Combined Application for Benefits

With the Combined Application for Benefits Form  [PDF] (English and Spanish versions available), you can apply or be recertified for one or more of the following assistance programs:

• Financial Assistance/TANF
• Supplemental Nutrition Assistance Program/SNAP (formerly known as Food Stamps)
• Medical Assistance

To complete the application, you may either: 

• Download and save the application form and fill it out on your computer, then print it or
• Print the application and fill it out by hand.

All application forms must be signed and dated and submitted to ESA (formerly known as IMA) in order to begin processing.

After you complete, sign and date your application, mail or take your application to an ESA (formerly IMA) service center.  

Find a Service Center nearest you.

You will still need to be interviewed for all programs except Medicaid. We recommend taking these documents along with you to that interview. If you are in need of an accommodation, you may request a waiver form.