Achengacheng En Chon Niwing,
Kinissou om fini Hawaii Pacific Health ren om samaw. Am ei Pirokramen Aninisin Moni ekan
aninisi chon niwing me ar famini ren mon omw niwinimangen pioing ren met e fofor non ei neni
ika me ekei tokterin Hawaii Pacific Health.
Chon nonom non Hawaii re angang aninisin non pioing me chon rese nonom ikei re angangen
emergency aninis mei tongeni angang monien aninis ika:
 Monien om famini e kukun seni 400 persent ren minen chon aramas ese wor nour moni
won ei fonuen Hawaii (Federal Poverty Guidelines (FPG)).
 Ika noun omw famini moni e watte seni 400 persent ir mei woungaw me tongeni angang
aninisin tumwun ika omw “balance” (met mei nusun) e 15 persentin monien om famini
me moni ika pisekum.
 Kopwe fokkun amasowa unusen taropwen aninis ika ewe Apilikeison Ren Aninisin Moni
iwe tinanong ngeni Hawaii Pacific Health ika pwan chon fofor aninis ren Hawaii Pacific
Health ngeni pwan ekoch chon aninis. A men auchea kopwe pwarata unusen om moni
tonong.
Ika ke mochen apply ika angang monien aninis, kosemochen amasowa ei taropwen aninis iwe
pwan apachanong noum taropwen ekkewe mettoch ai eisinuk won ewe checklist e nom non ei
taropwe.
Tinato ei taropwen aninisin moni me pwan noum taropwen won ewe checklist ngeni:
Hawai‘i Pacific Health
Attn: Financial Assistance Team
888 S. King Street, Tube 31
Honolulu, HI 96813
Ika mei wor omw kapas eis kosemochen kokori am ei ofesin Customer Service me 522-4013
won O‘ahu, 245-1119 won Kaua‘i, ika ese kamo me 1-866-266-3935.
Seni,
Iten
Depatmen
Pacheienong
Aninisin Moni- Atettenin Taropwe Mei Ketiw
Ika ke atoura noumw taropwen tungor (appilikeison), kopwe pwan pacheienong ekkei taropwe
(me fan). Kopwe pacheienong kapin noumw ekei taropwe, esapw ekkewe chok minen noom,
pwun sise tongeni pwan niwini sefaningonuk. Pworous ese unus a tongeni ammanga
kapwungunoon angang me niwin.
Kosemochen kopwe pacheienong porausen EMON ME EMONchon omw faminime won
ewe Taropwen Tungoren Aninisin Moni. “Chon famini” repwe nomw non omw famini ika re
uputiw ngonuk, re pwupwunu ngonuk, re mwut ngonuk (adoption), me re nomw reom.
 Taropwen affataomw moni tonong
 Unusen niwinum (Salary)
Chekin peiof ren ekkewe unungat maram sia nukusokuru
Taropwen W2 (mei katou non ei ier)
 Angang non imwomw/pwusin noum kampani (Self-employment)
Taropwen takisis (GE)
Taropwen Schedule C me/ikataropwen pwaratan omw win me omw nus (profit
and loss)
 Social Security
Taropwen 1099
Taropwen pwarata omw pekin aninis (benefit award letter) aretaropwen esinesin
seni bank mei affata omw deposit me ewe US Treasury
 Unemployment (Aninis non fansoun ese wor omw angang)
Taropwen PwarataOmw Insurance ("Determination of Insured Status")
Ika kese tongeni kuut ena taropwe, ka tongeni nounou ewe “Income Verification
Form” (F3)mei pacheienong me non ei taropwe. Emon chon angang me ewe
ofesin Unemployment epwe PWAN mina ei taropwe—ami me ruemon.
