Interview – ProSeniors

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This interview will help Ohio residents determine whether they are eligible for certain public benefits and the amount of benefits for which they may qualify. This interview will determine eligibility for the Medicare Premium Assistance Program, Expanded Medicaid, and Extra Help with Part-D. The interview will also determine eligibility for the Supplemental Nutrition Assistance Program and provide an estimated monthly benefit. During this interview, touch or hover over the grey question mark to get additional information about the question.

This interview will take approximately 20-30 minutes. You may pause the interview and return to the interview at any time by hitting the “Save and Continue Later” button. At that time a link will be provided that you can use to return to the interview.

Please confirm the following statements by checking the boxes:(Required)

I live in Ohio or I am completing this interview on behalf of someone who does live in Ohio;

I am a United States citizen;

People who are not U.S. Citizens may be eligible based on specific criteria and rules. These situations are not covered by this interview.

I understand this interview is not intended as legal advice;

I understand this interview is not a substitute for consulting an attorney;

I understand this interview does not establish an attorney-client relationship.

Please provide your contact information. We will send your answers to the email address you provide. Your email address will not be used for any other solicitations.

First Name(Required)

Last Name(Required)

Email(Required)

Email is required to save progress and provide details at the completion of this questionnaire.

Phone

Age(Required)

Age is required because SNAP benefits are dependent on an applicant's age.

Benefit calculations are based on the age of household members.

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Is it okay for Pro Seniors to contact you about your interview questions?(Required)

If you answer "Yes", Pro Seniors may be able to assist you in applying for benefits or answer additional questions. Availability to follow-up is dependent on whether Pro Seniors has help from student interns or other volunteers.

Yes

If you answer "Yes", Pro Seniors may be able to assist you in applying for benefits or answer additional questions about your benefits.

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Contact Me By:(Required)

Phone Call 9AM - Noon

Phone Call Noon - 3PM

Phone Call 3PM - 5PM

Marital information is crucial in determining eligibility of benefit programs. Married individuals are assumed to share income and resources. Disability status is required for the proper calculation of SNAP benefits. Households with a disabled individual may determine eligibility or increase monthly benefits.

Marital Status

If you are married and living with your spouse, most benefit programs count the income and resources of both you and your spouse when determining eligibility. You and your spouse are living together, if both of you live in the same household. The income and resources of both you and your spouse are counted, regardless of whether one or both of you are filing for benefits. You are still considered to be living together, if you or your spouse are temporarily absent from the household due to treatment in a hospital or nursing home.

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Married?

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Do you receive Social Security Disability, or does someone in your household receive Social Security Disability(Required)

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Are you, and members of your household, Unitd States Citizens?(Required)

Each program has specific rules and requirements for non-citizens. This interview is unable to provide you accurate information for resident-aliens.

If you are over 60, please call our Helpline for further guidance. 513-345-4160.

Do you receive Medicare?(Required)

Yes

Medicare is a federal health insurance that is available to people over 65 or people who have been deemed disabled for 2 or more years.

Please provide information regarding your spouse. Information is required for SNAP, Medicare Premium Assistance Programs, and Extra Help with Prescription Costs.

Spouse First Name

Spouse Last Name

Spouse Age

Spouse Disability

Are you disabled or do you care for someone else who is disabled?

Does your spouse receive Medicare?(Required)

Yes

Medicare is a federal health insurance that is available to people over 65 or people who have been deemed disabled for 2 or more years.

Household member information is important to determine eligibility for SNAP and Medicare assistance programs.

Not counting you or your spouse, how many relatives live with you and depend on you for at least one-half of their financial support? Do not count yourself or your spouse.(Required)

A relative is defined as someone related to you by blood, adoption, or marriage. The Extra Help program determines eligibility based on the household size of relatives that you provide at least one-half of their financial support.

Number of Child dependents aged 0-2 years old.

Number of Child dependents aged 3-18 years old.

How much do you spend on child dependant care costs?

These items may include child-care and/or education costs.

How many people live with you and share the cost of groceries and food with you? If you live alone, please enter 1. If you share meals with your spouse please enter 2. If there are other's that live with you and share meal costs, please enter the total number of people.(Required)

Please enter a number greater than or equal to 1.

SNAP benefits are determined by he amount of people the purchase and share meals together.

Please enter the full name and age of each additional person in the house.

First Name

Last Name

Age

Please thoroughly provide all monthly income from jobs, wages, and/or salaries.

Income Type

Income Value

Press the (+) to the right of the income to add additional sources of income.

Please thoroughly provide all your monthly income from social security, retirement benefits, and all other income.

Income Type

Income Value

Press the (+) to the right of the income to add additional sources of income.

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Please thoroughly provide all your gross income amounts, the sources of income.

Income Type

Income Value

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Please thoroughly provide all your gross income amounts, the sources of income.

Income Type

Income Value

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Your Total Income

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Your SNAP Income

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Your Other Income

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Your MPAP Income

Please thoroughly provide all your Spouse's monthly income from jobs, wages, and/or salaries.

Income Type

Income Value

Press the (+) to the right to add additional sources of income.

Please thoroughly provide all your Spouse's monthly income from social security, retirement benefits, and all other income.

Income Type

Income Value

Press the (+) to the right to add additional sources of income.

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Please thoroughly provide all your Spouse's gross income amounts, the sources of income.

