Form W-119D (page 1) LLF
Rev. 5/7/14
Eligibility Factors and Suggested Documentation Guide
For SNAP, copies of documents are acceptable whenever proof of eligibility is presented. For Cash Assistance (CA) and
Medical Assistance (MA), original documents are needed to verify identity and citizenship/alien status. Copies of documents
for all Eligibility Factors other than identity and citizenship/alien status are acceptable.
To prove this factor,
provide: ONE of the
following OR
Identity
You must establish identity for each person listed.
Photo I.D.
Driver’s license
U.S. passport
Naturalization certificate
Hospital/Doctor’s records
Adoption papers
Statement from another person
Birth/baptismal certificate
Validated Social Security Number
(SSN)
Marital Status
You must prove if you are married, divorced, separated
or widowed (not required for the Supplemental Nutrition
Assistance Program [SNAP]).
Marriage/Death certificates
Separation agreement
Divorce decree
Social Security records
Veterans Administration (VA) records
Statement from clergy
Census records
Newspaper notice
Statement from another person
Relationship
If you are related to a child in the household, you must
prove the relationship.
Birth certificate (long form)
Adoption papers/records
Court records
Medical records
Applicant’s statement
Newspaper notice
Statement from clergy
Statement from another person
Residence
You must verify your place of residence
(if applicable).
Statement from landlord/primary
tenant
Current rent receipt or lease
Mortgage records
Statement from another person
Current mail
School records
Household Composition/Size
You must prove who is living with you.
Statement from nonrelative landlord
School records
Statements from other persons
Age
You must prove the age of each person applying for
assistance, where appropriate.
Birth certificate
Baptismal records/certificate
Hospital records
Adoption papers/records
Naturalization certificate
Driver’s license
Insurance policy
Census records
School records
Statement from another person
Physician statement
Official correspondence from Social
Security Administration (SSA)
Absence/Death of Parent(s)
If the parent(s) of any child in your home is not living with
you, you must prove this (not required for SNAP).
Death certificate
Survivor’s benefit records
Hospital records
VA or military records
Divorce papers
Proof of remarriage
Newspaper notice
Insurance company records
Institutional records
Agency case records and burial
payment files
Statement from another person
Absent Parent Information
If the parent(s) of any child in your home is not living with
you, you must provide information you have about the
individual’s: name, address, SSN, birth date, and
employment (not required for SNAP).
Pay stubs
Tax returns
Social Security or VA records
Monetary determination letters
ID cards (health insurance)
Driver’s license or registration
Social Security Number
For Temporary Assistance, SNAP Benefits and Medical
Assistance only, you do not have to provide proof of
your SSN unless the SSN you give does not match the
SSA’s records or cannot be verified by the Agency.
Social Security card
Official correspondence from SSA
A Social Security number is not required
for aliens who are seeking Medical
Assistance for emergency treatment only
or are Medical Assistance – only
applicants who are pregnant.
*If you are applying for Supplementary Nutrition Assistance Program (SNAP) benefits or Medical Assistance only, you need to
bring one form for each Eligibility Factor checked.