Tracking Number: 315-***-**** Case Number: *B*PSL*

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Rights & Responsibilities

What I Should Know

PLEASE KEEP THIS FOR YOUR INFORMATION.

By completing and signing the State of Colorado Application for Public Assistance and other documents required to determine whether I'm eligible for public assistance benefits AND by accepting benefits that I am eligible to receive, I understand the following information and agree to the following requirements:

I must tell the truth; it is a crime to lie on this application. I may have to give papers that show what I've told you is true. I may have to tell you of any changes to the information I gave you on my application. If I think you made a mistake, I can ask for an appeal or fair hearing. The department will not discriminate.

The department will confirm citizenship and immigration status for everyone applying for benefits.

The department will tell you if your benefits change. The department or relevant federal agency will take back any benefits you should not have received.

Single game cash lottery or gambling winnings: For SNAP, I must report single game cash lottery or gambling winnings by any adult household member that are equal to, or greater than, $3500 before taxes or other amounts are withheld. These winnings will disqualify the entire SNAP household. For Cash Programs, Health First Colorado and Child Health Plan Plus, I must report any single game cash lottery or gambling winnings. These winnings may be considered a form of unearned income for my household. The Department of Health Care Policy and Financing (HCPF) is the state agency responsible for Medical Assistance Programs in Colorado such as Health First Colorado (Colorado Medicaid). The County Departments of Human/Social Services and Medical Assistance Sites are agencies that receive and process applications for all public assistance programs. In this statement, the term "department" is used to refer to all agencies. I must give the department all needed proof and documents before qualifying for benefits. The information I give on the application and in the application interview is confidential. However, the department can use or share the information with other program(s) that any of my family and/or household members are getting or are applying for. The information can only be used for purposes of treatment, payment, determining eligibility, and other program and administrative operations, or other purposes permitted by law for my family and/or household members or me. Additionally, this information may be disclosed to other Federal and State agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. It will also be determined if the information is factual. If any information is incorrect, SNAP may be denied and the applicant may be subject to criminal prosecution for knowingly providing incorrect information. Tracking Number: 315-***-**** Case Number: 1B7PSL8

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It is a crime to lie on the application or to take benefits that I know that my family and I are not eligible to receive and I may be subject to criminal prosecution for knowingly providing false information. Giving false information may be punished by a fine of up to $250,000 or a jail term of up to 20 years, or both. A person found to have intentionally given false information cannot get SNAP and/or Cash Programs for 12 months for the first offense, 24 months for the second offense, and permanently for the third offense. A court can also stop a person from getting SNAP for another eighteen months. I understand that any household member who breaks any of the rules on purpose can also be:

Barred from SNAP for one year to permanently, fined up to $250,000, imprisoned for up to 20 years, or both.

Barred from SNAP for an additional 18 months if court-ordered. Subject to prosecution under other applicable Federal and State laws. Receiving duplicate benefits of SNAP by lying about identity or residence will result in a ten (10) year disqualification for the first offense, a ten (10) year disqualification for the second offense and a permanent disqualification for the third offense. If I omit or provide any information (other than lying about identity or residence) that leads to duplicate benefits being issued, I can be disqualified for 12 months for the 1st offense, 24 months for the 2nd offense and permanently for the 3rd offense. A person convicted by a court or whose disqualification was obtained through an Intentional Program Violation (IPV) waiver for misrepresenting their residence in order to obtain assistance in two states at the same time will have their Colorado Works assistance denied for ten

(10) years.

If I am receiving SNAP, I must report if anyone in the household age 18 years or older has been convicted on or after 2/7/2014 and is not in compliance with the terms of their sentence of the following: aggravated sexual abuse, murder, sexual exploitation and or abuse of a child (ren) or sexual assault.

