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FOR BHF USELL2Supportive Living FacilityIMPORTANT NOTICE THIS AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT IS NECESSARY TO ACCOMPLISH THE STATUTORY PURPOSE AS OUTLINED IN SECTION 146.265 OF

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HFS 3745C N-4-05 IL478-2471 is needed by individuals or households who are applying for or seeking benefits or assistance programs from the Illinois Department of Healthcare and Family Services (HFS). This form is used to gather information about the applicant's household composition, income, expenses, and other relevant details to determine their eligibility for various programs, such as Medicaid, CHIP, SNAP, and TANF.

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