Statement of Circumstances
For use with Medicaid applications
Applicant Name
Case Number
Date
Date of Birth
Home Address
Mailing Address
Phone Number
Email
Please use this form to provide additional information, clarification, or explanation related to your 
Medicaid application.   
Client Signature
Date
Client Printed Name
OR
Disclaimer: We do not discriminate on the basis of race, ethnicity, color, national origin, religion, sex, age, or disability. Free language assistance 
services are available for people whose primary language is not English. We also provide free aids and services to assist with communicating the 
information effectively (such as interpreters, captioning, Braille, or large print). If you need these services, please contact us by phone or email.  
St Thomas/St. John District: 340-774-0930 ext. 4104 or sttjmap@dhs.vi.gov | St. Croix: 340-772-7100 or stxmap@dhs.vi.gov 
Privacy Notice: The information provided on this form will be used only for purposes of determining and verifying Medicaid eligibility.                                         
Your information is protected under state and federal privacy laws. 
FOR OFFICE USE ONLY
Received by: 
 	
	
	
Date: 
Client Prejury Statement:
Under penalty of perjury, I certify that the information presented in this document is true and accurate to 
the best of my knowledge. By signing below, I understand that providing false statements may result in 
termination, denial, or recovery of benefits.
Authorized Representative Signature
Phone Number
Email
Authorized Representative Name
Date
SIGN
SIGN
SIGN