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The Connecticut W 1130 form is an essential document designed for individuals seeking assistance through the Acquired Brain Injury (ABI) Waiver program. This program aims to provide support for those who have sustained an acquired brain injury, allowing them to live more independently in the community rather than in institutional settings. The form requires personal information, including the applicant's name, address, and contact details, as well as specific data about the injury, such as the date and diagnosis. Additionally, applicants must indicate their preference for living arrangements, whether in the community or a nursing home. Financial information is also a critical component, as the form requests details about monthly income and total assets, which help determine eligibility for Medicaid and other assistance programs. Completing the W 1130 form accurately is vital for individuals seeking the necessary support to enhance their quality of life and access vital resources.
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File Information
| Fact Name | Description |
|---|---|
| Form Purpose | The W-1130 form is used to request services under the Acquired Brain Injury (ABI) Waiver in Connecticut. |
| Governing Law | This form is governed by the Connecticut General Statutes, specifically under Title 17b, which pertains to social services. |
| Eligibility | Individuals with an acquired brain injury can apply for the ABI Waiver using this form. |
| Personal Information Required | Applicants must provide personal data, including name, address, and Social Security number. |
| Financial Information | The form requires details about monthly income and total assets to assess financial eligibility. |
| Freedom of Choice | Applicants must indicate their preference for living arrangements, either in the community or a nursing home. |
| Contact Information | If applicable, a contact person can be designated to assist with the application process. |
| Submission Details | The completed form should be returned to the Department of Social Services at the specified Hartford address. |
Connecticut W 1130 Sample
STATE OF CONNECTICUT |
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(Rev. 2/07) |
DEPARTMENT OF SOCIAL SERVICES |
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ACQUIRED BRAIN INJURY (ABI) WAIVER REQUEST FORM |
1.Personal Data
Name |
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Social Security # |
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Address |
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No. |
Street |
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Apt. No. |
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City |
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Telephone ( |
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Age |
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Single |
Married |
Widowed |
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State |
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Zip Code |
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Date of Birth |
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(month) |
(day) |
(year) |
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Divorced |
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Contact person if other than yourself:
Name |
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Telephone |
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Address |
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No. |
Street |
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Apt. No. |
City
Relationship
(check all that apply)
State
Conservator of Person
Other (specify)
Zip Code
Conservator of Estate
2.ABI Information
Do you have an acquired brain injury?
If Yes, please indicate date of injury |
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Yes
⁄
No
and diagnosis
3.Freedom of Choice - Please read the following and check the box that indicates your choice
If possible, I would prefer to live in the community rather than a nursing home or other institutional setting.
I would prefer to live in a nursing home or other similar setting.
4.Medicaid (Title 19) and Medicare Information
Please check the blocks that apply to you:
I am receiving Medicare benefits (enter claim number)
I am receiving Medicaid/Title 19 benefits (enter case number)
I have a Medicaid "Spenddown" (enter case number, if known)
I have applied for Medicaid benefits but have not received a decision
I have not applied for Medicaid benefits
THIS INFORMATION IS AVAILABLE IN ALTERNATE FORMATS. PHONE (800)
(800)
5.Financial Data
My total monthly income (for example, Social Security, SSI, disability benefits, pension benefits, Workers Compensation, wages, contributions, income from interest or dividends, etc.) is:
Amount |
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Source |
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My total assets (for example, cash, bank accounts, IRAs, life insurance, annuities, stocks, bonds, motor vehicles, property, etc.)
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Amount |
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Source |
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Signature of Applicant |
Date |
Signature of Conservator or Other Representative |
Date |
Typed or Printed Name of Conservator or Other Representative |
Date |
Return This Form To:
Department of Social Services
25 Sigourney Street
Hartford, CT
Attention: Social Work Services
10th Floor
Common mistakes
Filling out the Connecticut W-1130 form can be a straightforward process, but there are common mistakes that applicants often make. One significant error is failing to provide complete personal data. The form requires specific information such as your name, address, and Social Security number. Omitting any of these details can delay the processing of your request. Always double-check that all fields are filled out accurately before submission.
Another frequent mistake involves the section regarding the acquired brain injury (ABI) information. Some applicants either do not indicate whether they have an ABI or fail to provide the date of injury and diagnosis. This information is crucial for determining eligibility for the waiver. Incomplete responses can lead to automatic disqualification, so ensure that you answer this section thoroughly and accurately.
In the Freedom of Choice section, applicants sometimes overlook the importance of clearly indicating their preference for living arrangements. This choice directly impacts the services that may be available to you. Failing to check the appropriate box can result in misunderstandings about your needs and preferences, potentially affecting the outcome of your application.
