libertarian, or Republican parties. You may
specify any other party affiliation by checking “other” and then listing the party with which you wish to affiliate. If you do not want to register with a political par
ty affiliation
check “No Party,” or if you do not complete this section, your party affiliation will be listed as “No Party.” If you are already registered with a party affili
ation and no political
party change is being made with this application, you may leave this section blank or re-enter your political party affiliation.
9.
Place of Birth - Print the city/town, parish/county, state, and country of your birth place (for statistical purposes only).
10.
Mother’s Maiden Name - Print your mother’s maiden name, which is her last name at her birth. If unknown, write “unknown.”
11.
Email - Give your email address for election officials to contact you if there is a problem with your registration. Email addresses are protected from disclosure by law and
are for official use only.
12.
Phone - Give your phone numbers for election officials to contact you if there is a problem with your registration. Phone numbers are optional and a public record unless
you make a request for your phone numbers to be kept confidential by election officials.
13.
LA DL/ID Card # - Print your LA driver’s license or LA special identification card number, if issued. If you do not have one, check “I do not have a LA DL/ID card.” This ID
number remains confidential and is for official use only.
14.
Assistance in Voting Needed? - Indicate if you will need assistance in voting by checking either the “No” or “Yes” box. If “Yes,” write the reason for needing assistance. The
registrar of voters in your parish may contact you for proof of disability.
15.
Place of Last Residence - Print the address (number, street, city, and state) of your prior residence, if different from residence address in section 3 or write “Same.”
16.
Place of Last Registration - Print the state and parish (or county) of your last registration if you were registered in another parish or state prior to completing this
application. Important: Contact the local election office in your prior state and cancel your prior registration. Registering in Louisiana does not automatic
ally cancel or
transfer your voter registration from another state.
17.
Former Registered Name - If you are using this application to make a name change to your registration, print your former registered name (name you are changing) in this
section. If name changed by court order, provide a copy of the order with this application.
18.
Affirmation and Signature - Read the affirmation and sign your full name or make your mark and print the date this application was signed and completed. If assistance in
registering is being provided, make sure the applicant understands what they are affirming and that they meet the requirements to register to vote.
19.
Witnesses - If you are unable to sign your name, you may make your mark, but it must be witnessed by two people or it is not valid.
Mailing Instructions - If returned by mail, place in an envelope and mail to your Registrar of Voters Office. You can find your registrar of voters mailing address on the Registrar of
Voters Address Page, by visiting our website at www.geauxvote.com or by calling toll free at 1-800-883-2805. Your application or envelope must be postmarked 30 days prior to the first
election in which you seek to vote.
Online Voter Registration - Voter registration is also available at www.geauxvote.com and you may register online before the 20
th
day prior to the election. Please call your registrar of
voters if you do not receive your voter information card two weeks after registering.
