Utah Form 702, the Statement of Contribution, is the Department of Health and Human Services form you use to report that someone outside your household regularly pays part of your living expenses — rent, utilities, mortgage, or similar costs — while your Medicaid eligibility is being determined or reviewed.1DHHS – Medicaid Policy Manual. Table VIII – Verification and Interface Match Those third-party payments can count as unearned income, so the Department of Workforce Services (DWS) caseworker handling your file needs a clear record of who is paying, how much, and for what.
When Form 702 Applies
You will usually run into Form 702 in one of two moments: during your initial Medicaid application, when the caseworker learns that someone else helps with your expenses, or during an eligibility review or renewal after your living arrangement has changed. A parent who starts covering your electric bill, a friend who begins chipping in on rent, an ex-spouse paying the mortgage — any of those situations can trigger the form.
Not every shared-expense arrangement does. If you and a roommate split rent down the middle and each pay your own share, that is a shared cost rather than a contribution, and it may fall under Form 17 (Shared Household Shelter Costs) instead.1DHHS – Medicaid Policy Manual. Table VIII – Verification and Interface Match Form 702 is for payments made on your behalf — money that covers costs you would otherwise have to pay yourself.
What to Gather Before You Fill It Out
Collect the following before you sit down with the form:
- The contributor’s full name, their relationship to you, and current contact information.
- The type of expense being covered: rent, mortgage, utilities, insurance, or another specific household cost.
- The dollar amount and how often it is paid. If the amount varies, give a realistic average and note the range.
- When the contributions started and whether they are ongoing or temporary.
- Supporting records such as bank statements, canceled checks, Venmo or Zelle histories, or receipts. Utility bills paid directly by the contributor are particularly useful because the account holder’s name and the payer’s name will differ.
Filling Out the Form
Form 702 is typically provided by your DWS caseworker, either at an in-person appointment or in the documentation packet that follows your initial application. Some forms are also posted on the Utah Medicaid forms page.2Medicaid – Utah DHHS. Utah Medicaid Forms
Write clearly and use exact figures wherever you can. Put your case number on the form and on every page you attach, so nothing gets separated from your file. If the person contributing is willing to sign a brief statement confirming the arrangement, attach that too. A caseworker who can cross-reference your form against a signed statement from the contributor has far less reason to ask for more.
If you are not sure whether a particular payment counts as a reportable contribution, call your caseworker before you submit. Underreporting can cause eligibility problems if a payment surfaces during a later review, and overreporting can shrink your benefits for no reason.
Where to Submit It
You can send Form 702 and any supporting documents to DWS in four ways:
- Online through the myCase portal at jobs.utah.gov/myCase, which uploads directly to your electronic file and is the fastest option.3Medicaid – Utah DHHS. Medicaid – Utah DHHS
- By fax to 877-313-4717.
- By mail to PO Box 143245, Salt Lake City, UT 84114-3245.
- In person at your local DWS office.
Include your case number on every page, whichever channel you use.4Utah DHHS. Application for SNAP, Financial Assistance, Child Care, and Medicaid Mailed documents can take several business days to arrive and more time to be scanned and matched to your case.
For questions about your application status or which forms you still owe, call Medicaid Information at (801) 538-6155 or toll-free at 1-800-662-9651.2Medicaid – Utah DHHS. Utah Medicaid Forms
What Happens After You Submit
A caseworker reviews the contribution alongside the rest of your household income. If it counts as unearned income under Utah Medicaid rules, it is folded into your total household income for eligibility purposes. The caseworker may contact the contributor directly to confirm the arrangement, so it is worth giving that person a heads-up.
If DWS needs more information, you will get a request by mail or through myCase with a response deadline. Missing that deadline can delay your determination or trigger a temporary denial, so watch your mail and myCase notifications after you submit.
Report any later change — the contributions stop, the amount shifts, or a different person starts helping — to DWS promptly. You can do that through myCase, by calling your local DWS office, or by submitting an updated Form 702. Keeping the record current helps you avoid overpayment issues that can lead to repayment demands later.
One-Time Gifts and Household Members
Two situations come up often. The first is a one-time gift, like a relative paying a single month’s rent during a rough patch. Form 702 is designed for recurring contributions rather than isolated gifts, but it is safer to disclose and let the caseworker classify it than to leave it out. A single payment noted on the form is far less disruptive than an unreported pattern discovered later.
The second involves someone you live with. If a household member pays more than their proportional share of shared expenses, that arrangement may belong on Form 17 (Shared Household Shelter Costs) rather than Form 702.1DHHS – Medicaid Policy Manual. Table VIII – Verification and Interface Match Describe the arrangement in detail and let DWS assign the right form rather than guessing.