Finally, many individuals make errors in the financial data section. It is essential to report total monthly income and assets accurately. Miscalculating these figures or providing vague descriptions can lead to complications in determining eligibility for Medicaid benefits. Take the time to gather all necessary financial documents and ensure that the amounts listed are correct and clearly specified.
Key takeaways
Filling out the Connecticut W-1130 form is a crucial step for individuals seeking assistance under the Acquired Brain Injury Waiver. Here are some key takeaways to keep in mind:
- Accurate Personal Information: Ensure that all personal data, such as your name, address, and Social Security number, is filled out accurately to avoid processing delays.
- Understanding ABI: Clearly indicate whether you have an acquired brain injury, including the date of injury and diagnosis, as this information is vital for eligibility.
- Freedom of Choice: Make a choice between living in the community or a nursing home. This preference will influence the type of services you may receive.
- Medicaid and Medicare Details: Provide accurate information regarding your Medicaid and Medicare status. This includes any claim or case numbers, which are essential for verifying your benefits.
- Financial Data: Be prepared to disclose your total monthly income and assets. This information helps determine your financial eligibility for the waiver.
- Signature Requirement: Both the applicant and any conservator or representative must sign the form. Missing signatures can result in delays or denial of the request.
- Submission Instructions: Return the completed form to the specified address. Ensure it is sent to the Department of Social Services to avoid misrouting.
By following these guidelines, you can facilitate a smoother application process for the ABI Waiver in Connecticut.
Similar forms
The Connecticut W-1130 form is primarily used to request services under the Acquired Brain Injury (ABI) Waiver. One document that shares similarities is the Medicaid Application Form. Both forms collect personal information and financial data to determine eligibility for services. Just like the W-1130, the Medicaid Application requires details about income and assets, ensuring that applicants meet the financial criteria necessary for assistance. Both forms also emphasize the importance of accurate information, as discrepancies can lead to delays or denials in service provision.
Another document akin to the W-1130 is the Social Security Disability Insurance (SSDI) Application. This application is designed for individuals seeking financial assistance due to disabilities, including brain injuries. Similar to the W-1130, the SSDI application requires personal details, medical history, and information about the applicant's work history. Both documents aim to assess the individual's eligibility for support, making them crucial for those navigating the complexities of disability benefits.
The Supplemental Security Income (SSI) Application also parallels the W-1130 form. Like the W-1130, the SSI application focuses on providing financial aid to individuals with limited income and resources. It requires detailed financial disclosures and personal data, just as the W-1130 does. Both forms serve to evaluate the applicant's situation comprehensively, ensuring that those in need receive the appropriate assistance.
The Long-Term Care Application shares similarities with the W-1130 form as well. This document is utilized by individuals seeking long-term care services, whether in a facility or at home. Both forms gather information about the applicant's health condition, living preferences, and financial status. The Long-Term Care Application, like the W-1130, helps determine the level of care and support an individual qualifies for, making it an essential tool in the process of securing necessary services.
The Home and Community-Based Services (HCBS) Waiver Application is another document that resembles the W-1130. The HCBS application is designed for individuals seeking community-based support rather than institutional care. Both forms require personal and financial information to evaluate eligibility for services. They aim to empower individuals to live independently while ensuring that appropriate resources are allocated based on their specific needs.
The Individualized Service Plan (ISP) is also comparable to the W-1130 form. While the ISP is typically created after eligibility is established, it shares the focus on understanding the individual's needs and preferences. The W-1130 collects initial data that can inform the development of an ISP, ensuring that the services provided align with the individual's goals and circumstances. Both documents emphasize a person-centered approach to care and support.
The Client Assessment Form is another document similar to the W-1130. This form is often used to evaluate an individual's needs for various support services. Like the W-1130, it gathers essential personal and health information to create a comprehensive picture of the client's situation. Both forms aim to facilitate access to necessary resources and services, ensuring that individuals receive the care they require.
For those navigating rental agreements in New York, understanding the intricacies of various forms is essential. One valuable resource to aid in this process is the Templates and Guide, which provides comprehensive insights and templates that streamline the leasing process. These tools not only clarify the terms and obligations laid out in significant agreements but also empower both landlords and tenants to engage confidently in their transactions.
Finally, the Family Caregiver Support Program Application shares characteristics with the W-1130 form. This application is intended for caregivers seeking assistance and resources to support their loved ones. Both forms gather information about the individual needing care, as well as the caregiver's situation. By collecting relevant data, both documents help connect individuals and families with the support they need to navigate the challenges associated with caregiving and disabilities.