 Workers' Compensation (Aninis ika ke feiengaw non fansoun angang)
Chekin peiof ren ekkewe unungat maram sia nukusokuru
Taropwen pwarata omw pekin aninis (benefit award letter)
 Pension/Retirement
Chekin peiof ika taropwen pwarata met aninis ka kan angei iteiten maram
 Aninisin Veteran(Veteran’s benefits)
Chekin peiof ika taropwen pwarata met aninis ka kan angei iteiten maram
 Imwom/Neniomw (Rental/Real Estate)
Taropwen Schedule E
 Monien Tumwunun Semirit (Child Support)
Taropwen pwarata omw pekin aninis (benefit award letter) ika eche taropwen
kapwung mei pwarata omw moni tonong
 Aninisin Moni (Welfare)
Taropwen pwarata omw pekin aninis (benefit award letter) ika pwan eche
taropwe mei pwarata omw moni tonong
 Kapin unusen noumw taropwen takisis (tax forms) (mei ketiw non ei ier)
 Pacheienong ekkewe taropwen 1099 mei pwarata omw moni tonong me angang
PWAN omw moni tonong me ekkoch
 Unusen ewe taropwen 4506-T (TungorenTranscript ika kapin omw Tax
Return):https://www.irs.gov/pub/irs-pdf/f4506t.pdf
 Ika ka angei aninis me emon aramasomw/chienomw, en PWAN ewe a ngonuk aninis ami
me ruemon) oupwe mina ewe Statement of Support ika Residency Form (F2).
 Taropwen pwarata omw fich (are omw kosapw fich) ngeni Medicaid me/ika Quest
 Ika ese wor noumw taropwe me nein ekkei, iwe kopwe chok pusin makke me saini eche
taropwe mei affata ika pwata kese mwo tourato ekkoch ekkei taropwe (asan).
 Taropwen Hawai‘i Pacific Health Financial Assistance Application (kopwe mina unusen ei
form me pwan saini)
FINANCIAL ASSISTANCE APPLICATION (F1) (TAROPWEN TUNGOREN ANINISIN MONI)
KINIKIN EU: PORAUSEN EWE CHON NIWING (MAK NON PERES )
Iitomw(Saingonoon, Aewin, Nepwopwutaan Mesen Mmak Ren Nukanapan)
Ranin Uputiw
Nampan Account
Ewe Pwinin Maram Ke Angei Omw Aninis
KINIKIN RUU: ION EPWE WISEN MONI NIWINUM NON PIOING/ CHON NEMENI (MAK NON PERES)
Iitomw (Saingonoon, Aewin, Nepwopwutaan Mesen Mmak Ren Nukanapan)
Ranin Uputiw
Nampan Social Security
Address
Zip Code
Nampan Fon (Aewin)
Sop
En mei Pwupwunu?
 Use Pwupwunu  Uwa Pwupwunu Mwufesen Pwan Ekkoch:______
State
En mei faenini omw na Federal Tax Return?  Uu  Apw
Ika pwe “Apw”, pwata kese mwo faenini? ____________________
Nampan Fon (Orruan)
KINIKIN UNUNGAT: PORAUSEN FAMINI (Ekkewe ir mei nomw reom) Ren kapachetan pwan ekkoch, ka tongeni makkeinong me nesokurun ei taropwe)
Itenekkewe aramas re nomw reom (chochon omw famini)
Ranin Uputiw
Nampan Social Security
Nefinom ngeni ei aramas
Iten ei aramas a kapachanong
non omw Federal Tax Return?
1.
 Uu  Apw
2.
 Uu  Apw
3.
 Uu  Apw
4.
 Uu  Apw
5.
 Uu  Apw
6.