I know I have 30 calendar days to report any change to Connect for Health Colorado if I am receiving Advance Premium Tax Credits, Reduced Co-Pays or Deductibles, or I am enrolled in a Qualified Health Plan. If my family is enrolled in multiple insurance affordability programs, I must report changes to each organization in the appropriate time frame. I understand that a change in information could affect my eligibility and eligibility of member(s) of my household.The department will notify me in writing of how and when to tell the department of any changes. If I am receiving Cash Programs, I know that I must tell the organization providing the assistance if information I listed on this application changes by the 10th of the month following the change. I am aware I have 10 calendar days to report any changes if I am enrolled in Health First Colorado or Child Health Plan Plus (CHP+). Changes are to be reported to my local county office for Health First Colorado or to CHP+. I am responsible for paying fees, premiums and co-payments for myself and my family if they are required for Medical Assistance benefits.

If I do not tell the truth on my application or if information is left off of the application, or if I do not report changes to the department, as required, I may lose my assistance, and I may have to pay back the department for the assistance received when I was not eligible. If I have to pay back money to the department, I understand that state or federal salaries, rebates, or tax refunds that would be received by me or another person on this application may be taken.

Tracking Number: 315-***-**** Case Number: 1B7PSL8

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The law says the department must check the immigration status and citizenship for anyone who is applying. They will not check immigration status of family members who are not applying for benefits. I may be requested to verify proof of non-citizen registration documentation received from the United States Citizen and Immigration Service (USCIS) for every non-citizen member in my house who is applying for benefits. The department will verify information with USCIS and any information received from USCIS may affect my eligibility and benefits. Federal law (Public Law 97-98) requires me to give the department the Social Security number and/or alien registration number of all persons who are applying for public assistance. I must also provide the Social Security number and/or alien registration number for all sponsors. For Adult Financial and Colorado Works programs, sponsor information will be confirmed with USCIS and the information received from USCIS may affect sponsor repayment for my eligibility and benefits. My sponsor and I may be responsible for reimbursing the state for benefits that I receive. The following applies to all qualified non-citizens applying for Cash Programs: As a condition of my eligibility for financial assistance programs I agree that, during the time I am receiving such assistance, I will not sign an Affidavit of Support to sponsor a non-citizen who is seeking permission to enter or remain in the United States. I understand that any Affidavit of Support signed prior to July 1, 1997 does not affect my eligibility for assistance. If I do not agree, I will no longer be eligible for financial assistance from the State of Colorado.

I do not have to be a U.S. citizen to apply for assistance. Please do not let the fear about immigration status stop you from seeking benefits for your family. If I am a resident of an institution and jointly applying for SSI and SNAP prior to leaving the institution, the filing date of the application is my date of release from the institution. Processing time will begin from the date the application is received in the SNAP office.

Privacy Act Information: The department is authorized to collect information on the application, including Social Security numbers and will confirm information that may affect initial or ongoing eligibility and payments for all persons listed on my application. I am allowing the department to use Social Security numbers (SSN) and other information from my application to request and receive information or records to confirm the information in my application. SNAP will be denied to individuals that do not provide a Social Security number, and Social Security numbers will be used and disclosed in the same manner for both eligible and ineligible members. I release the department from all liability for sharing this information with other agencies for this purpose. For example, the department may get and share information with any of the following agencies: Social Security Administration; Internal Revenue Service; United States Customs and Immigration Services; Colorado Department of Labor and Employment; financial institutions (banks, savings and loans, credit unions, insurance companies, landlords, leasing agents, etc.); child support services; employers; courts; and other federal or state agencies; and for SNAP, law enforcement officials for the purposes of apprehending persons fleeing to avoid the law. If a SNAP, Colorado Works, and/or Adult Financial over-payment occurs against my household, the information on this application, including all Social Security numbers, may be referred to Federal and State agencies, as well as private claims collection agencies for claims collection action.

