Supplemental Nutrition Assistance Program SNAP Application/Recertification by New York State Office of Temporary and Disability Assistance Lyrics
NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE SNAP APPLICATION / RECERTIFICATION
Application Date Interview Date Center/Office Unit Worker Case Type Case Number Registry Number Version Lifeline Apply Recertify
Lang
Name:
Telephone Number:
Other phone where you can be reached:
Residence Address, Apt.#, City, NY, Zip Code
Mailing Address (if different), Apt.#, City, NY, Zip Code
Other Name:
Are You:
Applying or
Recertifying
Do you want to receive notices in:
Spanish and English or
English Only
We must accept your application if, at a minimum, it contains your name, address (if you have one), and signature in this box.
APPLICANT/REPRESENTATIVE SIGNATURE DATE SIGNED
List everyone who lives with you even if they are not applying. List yourself first.
First Name
Last Name
Social Security Number (SSN) of applying member (If none, write “NONE”)
Date of Birth
Marital Status
Sex M or F
Is this person applying?
Relationship to you
Do you buy and/or prepare food with this person?
Hispanic or Latino? Enter Y (Yes) or N (No) for each race*
*Race/Ethnic Codes: I – Native American or Alaskan Native
A - Asian
B – Black or African American
P – Native Hawaiian or Pacific Islander
W – White
U – Unknown (MA Only)
Are you and is everyone living with you a US citizen?
If No, who is not a citizen?
Has a court issued a warrant because it found that you or anyone living with you is fleeing to avoid prosecution, custody or confinement for a felony or an attempted felony?
Are you or is anyone living with you in violation of probation or parole according to a court?
Have you or has anyone living with you ever been disqualified from receiving SNAP because of fraud or intentional program violation?
Are you or is anyone in your household applying for or receiving SNAP or Temporary Assistance in another place?
Are you or is anyone living with you blind, disabled or pregnant?
If Yes, who
Are you or is anyone living with you a veteran?
If Yes, who
Do you or does anyone live in a drug or alcohol treatment center, State-certified group living facility or State-certified supervised/supportive apartment?
If you are recertifying for SNAP, list on the Page 6 what has changed since your last application or recertification (such as moved, had a baby, someone moved in or out of your household).
You may use the page 6 if you need more room or there is other information that you think we might need.
INCOME
List ALL your income and the income of anyone living with you. This includes, but is not limited to wages, income from self-employment (for example: babysitting, cleaning, income from a roomer or boarder) child support, pensions, veterans benefits, disability, social security or SSI, grant for scholarships for rent or food, Temporary Assistance, and income from friends or relatives.
Name of Person Receiving Income
Source of Income
Hours Worked Per Month
How Often is it Received? (for example, weekly, bi-weekly, monthly)
Gross Amount Received Before Deductions
Do you or does anyone living with you have child/dependent care costs related to employment or training?
If Yes, who
Amount paid
How often paid (e.g., weekly, monthly)
Have you or has anyone living with you changed or quit jobs or reduced any form of income in the last 30 days – including reduced work hours or income?
Do you or does anyone living with you have any potential income that has not yet been received?
If Yes, explain on Page 6.
Do you or does anyone living with you receive a Personal Needs Allowance (PNA) or a Meal Allowance?
If Yes, who
Have you or has anyone in your household set aside any income under “PASS: Plan To Achieve Self Support” approved by the Social Security Administration?
If Yes, who
Are you or is anyone living with you participating in a strike?
If Yes, who
RESOURCES
Resources do not affect the eligibility of most households applying for SNAP. However, some resource information is used to determine if you qualify for expedited processing of your application.
How much money does everyone in your household have? (For example, on your person; in your home, in checking and savings accounts, or other locations, including jointly held accounts)
Belongs to
Other financial assets? (For example, stocks, bonds, retirement accounts, savings bonds, mutual funds, IRAs, trust funds, money market certificates)
If Yes, amount
Type
Owner
How many cars, trucks or other vehicles do you or anyone in your household have?
Year
Make
Model
Owner
Do you or anyone applying own any property including your own home?
If yes, list property
Owner
Has anyone applying sold, given away or transferred cash or property in the last three months to qualify for SNAP?
LIVING ARRANGEMENTS AND EXPENSES
Check all the descriptions that apply to your household:
Own home or paying for home
Renting
Migrant/seasonal farmworker
No permanent residence
Live with relatives or friends
List expenses:
Monthly rent or mortgage payment
Tax on home per year
Insurance on home per year
Pay separately for Heat?
