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GOVERNMENT OF THE DISTRICT OF COLUMBIA DEPARTMENT OF HUMAN SERVICES ECONOMIC SECURITY ADMINISTRATION COMBINED APPLICATION FOR DC* FOOD STAMPS (SNAP BENEFITS) CASH ASSISTANCE (TANF for FAMILIES with CHILDREN or INTERIM DISABILITY ASSISTANCE for the DISABLED) MEDICAID (for the ELDERLY or DISABLED) HEALTHCARE ALLIANCE/ IMMIGRANT CHILD PROGRAM *APPLICANTS FOR MEDICAID FOR FAMILIES WITH CHILDREN (INCLUDING TANF APPLICANTS) OR A NON-DISABLED/NON-ELDERLY ADULT MUST FILE A DC HEALTH LINK APPLICATION (See Next Page) If you live in DC, you can use this form to apply for benefits. If you need help with this form, just ask your worker or another ESA employee. You can also call (202) 727-5355. Free interpreters are available. Please bring this to your Service Center. To find out which Center is closest to you, call (202) 727-5355. You may also mail this form to DHS/ CRMU, 645 H St., NE, Washington, DC 20002. �� Sí, hablo ESPAÑOL (SPANISH) Si usted vive en DC, puede usar este formulario para solicitar beneficios. Si necesita ayuda con este formulario, pídale ayuda a su trabajador u otro empleado de ESA. También puede llamar al (202) 727-5355. Intérpretes gratis están disponibles. Por favor, lleve este formulario al Centro de Servicio de su área. Para saber cuál Centro le queda más cerca, llame al (202) 727-5355. También puede enviar este formulario por correo a 645 H St., NE, Washington, DC 20002. FOR AGENCY USE ONLY �� Application �� Recertification Case Name _____________________ Case #_____________ Date Rec’d _________________ Prog. Approved __________ Date Disp. _________________ Prog. Denied ____________ ESA Combined Application: December 2015 (202) 727-5355 (202) 727- (202) 727-5355 5355 Washington, DC 20002.” (202) 727-5355. (202) 727-5355. 727- 5355 (202) 727-5355 5355 645 H St., NE Washington, DC 20002.” 645 H St., NE, Washington, DC 20002. 645 H St., NE


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