MAP CASE NO:
APPLICANT: _______________________________MARITAL STATUS: ______
BIRTH DATE:_____________         SSN: _______________________
                            CHECK IF NO FIXED ADDRESS
HOME ADDRESS: _______________________________________
MAILING ADDRESS: ____________________________________________
HOME PHONE: (         )___________________        WORK PHONE:  (         ) ________________
MOBILE PHONE:  (        ) _________________________
PREGNANT:
DISABLED:
AGED:
    TANF:
  FOSTER CARE:
EMANCIPATED MINOR:
HOUSEHOLD COMPOSITION
SEX
INCOME TYPE 
(Earnings, Social 
Security, 
Unemployment, 
etc.)
RESOURCE(S) 
Saving, 
Checking, 
Property)
HEALTH 
INSURANCE 
PROVIDER
SIGNATURE OF APPLICANT: ________________________________________
DATE: ________________________________
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 constitue fraud for which I may lose my Medical Assistance coverage or can be prosecuted for a crime.
GOVERNMENT OF THE VIRGIN ISLANDS
Department of Human Services
"Working Together to Make a Difference"
MEDICAL ASSISTANCE PROGRAM
RELATIONSHIP TO 
APPLICANT
NAME
DATE OF 
BIRTH
SOCIAL SECURITY 
NUMBER
STATEMENT OF FACTS