If yes, specify type of heating:
Gas
Electric
Oil
Wood
Coal
Propane
Other (list)
Heat Co. Name
Heat Co. Acct. No.
Pay for air conditioning, either in your electric bill or as a separate fee?
Pay separately for utilities (other than heating/cooling)? (for example, lights, cooking gas, washer/dryer fees, garbage/trash, water, initial installation of utilities)?
Does anyone else pay any of these expenses for you (some examples are Section 8 or other subsidy program)?
If yes, who pays what?
Do you or does anyone living with you pay court-ordered child support?
If yes, who
Name(s) of child(ren) support is being paid for
Payment amount
Frequency of payments (for example, weekly, bi-weekly, monthly)
Are you, and/or anyone living with you, blind/disabled or at least age 60? If so, does such person have medical bills?
If yes, list on the page 6 what they are for, how much and who is responsible for payment.
Are you, and/or anyone living with you, on Medicaid with a spendown?
If yes, who
Amount
Are you, and/or anyone living with you (16 years old or older) enrolled in school or training?
If yes, who
where
READ THE IMPORTANT INFORMATION BELOW
SNAP PENALTY WARNING – Any information you provide in connection with your application for SNAP will be subject to verification by Federal, State and local officials. If any information is incorrect, you may be denied SNAP. You may be subject to criminal prosecution for knowingly providing incorrect information.
You will never be able to get SNAP again if you are found guilty in a court of law for the second time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP; or found guilty in a court of law of selling or getting firearms, ammunition or explosives in exchange for SNAP; or found guilty in a court of trafficking in SNAP worth $500 or more. Trafficking includes the illegal use, transfer, acquisition, alteration or possession of SNAP, authorization cards or access devices; or found guilty of committing a third Intentional Program Violation (IPV).
You will not be able to get SNAP for two years if you are found guilty in a court of law for the first time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP.
If you have committed your: First IPV, you will not be able to get SNAP for one year. Second IPV, you will not be able to get SNAP for two years.
A court could also bar you from receiving SNAP for an additional 18 months. If you make a false statement about who you are or where you live in order to get multiple SNAP benefits, you will not be able to get SNAP for ten years (or permanently if this is the third IPV).
You may be found guilty of an IPV if you make a false or misleading statement, or misrepresent, conceal or withhold facts; or commit any act that constitutes a violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of SNAP benefits, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system.
You could also be fined up to $250,000, sent to jail for up to 20 years, or both.
Anyone who is fleeing to avoid prosecution, custody or confinement for a felony, or who is violating a condition of probation or parole, is not eligible to receive SNAP.
If you get more SNAP benefits than you should have (overpayment), you must pay them back. If your case is active, we will take back the amount of the overpayment from future SNAP benefits that you get. If your case is closed, you may pay back the overpayment through any unused SNAP benefits remaining in your account, or you may pay cash. If you have an overpayment that is not paid back, it will be referred for collection in a number of ways, including automated collection by the federal government. Federal benefits (such as Social Security) and tax refunds that you are entitled to receive may be taken to pay back the overpayment. The debt will also be subject to processing charges.
Any expunged SNAP benefits will be put towards your overpayment. If you apply for SNAP again, and have not repaid the amount you owe, your SNAP benefits will be reduced if you begin to get them again. You will be notified, at that time, of the amount of reduced benefits you will get.
CONSENT – I understand that by signing this application form I agree to any investigation made by the New York State Office of Temporary and Disability Assistance or my local social services district to verify or confirm the information I have given or any other investigation made by them in connection with my request for SNAP. If additional information is requested, I will provide it. I will also cooperate with State and Federal personnel in a SNAP Quality Control Review.
CONSENT FOR RELEASE OF CONFIDENTIAL UNEMPLOYMENT INSURANCE (UI) INFORMATION – I authorize the New York State Department of Labor
(DOL) to release any confidential information, maintained by DOL for Unemployment Insurance (UI) purposes, to the New York State Office of Temporary and Disability Assistance (OTDA). This information includes UI benefit claims and wage records. I understand that OTDA, along with State and local agency employees working in local social services district offices, will use the UI information for establishing or verifying eligibility for, and the amount of, TA, MA, or FS benefits applied for in this application and for investigations to determine whether I received benefits to which I was not entitled.