Tracking Number: 315-***-**** Case Number: 1B7PSL8

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The EBT (or Quest) card is used to pay me most of my public assistance benefits. I cannot trade or sell EBT cards. The only people allowed to use my household’s EBT card are members of my household, my authorized representative(s), and individuals outside my household that have my permission to use my EBT card to access benefits for the people in my household. I cannot use my EBT card to access my cash benefits at locations identified as prohibited locations including licensed gaming establishments, in-state simulcast facilities, tracks for racing, commercial bingo facilities,stores or establishments in which the principal business is the sale of firearms, retail establishment licensed to sell malt, vinous, or spirituous liquors, establishments licensed to sell medical marijuana or medical marijuana-infused products, or retail marijuana or retail marijuana products, establishments that provide adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment. Continued misuse of my EBT card at prohibited locations will cause my cash benefits to be suspended on my EBT card and/or my cash benefits to be terminated for a period of 30 days requiring a new application. I can name someone or an organization to be my representative. I must do this in writing. The person and/or organization I designate to be my authorized representative may help me apply for assistance, get my benefits, and use my benefits to buy food for me. I may name one person to help me with each separate task or I may name one person to help me with all of these tasks.

If I think the department made a mistake, I can ask for a Fair Hearing. The department will tell me in writing how to make an appeal. I can ask for a Fair Hearing either verbally or in writing. My case may be presented by a member of my household or my representative, such as legal counsel, friend, or relative. I may request an appeal for any action on any program except for the CHP+ program If I think the CHP+ program made a mistake, I can ask for an appeal. CHP+ tells me about how to make an appeal in writing.

Colorado Works is not an entitlement program and benefits are not guaranteed. To remain eligible, I may be required to complete an assessment and develop a plan. Unless exempted, I will be required to participate in work readiness activities As an applicant for Colorado Works, if I refuse to cooperate with Child Support Services at the time I apply or while receiving cash assistance through Colorado Works, without good cause, I will not receive assistance or a basic cash assistance grant for my family. Good cause for not working with Child Support can be, but is not limited to; potential physical or emotional harm to a child(ren), parent or caretaker relative; pregnancy or birth of a child related to incest or forcible rape;legal adoption before court or a parent receiving pre-adoption services; or other reasons determined to be in the best interest of the child. In order to cooperate with Child Support Services, I will be required to complete additional documentation concerning the child(ren), parentage of the child(ren) and provide all court documents that concern the child(ren).

If I am an adult between the ages of 18 and 52, with no children under the age of 18 in my SNAP house, I will only be eligible to receive SNAP benefits for three months, unless one of the following applies: I work in a job 80 hours each month and report my hours worked to my local Employment First office, or I meet the Workfare program requirements or work program requirements set by the Employment First office.Additionally, I may continue to receive my SNAP benefits if I am determined to be physically or mentally unable to work or if the SNAP office identifies other Tracking Number: 315-***-**** Case Number: 1B7PSL8

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applicable exemptions. If I meet any of these criteria, I will be able to continue receiving SNAP as long as I remain eligible.

I understand and agree that to receive SNAP, certain members of the household need to register for work. This means that certain members of the household must: A) Report to the Employment First (work program) when the SNAP office schedules an appointment. B) Comply with the instructions the Employment First (work program) gives including reporting for all scheduled appointments and following through on the written agreements signed.C) Provide information to the SNAP office or the Employment First (work program) about any jobs me or my household member(s) get while on SNAP. D) Tell the SNAP office or the Employment First (work program) if me or my household member(s) are not able to work – I will be asked to provide verification; work any workfare hours assigned; go to job interviews arranged for me or my household member(s). Anyone who does not follow the work requirements may be disqualified from receiving SNAP.

