Imagingcenter4 dhs state ia us 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your County Number, Worker Name, and Case Number at the top of the form. Ensure all information is accurate.
3. In the 'Information About Your Family' section, list yourself and any household members. Include their names, relationships, ages, and Social Security Numbers.
4. Update your mailing and living addresses if they have changed. Provide details for any guardians or representatives if applicable.
5. In the 'Expenses' section, detail your medical expenses and other relevant costs. Attach proof of these expenses as required.
6. List all sources of income for everyone in your household under the 'Income' section. Be sure to include gross amounts per month.
7. Complete the 'Assets' section by listing vehicles and financial assets. Attach recent bank statements as proof.
8. Finally, sign on Page 4 where indicated, certifying that your information is correct. Remember to send all necessary documentation with your form.

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