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Get OR SDS 0539A 2019-2024

Page 1 of 12 Date received SDS 0539A 05/08 People living with you Use extra paper if needed How many people live with you First Relationship Sex M Are they applying for benefits If yes give types and complete the following Do they intend to stay in Oregon SSN Other important people A. Application Form Instructions Click on a question mark to find out more about verification of certain eligibility requirements. If you would like to apply for benefits please contact your local office Please notify your worker if you need to receive printed information in an alternate format such as Braille large print audio tape or computer disk. See form DHS 1005 Client Information Seniors and People with Disabilities SDS 539A Contact date/Date of request Last name First name MI Address City State Zip code Telephone Mailing address if different Date of birth Social Security Marital status single married divorced widowed separated Citizenship U*S* citizen non-citizen Gender M F Disabled yes no Blind yes no Do you intend to stay in Oregon I live in house room board adult foster home apartment nursing facility other specify Veteran spouse is or was a veteran Name of veteran VA claim no. Service no. Served from / through Registered Native American Member name Tribe name/number Client Date sent Case number Prime number Program Branch code Worker I am applying for Medical assistance Food Benefits Services Worker phone The Department of Human Services DHS will not discriminate against anyone. This means DHS will help all who qualify. The Department will not deny help to anyone based on age race color national origin sex sexual orientation religion political beliefs or disability. This person is an emergency contact has power of attorney is a guardian is a conservator is my authorized representative who can work with the agency on my behalf is my alternate payee who can get my benefits for me Name Last first MI Home phone Income I or other applicants are receiving or have applied for money from the following check all items that apply and provide information Source Supplemental Security Income Money from friends/relatives Veteran s benefits Payment from property sale Payment from rental property Railroad retirement Other retirement/pension Indian payment Income from a lodger Insurance claim Inheritance Tax refund Dividend/interest/trust Court-ordered income Annuity Current employment Unemployment compensation Workers compensation Child support/alimony Other Receive Applied for Amount Recipient claim number of injuries below and complete the appropriate DHS 0451 form* Name no If yes give the person s and dates Date and Type of Injury Employment Resources If yes to either of the above questions complete the following Name of employer Person employed Pay type hourly salaried Gross pay per pay period not take-home pay Pay period every 2 weeks monthly twice a month weekly the last 30 days. If yes please provide information below Previous employer Date last worked Date of final pay Amount of final pay Information about them* Item Location account no.

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