 Uu  Apw
KINIKIN RUANU: MONI TOUU (Pwarata mwooni touu seni imwomw meren chon omw famini meinisin)
Renten Imwomw: $
Mortgage: $
Pwan Ekkoch (Unusen): $
KINIKIN NIMU: MONTHLY GROSS INCOME (List income for all family members before taxes)
Salary (Unusen Niwinum)
Workers' Compensation (Aninis ika ke
Rental/Real Estate
feiengaw non fansoun angang)
Pwan Ekkoch Moni Tonong:
Social Security
Pension/Retirement
Child Support (Momon Tumwunun Semirit)
Seni minne neni/aramas:
Unemployment (Aninis ika e kouno omw
angang)
Veterans' Benefits (Aninisin Veteran)
Aninisin Moni (Welfare)
Ifa Ukukun:
Uwa weiweiti pwe Hawaii Pacific Health repwe tongeni katonochu me apwunguweno ekkei poraus me non ei Taropwen Tungoren Aninisin Moni fan nemenien Hawaii Pacific Health, iwe
uwa pwan weiweiti nge ika ai upwe pusin saini ei taropwe, epwe chok pwarata pwe ngang mei tipeew ngeni ai we nenien angang ar repwe aea fengeni porausei, ika mei wor popun mei
auchea. Uwa ppwon pwe ei pworous a katou seni ei non ei taropwen ppwon mei ennet, pwung me wenechchar non ukukun met ai sinei. Uwa pwan weweiti pwe ai upwe mwakeneta
pworous non pusin ai mwochen mei tongeni ai upwe angei tipisin are ika ai fich ngeni ai upwe nounou aninis epwe fen pwan tongeni kouno.
Uwa weiweiti pwe a wor ekkoch tokter/chon awora iir rese nomw fan tettenin Hawaii Pacific Health. Uwa weiweit pwe ei pirokramen aninis me ei apilikeison ren aninisin moni ese tongeni
pochokun ngeni ai niwinimang (me akomw). Uwa pwan weiweiti pwe upwe tongeni resif ekkoch bill seni ekkewe chon awora, nge ei taropwen tungor esapw tongeni momoni
______________________________________________________
Sainen Iten ewe Chon Niwing/Chon Nemeni
______________________
Pwinin Maram
______________________________________________________
Makke itomw (Mak non Peres)
______________________
Nefinomw ngeni ewe Chon Niwing
Kapasen Aninis me/ika Taropwen Ia Ke Nomw Ia (F2)
ren Ekkewe Repwe Tungoren Aninisin Moni
Ika ke angei aninis, en me ewe/ekkewe chon awora aninis oupwe amasowa ei taropwe. Ika ke angei aninis seni nifinifin
aramas, mei auchea emon me emon epwe fori “Kinikin B” non ei taropwe.
Kinikin A: Epwe fofor meren ewe chon nuing/chon nemeni:
Ngang,_________________________________________________, uwa nomw non ei neni (me fan):
(Iten Chon Niwing/Chon Nemeni)
______________________________________________________________________________________________
(Address/Nampan Posto)
Uwa angei aninis seni _________________________________________
(Iten Chon Awora Aninis)
________________________
(Tefom En Chon Awora Aninis)
Ewe/ekkewe chon awora aninis re awora: (kosemochen fini menni ekkei)
[ ] Imw[ ] Mwenge [ ] Moni[] Pwan eu/ekkoch sokkun auchean aninis
_________________________________________
Sainnen Iten Chon Nuing/Chon Nemeni
_____________________
Pwinin Maram
Kinikin B I: Epwe fofor meren ewe chon awora aninis:
Ngang,_________________________________________________, uwa awora ngeni
(Iten Chon Awora Aninis)
_________________________________________________, ei/ekkei pekin aninis:
(Iten Chon Nuing/Chon Nemeni)
(Kosemochen fini menni ekkei)
[ ] Imw [ ] Mwenge [ ] Moni [ ] Pwan eu/ekkoch sokkun auchean aninis
Ika pwe moni, ifa ukukun:
_________________________________
(Non Ei Maram)
_____________________
(Ifa Ukukun)
_________________________________
(Eu Maram Ano)
_____________________
(Ifa Ukukun)
_________________________________
(Ruu Maram Ano)
_____________________
(Ifa Ukukun)