I must cooperate fully with state and federal staff if my case is reviewed. My information on this application may be reviewed and confirmed by the department, or its representatives. My household will not be eligible for SNAP if I refuse to cooperate with any review of my case, including a quality control review. I cannot use SNAP benefits to buy nonfood items, such as alcohol or cigarettes. I can be disqualified for using SNAP to pay for items purchased on credit. If a court of law finds a person guilty of using SNAP benefits to illegally purchase or receive controlled substances that individual shall be disqualified for two years for a first offense and permanently for a second offense.Individuals found by a Federal, State, or local court to have used or received benefits in a transaction involving the sale of firearms, ammunition, or explosives shall be permanently ineligible to receive SNAP upon the first occasion of such violation. If a court of law finds a person guilty of having trafficked benefits for an aggregate amount of $500 or more, that individual will be permanently ineligible to receive SNAP upon the first occasion of such violation. The trafficking of benefits means:

a. The buying, selling, stealing, or otherwise effecting an exchange of SNAP benefits issued and accessed via Electronic Benefit Transfer (EBT) cards, card numbers and personal identification numbers (PINs), or by manual voucher and signature, for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone ; or,

b. The exchange of SNAP benefits or EBT cards for firearms, ammunition, explosives, or controlled substances; or,

c. A SNAP participant, including the participant’s designated authorized representative, who knowingly transfers SNAP benefit to another who does not, or does not intend to, use the SNAP benefits for the SNAP household for whom the SNAP benefits were intended; or

d. The reselling of food that was purchased with SNAP benefits for cash; or e. Obtaining a cash deposit when returning water or other containers that were purchased with SNAP benefits. Purchasing water containers is an eligible food item that can be paid for with SNAP benefits; however, when the container is returned, the deposit should be returned to the client’s EBT card and not given to the client in cash. f. Attempting to buy, sell, steal, or otherwise affect an exchange of SNAP benefits issued and accessed via Electronic Benefit Transfer (EBT) cards, card numbers and personal identification numbers (PINs), or by manual voucher and signatures, for cash Tracking Number: 315-***-**** Case Number: 1B7PSL8

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or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone.

If I do not report and provide proof of mortgage, housing fees, property insurance, property taxes, court ordered child support payments, child or adult care, and medical expenses paid by people in my household who are elderly or who have a disability, I am stating that I do not want that specific deduction used to determine my SNAP benefit amount.

I can ask for SNAP apart from asking for benefits from other programs. My eligibility for SNAP will be determined apart from any other programs. The SNAP office shall process all SNAP applications in accordance with SNAP timeliness, noticing, and fair hearing requirements, even if I am applying for other programs. Colorado residents who have a qualifying disability, such as persons receiving SSI or SSDI benefits, or residents who are at least 65 years of age (or a surviving spouse age 58 or older) might also qualify for a Property Tax/Rent/Heat Rebate from the Department of Revenue. Visit www.TaxColorado.com and click on the PTC button at the top of the page or call 303-***-**** for details. I understand the Department is authorized to collect and process my household information and confirm that information through federal databases that verify the information. Everyone on my form has given me permission to share and submit their information and to receive communications about their eligibility and enrollment. I will immediately notify the State of any medical claim or lawsuit I have. I will cooperate with the State in collecting the medical bills the State has paid. The state may collect from any insurance company or court settlement for medical bills that the State has paid. If I am on Medical Assistance and receive money for the same medical bills that the State has paid, I will give the money to the State. I assign to the State all rights to payment for medical expenses and treatment. I also assign my right to appeal a denial of benefits by another party responsible for payment for the benefits to the State.

Federal and Colorado state law require the Department of Health Care Policy and Financing to recover all medical assistance benefits, including capitation payments, paid on behalf of Health First Colorado clients from the estates of deceased Health First Colorado clients who were permanently institutionalized. For Health First Colorado clients who were over the age of 55 when benefits were provided, the Department recovers payments for nursing facility services, home and community-based services, and related hospital and prescription drug services. There are certain exemptions to estate recovery. For further information, please contact your county and request the “Medical Assistance Estate Recovery Program” brochure. CCCAP Authorization to Supply Information

Authorization to Supply Information

I hereby authorize the County Department of Social/Human Services, in the course of administering the social services program, to supply information to any of the entities listed below. I release the county department from any and all liability for supplying such information.

