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
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