_________________________________________
Sainnen Iten Chon Awora Aninis
_____________________
Pwinin Maram
Kinikin B II: Epwe fofor meren ewe chon awora aninis:
Ngang,_________________________________________________, uwa awora ngeni
(Iten Chon Awora Aninis)
_________________________________________________, ei/ekkei pekin aninis:
(Iten Chon Niwing/Chon Nemeni)
(Kosemochen fini menni ekkei)
[ ] Imw [ ] Mwenge [ ] Moni [ ] Pwan eu/ekkoch sokkun auchean aninis
Ika pwe moni, ifa ukukun:
_________________________________
(Non Ei Maram)
_____________________
(Ifa Ukukun)
_________________________________
(Eu Maram Ano)
_____________________
(Ifa Ukukun)
_________________________________
(Ruu Maram Ano)
_____________________
(Ifa Ukukun)
_________________________________________
Sainnen Iten Chon Awora Aninis
_____________________
Pwinin Maram
Kinikin B I: Epwe fofor meren ewe chon awora aninis:
Ngang,_________________________________________________, uwa awora ngeni
(Iten Chon Awora Aninis)
_________________________________________________, ei/ekkei pekin aninis:
(Iten Chon Niwing/Chon Nemeni)
(Kosemochen fini menni ekkei)
[ ] Imw [ ] Mwenge [ ] Moni [ ] Pwan eu/ekkoch sokkun auchean aninis
Ika pwe moni, ifa ukukun:
_________________________________
(Non Ei Maram)
_____________________
(Ifa Ukukun)
_________________________________
(Eu Maram Ano)
_____________________
(Ifa Ukukun)
_________________________________
(Ruu Maram Ano)
_____________________
(Ifa Ukukun)
_________________________________________
Sainnen Iten Chon Awora Aninis
_____________________
Pwinin Maram
Taropwen Pwaratan Moni Tonong Ren Unemployment (F3)
faniten Ekkewe Chon Nuing Repwe Apply Ren Aninisin Moni
Ika ke angei aninisin unemployment, kopwe amasowa ei taropwe pwe aipwe apwunguweno omw fich ngeni
omw kopwe angei aninis ren ei Pirokramen Aninisin Moni. Kosemochen kopwe fori Kinikin A non ei taropwe,
iwe pwan emon representative me ewe Ofesin Unemployment epwe fori Kinikin B.
Kinikin A: Ei kinikin epwe fofor me ren ewe a angei aninisin unemployment.
Itomw: ______________________________
Nampan Social Security: ___________
Address/Posto:
Nampan Fon:_____________________
______________________
______________________________
______________________________
Uwa mwumwuta ngeni ewe Pwutain Angang me Industry, fan Pekin Insurance ren Unemployment
(Department of Labor & Industrial Relations, Unemployment Insurance Division) ar repwe mutauu
porausen ai unemployment. Repwe chok aea porausei faniten ar angangen apwunguweno ai fich ngeni
ai upwe angei aninis seni ewe Hawaii Pacific Health Pirokramen Aninisin Moni.
_________________________________________
Sainnen Ewe A Tungoren Aninis
_____________________
Pwinin Maram
Kinikin B: Epwe fofor me ren ewe representative ren (state) ____________________________
Pwutain Angang me Industry, fan Pekin Insurance ren Unemployment.
Unemployment Benefit Information (Porausen Aninisin Unemployment)
Weekly Benefit amount (Ukukun AninisomNon Eu Wik):_______________________________
Maximum benefit entitlement (ewe koukun / met ke tongeni fich ngeni): ______________________
Benefit year begin (poputan): ______________
Benefit year end (nesoponon): _______________
Print Name (Makke Itom): ________________
Title (Kinikinin): _______________________
Contact Number (Nampan Fon): _______________________
_________________________________________
Representative Signature (Sainnen Iten Representative)
_____________________
Pwinin Maram