Tracking Number: 315-***-**** Case Number: 1B7PSL8

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Any child care provider I may choose to use;

Any employer for whom I currently work or have worked; Any school or training institution I may be attending; Any housing authority; and/or,

Any other information that may be pertinent to my application for or receipt of public assistance programs including Head Start and Early Head Start. CCCAP Authorization to Release Information

I authorize the persons, agencies, or institutions entered below to supply information to the County Department of Social/Human Services concerning my application for or receipt of social services. I also allow inspection and reproduction of records in their possession pertaining to me by any authorized representative of the county department. I release the person, agency, or institution from any and all liability for supplying such information. Any child care provider I may choose to use;

Any employer for whom I currently work or have worked; Any documentation submitted for self-employment;

Any school or training institution I may be attending; Any housing authority; and/or

Any other information that may be pertinent to my application for or receipt of public assistance programs including Head Start and Early Head Start. USDA Nondiscrimination Policy

Do Not Send Applications Here

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at 800-***-****. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: Tracking Number: 315-***-**** Case Number: 1B7PSL8

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https://www.usda.gov/sites/default/files/documents/USDA-OASCR%20P-Complaint-Form-0508-00 02-508-11-28-17Fax2Mail.pdf, from any USDA office, by calling 833-***-****, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to: 1. mail:

Food and Nutrition Service, USDA

1320 Braddock Place, Room 334

Alexandria, VA 22314; or

2. fax:

833-***-**** or 202-***-****; or

3. email:

ad0edt@r.postjobfree.com

This institution is an equal opportunity provider. Do Not Send Applications Here

Medical Assistance Nondiscrimination PolicyThe Department of Health Care Policy and Financing and Connect for Health Colorado do not discriminate on the basis of race, color, ethnic or national origin and expression, marital status, religion, creed, political beliefs, or disability in any of its programs, services and activities. For further information about the Department’s policy, to request free disability and/or language aids and services, or to file a discriminating complain, contact: 504/ADA Coordinator, 1570 Grant St., Denver, CO 80203, Phone: 303-***-****, Fax: 303-***-****, State Relay: 711, Email: ad0edt@r.postjobfree.com . For information about Connect for Health Colorado’s policy, aids and services or to file a discrimination complaint, contact: General Counsel, 3773 Cherry Creek N. Dr., Suite 1005, Phone: 303-***-****, Fax: 303-***-****. Complaints can also be filed with the U.S Department of Health and Human Services Office for Civil Rights at http://www.hhs.gov/ocr/filing-with-ocr/index.html . For Other Programs: For information about the Colorado Department of Human Services policies, to request free disability and/or language aids and services, or to file a discrimination complaint, contact: 504/ADA Coordinator, 1575 Sherman St Denver, CO 80203, Phone: 303-***-****, Fax: 303-***-****, State Relay: 711, Email: ad0edt@r.postjobfree.com . For additional information please visit www.colorado.gov/cdhs . Civil rights complaints can also be filed with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf or by mail, phone, or fax at: 1961 Stout Street Room 08-148 Denver, CO 80294, Telephone: 800-***-****, Fax: 202-***-****, TDD: 800-***-****. Complaint forms are available at https://www.usda.gov/sites/default/files/documents/USDA-OASCR P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf . Domestic violence information and services are available to me. If I ever feel I am in immediate danger I should call 911. If I would like to receive information regarding safety Tracking Number: 315-***-**** Case Number: 1B7PSL8

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and services in Colorado, I will call the Colorado Coalition Against Domestic Violence at 303-***-**** or toll free at 1-888-***-****. I may also find the location of services near me by going to www.colorado.gov/cdhs/dvp .The National Domestic Violence Hotline at 1800799SAFE (7233) or TTY 1-800-***-**** or www.thehotline.org can also provide information. If I am a survivor of domestic violence, sexual assault, or stalking, the Address Confidentiality Program (ACP) can provide me with a legal substitute address to use instead of my physical address for use with state and local government agencies. I can find out more about the ACP at acp.colorado.gov . If I need or receive either of these services, I should tell my department worker.

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