Doh 5017-2026

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4.3 out of 5

48 votes

The document is an application form for the Family Planning Benefit Program (FPBP) provided by the New York State Department of Health. It collects personal and household information, including contact details, income sources, citizenship status, and health insurance coverage. The form outlines the rights and responsibilities of applicants, confidentiality assurances, and requirements for documentation to determine eligibility for family planning benefits.

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Begin with SECTION A: CONTACT INFORMATION. Fill in your first name, middle initial, last name, and primary language spoken. Provide your home address and, if necessary for confidentiality, a different mailing address.
Move to SECTION B: HOUSEHOLD INFORMATION. List all individuals living with you who are applying for FPBP, including their names, dates of birth, and whether they are applying for benefits.
In SECTION C: HOUSEHOLD INCOME, detail the income sources for each person listed in Section B. Include types of income and amounts received before taxes.
Complete SECTION D: CITIZENSHIP by confirming U.S. citizenship status for all applicants and providing necessary documentation as required.
Finally, review the TERMS, RIGHTS AND RESPONSIBILITIES section carefully before signing and submitting your application.

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Versions	Form popularity	Fillable & printable
2014	4.8 Satisfied (102 Votes)
2009	4.3 Satisfied (48 Votes)

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