SUA (STANDARD UTILITY ALLOWANCE) INFORMATION – I understand that SNAP recipients are categorically income eligible for the Home Energy Assistance Program (HEAP). If I am not included in the annual automatic HEAP payment process for certain SNAP recipients, my household intends to apply for a HEAP benefit within the next 12 months. If I decide not to apply for HEAP within the next 12 months, I will let my worker know.
TELEPHONE ALLOWANCE INFORMATION – I understand that SNAP recipients are eligible for a telephone allowance if they pay to use a home phone, cell phone, phone, phone calling card or coin operated pay phone. If I do not have any cost to make phone calls, I will let my worker know.
CHANGES – I agree to inform the agency promptly of any change in my needs, income, property, living arrangement, pregnancy status or address to the best of my knowledge or belief in accordance with my reporting requirements.\
REQUIREMENT TO REPORT/VERIFY HOUSEHOLD EXPENSES – I understand that my household must report child care and utility expenses in order to get a SNAP deduction for these expenses. I further understand that my household must report and verify rent/mortgage payments, property taxes, insurance, medical expenses and child support paid to a non-household member in order to get a SNAP deduction for these expenses. I understand that failure to report/verify the above expenses will be seen as a statement by my household that I/we do not want to receive a deduction for those unreported/unverified expenses. A deduction for these expenses may make me eligible for SNAP or may increase my SNAP benefits. I understand that I may report/verify these expenses at any time in the future. This deduction would then be applied to the calculation of SNAP in future months in accordance with the rules for change reporting and processing changes.
PRIVACY ACT STATEMENT – COLLECTION AND USE OF SOCIAL SECURITY NUMBER (SSN) – The collection of SSN’s is authorized for each household member with respect to SNAP pursuant to the Food Stamp Act of 1977 (as amended, 7 US Code 2011-2036). The information we collect will be used to determine whether your household is eligible or continues to be eligible for benefits. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. The information will be used to check identity, to verify earned and unearned income, and to determine if applicants or recipients can receive money or other help. The information may be disclosed to State and Federal agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
If you or anyone applying/recertifying does not have an SSN, a SSN must be applied for at the Social Security Agency.
CITIZENSHIP/IMMIGRATION STATUS – I swear and/or affirm under penalty of perjury that the information I have provided about the citizenship and immigration status of my self and everyone living with me is true and correct. I understand that any information I provide to verify the immigration status of anyone applying for SNAP may be checked for authenticity with the United States Citizenship and Immigration Services.
For SNAP, citizenship must be documented only if questionable.
NON-DISCRIMINATION NOTICE – In accordance with Federal Law and U.S. Department of Agriculture (USDA) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political belief, or disability. To file a complaint of discrimination write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
LIFELINE: For applicants/recipients of SNAP: The Office of Temporary and Disability Assistance may or may not release your name and address to your telephone service provider. Your telephone service provider may or may not use this information to enroll you in their Lifeline Service for a discounted telephone rate.
If you do not want this information released, check this box
You may contact your telephone service provider directly for enrollment in the discounted rate Lifeline Service.
Medicaid-only applicants/recipients must contact their telephone service provider directly for enrollment in the discounted rate Lifeline Service.
AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to apply for SNAP for you. You can also authorize someone outside your household to get SNAP benefits for you and to use them to buy food for you. If you would like to authorize someone, you must do so in writing. You may do so by printing the person’s name, address and phone number below. When an Authorized Representative is applying on behalf of a SNAP Household that does not reside in an institution, both the Authorized Representative and the SNAP Head of Household or other responsible adult member of the household must sign and date the signature sections at the bottom of this page.
IF YOU WOULD LIKE TO AUTHORIZE SOMEONE, PRINT THE PERSON’S NAME, ADDRESS AND TELEPHONE NUMBER, AND SIGN BELOW.
Name
Address
Phone
CERTIFICATION: I swear and/or affirm under the penalties of perjury that the information I have given or will give to the local
Social Services district is correct. Your signature is required below to complete the application process.
APPLICANT SIGNATURE
DATE SIGNED
Authorized Representative SIGNATURE
DATE SIGNED
IF YOU HELPED COMPLETE THIS APPLICATION / RECERTIFICATION FOR SOMEONE ELSE, PRINT YOUR NAME AND ADDRESS HERE. YOU MAY ALSO VOLUNTARILY PRINT YOUR TELEPHONE NUMBER.
