SIGNATURE OF APPLICANT: 
DATE: 
HOME ADDRESS: __________________________________   MAILING ADDRESS: ________________________________________________ 
PREGNANT: 
DISABLED: 
AGED: 
TANF: 
FOSTER CARE: 
FORMER FOSTER CARE: 
EMANCIPATED MINOR: 
Check If No 
Fixed Address 
GOVERNMENT OF THE VIRGIN ISLANDS 
Department of Human Services 
"Working Together to Make a Difference" 
MEDICAL ASSISTANCE PROGRAM 
STATEMENT OF FACTS 
YOU MUST COMPLETE ALL FIELDS ON THIS APPLICATION TO RECEIVE A TIMELY ELIGIBILITY DETERMINATION 
MAP CASE NO:  
HOUSEHOLD COMPOSITION 
NAME 
DATE OF 
BIRTH 
SEX 
RACE*
RELATIONSHIP TO 
APPLICANT 
SOCIAL 
SECURITY 
NUMBER 
INCOME TYPE 
(Earnings, Social 
Security, 
Unemployment, etc.) 
RESOURCE(S) 
Saving, Checking, 
Property) 
HEALTH 
INSURANCE 
PROVIDER 
*Race Codes: 1=White or Caucasian, 2=Black or African American, 3=Native Alaskan or American Indian, 11=Asian, 16=Hawaiian, Pacific Islander, 17=Decline to Answer, 18=Other
I certify through my signature that the answers given are true and correct to the best of my knowledge and belief. I realize that deliberate misrepresentation or 
concealment of facts may constitute fraud for which I may lose my Medical Assistance coverage or can be prosecuted for a crime. 
APPLICANT: ______________________________________  MARITAL STATUS: ______     BIRTH DATE: ______________ SSN: ___________________________ 
MOBILE PHONE: (     )________________________________HOME PHONE: (   )_____________________________WORK PHONE: (      )_________________ 
EMAIL: ____________________________________________________     PREFERRED METHOD OF CONTACT :______________________________________