Official Connecticut W 1130 Template in PDF
Structure
The Connecticut W 1130 form is an essential document for individuals seeking assistance through the Acquired Brain Injury (ABI) Waiver program. This form serves as a formal request for support from the Department of Social Services, specifically tailored for those who have experienced an acquired brain injury. It collects personal information, including the applicant's name, address, and Social Security number, as well as details about their injury and diagnosis. The form also emphasizes the importance of choice regarding living arrangements, allowing applicants to express their preference for community living or institutional care. Additionally, it addresses the applicant's Medicaid and Medicare status, which is crucial for determining eligibility for various benefits. Financial data is another key component, requiring individuals to disclose their monthly income and total assets. By providing this comprehensive information, the W 1130 form plays a pivotal role in facilitating access to necessary services and support for those affected by ABI in Connecticut.
Connecticut W 1130 Example
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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⁄ |
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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 |
⁄ |
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
Document Specifications
| Fact Name | Fact Details |
|---|---|
| Form Purpose | The W-1130 form is used to request services under the Acquired Brain Injury (ABI) Waiver program in Connecticut. |
| Governing Law | This form is governed by the Connecticut General Statutes, specifically Section 17b-280, which outlines the provisions for the ABI Waiver program. |
| Eligibility Criteria | Applicants must have an acquired brain injury and meet specific financial and medical criteria to qualify for services. |
| Submission Instructions | The completed form should be returned to the Department of Social Services at 25 Sigourney Street, Hartford, CT 06106-5033. |
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