Name
Address
Phone
Application Date Interview Date Center/Office Unit Worker Case Type Case Number Registry Number Version Lifeline Apply Recertify
Lang
Name:
Telephone Number:
Other phone where you can be reached:
Residence Address, Apt.#, City, NY, Zip Code
Mailing Address (if different), Apt.#, City, NY, Zip Code
Other Name:
Are You:
Applying or
Recertifying
Do you want to receive notices in:
Spanish and English or
English Only
We must accept your application if, at a minimum, it contains your name, address (if you have one), and signature in this box.
APPLICANT/REPRESENTATIVE SIGNATURE DATE SIGNED
List everyone who lives with you even if they are not applying. List yourself first.
First Name
Last Name
Social Security Number (SSN) of applying member (If none, write “NONE”)
Date of Birth
Marital Status
Sex M or F
Is this person applying?
Relationship to you
Do you buy and/or prepare food with this person?
Hispanic or Latino? Enter Y (Yes) or N (No) for each race*
*Race/Ethnic Codes: I – Native American or Alaskan Native
A - Asian
B – Black or African American
P – Native Hawaiian or Pacific Islander
W – White
U – Unknown (MA Only)
Are you and is everyone living with you a US citizen?
If No, who is not a citizen?
Has a court issued a warrant because it found that you or anyone living with you is fleeing to avoid prosecution, custody or confinement for a felony or an attempted felony?
Are you or is anyone living with you in violation of probation or parole according to a court?
Have you or has anyone living with you ever been disqualified from receiving SNAP because of fraud or intentional program violation?
Are you or is anyone in your household applying for or receiving SNAP or Temporary Assistance in another place?
Are you or is anyone living with you blind, disabled or pregnant?
If Yes, who
Are you or is anyone living with you a veteran?
If Yes, who
Do you or does anyone live in a drug or alcohol treatment center, State-certified group living facility or State-certified supervised/supportive apartment?
If you are recertifying for SNAP, list on the Page 6 what has changed since your last application or recertification (such as moved, had a baby, someone moved in or out of your household).
You may use the page 6 if you need more room or there is other information that you think we might need.
INCOME
List ALL your income and the income of anyone living with you. This includes, but is not limited to wages, income from self-employment (for example: babysitting, cleaning, income from a roomer or boarder) child support, pensions, veterans benefits, disability, social security or SSI, grant for scholarships for rent or food, Temporary Assistance, and income from friends or relatives.
Name of Person Receiving Income
Source of Income
Hours Worked Per Month
How Often is it Received? (for example, weekly, bi-weekly, monthly)
Gross Amount Received Before Deductions
Do you or does anyone living with you have child/dependent care costs related to employment or training?
If Yes, who
Amount paid
How often paid (e.g., weekly, monthly)
Have you or has anyone living with you changed or quit jobs or reduced any form of income in the last 30 days – including reduced work hours or income?
Do you or does anyone living with you have any potential income that has not yet been received?
If Yes, explain on Page 6.
Do you or does anyone living with you receive a Personal Needs Allowance (PNA) or a Meal Allowance?
If Yes, who
Have you or has anyone in your household set aside any income under “PASS: Plan To Achieve Self Support” approved by the Social Security Administration?
If Yes, who
Are you or is anyone living with you participating in a strike?
If Yes, who
RESOURCES
Resources do not affect the eligibility of most households applying for SNAP. However, some resource information is used to determine if you qualify for expedited processing of your application.
How much money does everyone in your household have? (For example, on your person; in your home, in checking and savings accounts, or other locations, including jointly held accounts)
Belongs to
Other financial assets? (For example, stocks, bonds, retirement accounts, savings bonds, mutual funds, IRAs, trust funds, money market certificates)
If Yes, amount
Type
Owner
How many cars, trucks or other vehicles do you or anyone in your household have?
Year
Make
Model
Owner
Do you or anyone applying own any property including your own home?
If yes, list property
Owner
Has anyone applying sold, given away or transferred cash or property in the last three months to qualify for SNAP?
LIVING ARRANGEMENTS AND EXPENSES
Check all the descriptions that apply to your household:
Own home or paying for home
Renting
Migrant/seasonal farmworker
No permanent residence
Live with relatives or friends
List expenses:
Monthly rent or mortgage payment
Tax on home per year
Insurance on home per year
Pay separately for Heat?
