Get Take Charge Card Form

Filling out the Take Charge Card Form online can be a straightforward process when guided step by step. This guide will help you navigate through each section of the form to ensure you provide accurate and complete information.

Follow the steps to successfully complete the Take Charge Card Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling out the 'Tell Us About You' section. Provide your first name, middle initial, maiden name (if applicable), and last name. Include your mailing address, residential address (if different), social security number, date of birth, and email address.
3. Indicate your parish of residence and provide contact numbers, including your home, cell, and daytime phone numbers. Clearly state your best days and times to be contacted.
4. Select your marital status and optionally provide your race and ethnic background.
5. Answer the pregnancy-related questions. Indicate if you are currently pregnant and whether you were pregnant in the last three months.
6. Provide your citizenship or immigration status. State if you are a U.S. citizen or a lawful permanent resident, and supply relevant details if applicable.
7. Fill in the 'Tell Us About the Other People Living With You' section. List your spouse first (if applicable) followed by any children under 18, including their names, dates of birth, social security numbers, and relationship to you.
8. If you have health insurance, complete the relevant health insurance information. If not, proceed to the next section.
9. Share details regarding any medical procedures that may affect your eligibility for services. Indicate whether you have had a procedure such as a tubal ligation.
10. Report income from work for yourself, spouse, or children under 18. Provide the employer's name, income amount, and payment frequency.
11. Detail any other income sources, such as Social Security, unemployment benefits, and others. Clearly specify the amounts and who receives them.
12. Complete sections related to child support and alimony payments made to individuals outside your household.
13. Indicate if you incur costs for childcare or adult care in order to work or study. Provide details of these expenses.
14. At the end of the application, sign and date the form to confirm accuracy and consent for verification of the information provided.
15. Save your changes, download a copy of the completed form, and prepare to send it. You can mail the application and proofs to the designated address or fax it as stated.

Complete your Take Charge Card Form online today and take the first step toward accessing family planning services.