State of Connecticut Department of Social Services Application for Medicare Savings Programs (QMB, SLMB, ALMB) Use this form to apply for Medicare Savings Program benefits. If you currently receive these benefits, please renew using the Renewal Form for Medicare Savings Programs (W-1QMBR).
W-1QMB (Rev 8/16)
Do you need a reasonable accommodation or special help to complete your application because you have a disability? Yes No If yes, complete the next question and see page 3 about how we can help . If you need a reasonable accommodation or special help, tell us what kind of help you need:
Tell us about yourself Name (first, middle, last)
Sex (M or F) Social Security #
Date of Birth
Home Street Address
City
State
Zip Code
Mailing Address (if different)
City
State
Zip Code
Best phone # to reach you
Marital Status (check one): Never Married
Married
Separated
Divorced
Widowed
This application is for (check one): Yourself only Yourself and your spouse
Spouse’s Name (first, middle, last)
Spouse’s Social Security #
Spouse’s Date of Birth
Title VI of the Civil Rights Act of 1964 allows us to ask for race and ethnic origin information. You do not have to give it to us. The information helps to make sure that we are following federal civil rights law. If you do not want to give us this information, it will not affect your application. Are you of Hispanic, Latino/a, or Spanish origin? No Yes (if yes, check all that apply) Mexican, Mexican-American or Chicano/a Cuban Puerto Rican Other Hispanic, Latino/a or Spanish Racial Heritage (check all that apply): White Black or African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Samoan Guamanian or Chamorro Other Pacific Islander Tell us about your citizenship status Are you a U.S. citizen? (check one) What is your alien registration number? What is your country of origin? What are the date and place that you came into the country? What is your sponsor’s name? (if applicable)
If no, what is your non-citizen status? (refugee, entrant, permanent resident, etc.)
Yes No Yes No
Yourself Your Spouse
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Return to: PO Box 1320, Manchester, CT 06045
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