If yes, specify type of heating:
Gas
Electric
Oil
Wood
Coal
Propane
Other (list)
Heat Co. Name
Heat Co. Acct. No.
Pay for air conditioning, either in your electric bill or as a separate fee?
Pay separately for utilities (other than heating/cooling)? (for example, lights, cooking gas, washer/dryer fees, garbage/trash, water, initial installation of utilities)?
Does anyone else pay any of these expenses for you (some examples are Section 8 or other subsidy program)?
If yes, who pays what?
Do you or does anyone living with you pay court-ordered child support?
If yes, who
Name(s) of child(ren) support is being paid for
Payment amount
Frequency of payments (for example, weekly, bi-weekly, monthly)
Are you, and/or anyone living with you, blind/disabled or at least age 60? If so, does such person have medical bills?
If yes, list on the page 6 what they are for, how much and who is responsible for payment.
Are you, and/or anyone living with you, on Medicaid with a spendown?
If yes, who
Amount
Are you, and/or anyone living with you (16 years old or older) enrolled in school or training?
If yes, who
where
READ THE IMPORTANT INFORMATION BELOW
SNAP PENALTY WARNING – Any information you provide in connection with your application for SNAP will be subject to verification by Federal, State and local officials. If any information is incorrect, you may be denied SNAP. You may be subject to criminal prosecution for knowingly providing incorrect information.
You will never be able to get SNAP again if you are found guilty in a court of law for the second time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP; or found guilty in a court of law of selling or getting firearms, ammunition or explosives in exchange for SNAP; or found guilty in a court of trafficking in SNAP worth $500 or more. Trafficking includes the illegal use, transfer, acquisition, alteration or possession of SNAP, authorization cards or access devices; or found guilty of committing a third Intentional Program Violation (IPV).
You will not be able to get SNAP for two years if you are found guilty in a court of law for the first time of buying or selling controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) in exchange for SNAP.
If you have committed your: First IPV, you will not be able to get SNAP for one year. Second IPV, you will not be able to get SNAP for two years.
A court could also bar you from receiving SNAP for an additional 18 months. If you make a false statement about who you are or where you live in order to get multiple SNAP benefits, you will not be able to get SNAP for ten years (or permanently if this is the third IPV).
You may be found guilty of an IPV if you make a false or misleading statement, or misrepresent, conceal or withhold facts; or commit any act that constitutes a violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of SNAP benefits, authorization cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system.
You could also be fined up to $250,000, sent to jail for up to 20 years, or both.
Anyone who is fleeing to avoid prosecution, custody or confinement for a felony, or who is violating a condition of probation or parole, is not eligible to receive SNAP.
If you get more SNAP benefits than you should have (overpayment), you must pay them back. If your case is active, we will take back the amount of the overpayment from future SNAP benefits that you get. If your case is closed, you may pay back the overpayment through any unused SNAP benefits remaining in your account, or you may pay cash. If you have an overpayment that is not paid back, it will be referred for collection in a number of ways, including automated collection by the federal government. Federal benefits (such as Social Security) and tax refunds that you are entitled to receive may be taken to pay back the overpayment. The debt will also be subject to processing charges.
Any expunged SNAP benefits will be put towards your overpayment. If you apply for SNAP again, and have not repaid the amount you owe, your SNAP benefits will be reduced if you begin to get them again. You will be notified, at that time, of the amount of reduced benefits you will get.
CONSENT – I understand that by signing this application form I agree to any investigation made by the New York State Office of Temporary and Disability Assistance or my local social services district to verify or confirm the information I have given or any other investigation made by them in connection with my request for SNAP. If additional information is requested, I will provide it. I will also cooperate with State and Federal personnel in a SNAP Quality Control Review.
CONSENT FOR RELEASE OF CONFIDENTIAL UNEMPLOYMENT INSURANCE (UI) INFORMATION – I authorize the New York State Department of Labor
(DOL) to release any confidential information, maintained by DOL for Unemployment Insurance (UI) purposes, to the New York State Office of Temporary and Disability Assistance (OTDA). This information includes UI benefit claims and wage records. I understand that OTDA, along with State and local agency employees working in local social services district offices, will use the UI information for establishing or verifying eligibility for, and the amount of, TA, MA, or FS benefits applied for in this application and for investigations to determine whether I received benefits to which I was not entitled.