Income Type

Income Value

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Please thoroughly provide all your Spouse's gross income amounts, the sources of income.

Income Type

Income Value

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Spouse's Total Income

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Spouse's SNAP Income

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Spouse's OTHER Income

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Spouse's MPAP Income

Please thoroughly provide all your Household's monthly income from jobs, wages, and/or salaries.

Income Type

Income Value

Press the (+) to add additional sources of income.

Please thoroughly provide all your Household's monthly income from social security, retirement benefits, and all other income.

Income Type

Income Value

Press the (+) to add additional sources of income.

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Please thoroughly provide all your Household gross income amounts, the sources of income.

Income Type

Income Value

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Household Total Income

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Household SNAP Income

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Household OTHER Income

Liquid Assets

Please provide the following information as accurately as possible. If you, and another household member, have separate resources, please add them together and provide the total.

Cash on Hand

Checking/Savings Accounts

Stocks & Retirement Savings such as Stocks, Bonds, Mutual Funds, or 401ks

Spouse Cash on Hand

Spouse Checking/Savings Accounts

Spouse Stocks & Retirement Savings such as Stocks, Bonds, Mutual Funds, or 401ks

Household Cash on Hand

Household Checking/Savings Accounts

Household Stocks & Retirement Savings such as Stocks, Bonds, Mutual Funds, or 401ks

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Investment Assets

Please provide the following information as accurately as possible. If you, and another household member, have separate resources, please add them together and provide the total.

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Retirement Assets

Please provide the following information as accurately as possible. If you, and another household member, have separate resources, please add them together and provide the total.

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Retirement Savings such as 401k or IRAs

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Spouse Retirement Savings such as 401k or IRAs

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Household Retirement Savings such as 401k or IRAs

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Trusts

Please provide the following information as accurately as possible. If you, and another household member, have separate resources, please add them together and provide the total.

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Insurance Policies with a Cash Surrender Value. Please put in the cash surrender value.

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Spouse Insurance Policies with a Cash Surrender Value. Please put in the cash surrender value.

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Household Insurance Policies with a Cash Surrender Value. Please put in the cash surrender value.

Do you own or are you buying a home?(Required)

If you have a mortgage on your home, choose "yes."

Yes

Equity Value of Non-Home Real Property

Please provide the following information as accurately as possible. If you, and another household member, have separate resources, please add them together and provide the total. Equity is the total value of your home/land minus the total amount you still owe on your home/land.

Equity Value of your home.

Equity value of any additional homes or land.

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Spouse Equity Value of your home.

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Household Equity Value of your home.

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Spouse Equity value of any additional homes or land.

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Household Equity value of any additional homes or land.

Some programs count the value of additional vehicles as assets. However, SNAP will exclude one vehicle from consideration, and Medicare Premium Assistance Programs will not count vehicles that are used for transportation. National Automobile Dealers Association (NADA) Pricing Guide

Does anyone in your household own a licensed vehicle?(Required)

Yes

Licensed vehicles include cars, trucks, motorcycles, boats, snowmobiles, trailers, and RVs.

Highest Fair Market Value (FMV) licensed vehicle.

A vehicle's Fair Market Value (FMV) is the average trade-in valude in the most recently published "National Automobile Dealers Association (NADA) Guide" minus any remaining amount owed on a loan. See link above.

Second highest Fair Market Value (FMV) licensed vehicle.

Leave blank or zero if you don't own a second vehicle.

Third highest Fair Market Value (FMV) licensed vehicle.

Leave blank or zero if you don't own a third vehicle.

Fourth highest Fair Market Value (FMV) licensed vehicle.

Leave blank or zero if you don't own a fourth vehicle.

Additional Fair Market Value (FMV) of licensed vehicles

Do to the complexity of the interview, please include the Fair Market Value for the vehicles for household members. Please add the values of the lowest valued vehicles owned by the household. Please add the FMV of any and all remaining vehicles. If you don't own any additional vehicles, please leave the field blank or zero.

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Vehicle Asset Total HH = 1

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Vehicle Asset Total HH = 2

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Vehicle Asset Total HH = 3

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Vehicle Asset Total HH = 4

Please make a best estimation of monthly costs for the following utilities.

If you do not pay for a utility out-of-pocket, please leave the value 0.

Gas/Electricity

Water

Telephone

Trash

How much do you pay for the following medical related expenses:

Health Insurance/Medicare Premium

Other Monthly Medical Costs

How much do you pay for the following household expenses?

Rent/Mortgage

House Insurance

HOA Fee

Housing Taxes

We thank you for completing the interview. Momentarily, you will receive an email with a print out of your eligibility and instructions with how to apply for your eligible programs.

It is important to know that this is an estimate based on the interpretation of the Ohio Administrative Code.

If you are over 60 and an Ohio resident, and would like to discuss the results with an attorney, please call our legal helpline to schedule an appointment. (513) 345-4160.

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SNAPNETINCOME

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SNAP Eligible

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Separate SNAP Household

Allows post to final data explaining that user might be eligible for a separate AG determination and to re-run the formula with just their marital assets and income.

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SNAP Benefits

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MedicaidEligible

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MPARP Results

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LISTYPE

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MPAPAsset

Phone

This field is for validation purposes and should be left unchanged.

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Trusts

Equity Value of Non-Home Real Property

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