SUA (STANDARD UTILITY ALLOWANCE) INFORMATION – I understand that SNAP recipients are categorically income eligible for the Home Energy Assistance Program (HEAP). If I am not included in the annual automatic HEAP payment process for certain SNAP recipients, my household intends to apply for a HEAP benefit within the next 12 months. If I decide not to apply for HEAP within the next 12 months, I will let my worker know.
TELEPHONE ALLOWANCE INFORMATION – I understand that SNAP recipients are eligible for a telephone allowance if they pay to use a home phone, cell phone, phone, phone calling card or coin operated pay phone. If I do not have any cost to make phone calls, I will let my worker know.
CHANGES – I agree to inform the agency promptly of any change in my needs, income, property, living arrangement, pregnancy status or address to the best of my knowledge or belief in accordance with my reporting requirements.\
REQUIREMENT TO REPORT/VERIFY HOUSEHOLD EXPENSES – I understand that my household must report child care and utility expenses in order to get a SNAP deduction for these expenses. I further understand that my household must report and verify rent/mortgage payments, property taxes, insurance, medical expenses and child support paid to a non-household member in order to get a SNAP deduction for these expenses. I understand that failure to report/verify the above expenses will be seen as a statement by my household that I/we do not want to receive a deduction for those unreported/unverified expenses. A deduction for these expenses may make me eligible for SNAP or may increase my SNAP benefits. I understand that I may report/verify these expenses at any time in the future. This deduction would then be applied to the calculation of SNAP in future months in accordance with the rules for change reporting and processing changes.
PRIVACY ACT STATEMENT – COLLECTION AND USE OF SOCIAL SECURITY NUMBER (SSN) – The collection of SSN’s is authorized for each household member with respect to SNAP pursuant to the Food Stamp Act of 1977 (as amended, 7 US Code 2011-2036). The information we collect will be used to determine whether your household is eligible or continues to be eligible for benefits. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. The information will be used to check identity, to verify earned and unearned income, and to determine if applicants or recipients can receive money or other help. The information may be disclosed to State and Federal agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
If you or anyone applying/recertifying does not have an SSN, a SSN must be applied for at the Social Security Agency.
CITIZENSHIP/IMMIGRATION STATUS – I swear and/or affirm under penalty of perjury that the information I have provided about the citizenship and immigration status of my self and everyone living with me is true and correct. I understand that any information I provide to verify the immigration status of anyone applying for SNAP may be checked for authenticity with the United States Citizenship and Immigration Services.
For SNAP, citizenship must be documented only if questionable.
NON-DISCRIMINATION NOTICE – In accordance with Federal Law and U.S. Department of Agriculture (USDA) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political belief, or disability. To file a complaint of discrimination write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
LIFELINE: For applicants/recipients of SNAP: The Office of Temporary and Disability Assistance may or may not release your name and address to your telephone service provider. Your telephone service provider may or may not use this information to enroll you in their Lifeline Service for a discounted telephone rate.
If you do not want this information released, check this box
You may contact your telephone service provider directly for enrollment in the discounted rate Lifeline Service.
Medicaid-only applicants/recipients must contact their telephone service provider directly for enrollment in the discounted rate Lifeline Service.
AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to apply for SNAP for you. You can also authorize someone outside your household to get SNAP benefits for you and to use them to buy food for you. If you would like to authorize someone, you must do so in writing. You may do so by printing the person’s name, address and phone number below. When an Authorized Representative is applying on behalf of a SNAP Household that does not reside in an institution, both the Authorized Representative and the SNAP Head of Household or other responsible adult member of the household must sign and date the signature sections at the bottom of this page.
IF YOU WOULD LIKE TO AUTHORIZE SOMEONE, PRINT THE PERSON’S NAME, ADDRESS AND TELEPHONE NUMBER, AND SIGN BELOW.
Name
Address
Phone
CERTIFICATION: I swear and/or affirm under the penalties of perjury that the information I have given or will give to the local
Social Services district is correct. Your signature is required below to complete the application process.
APPLICANT SIGNATURE
DATE SIGNED
Authorized Representative SIGNATURE
DATE SIGNED
IF YOU HELPED COMPLETE THIS APPLICATION / RECERTIFICATION FOR SOMEONE ELSE, PRINT YOUR NAME AND ADDRESS HERE. YOU MAY ALSO VOLUNTARILY PRINT YOUR TELEPHONE NUMBER.
Name
Address
Phone