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Maryland Benefit Review Form Due Now

1. Do you still live at 13604 Monarch Vista Dr Germantown MD 20874 Yes No

If you have selected NO, provide your new address. New address

** ***dal Court Maryland 20886

2. Tell us about the individuals that live with you. Has any individual(s) left the household? Yes No

Name Date of

Birth

Citizenship Marital Status Lives with you? Enter changes or date individual left

PeterCole 1945-12-25 US Citizen Separated Yes No Has any individual moved into your home that is not listed above? Yes No Complete the below section for all household members that are not listed above. Provide proof of identity. (examples: birth certificate, drivers license) Name Date of Birth Citizenship Marital Social Security Relationship Date moved Status Status Number to you into home

If more than 3 individuals moved into your home, please attach another sheet of paper and list any additional household members. Include their name, Date of Birth, SSN, and date the individual moved into your home. 3. Tell us about your shelter costs. Do not pay

Provide proof of all your shelter costs. (examples: lease, rent receipt, mortgage bill, utility bills) Shelter: Rent Ground Rent Mortgage Property Taxes Homeowners Insurance Condo or HOA Fees

$ 1600

$ 0 $ 0 $ $ 0 $

Utilities: Telephone Gas Electric Water Sewage Garbage Oil/Propane/Kerosene Coal/Wood

$ 175 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0 $ 0

Type of Housing? Own FMHA Rent - Section 8 Rent - Subsidized Rent- not section 8 or subsidized 4. Tell us about the household’s total gross earned income. Do you or anyone in your household have a change in your gross earned income with your current employer by more than

$100 (including earnings from self employment)? Yes No Current Employer Details

Household member Employer Name Date job started Monthly Still work here? Date job ended

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Earnings/Amount

Have you or anyone in your household started a new job (including self employment)? Yes No Complete the below section for all new job(s) that are not listed above. New Employer Details

Household member Employer Name Date job started Monthly Earnings Still work here? Date job ended Provide proof of your gross earned income for the past 30 days.(examples: paystubs, employer letter, tax return with schedule C)

5. Tell us about the household’s total gross unearned income. Examples of types of unearned income are SSI, Social Security, Child Support, Unemployment Insurance Compensation, Alimony, Workman’s Compensation, etc.

Do you or anyone in your household have a change in your current gross unearned income by more than $100 ? Yes No

Current Unearned Income Details

Household

member

Income Type Date started Monthly Amount Still receiving this income?

Date when stopped

Peter Cole Benefits/Pensions 2022-06-08 Yes No 2022-11-01 Have you or anyone in your household started receiving unearned income? Yes No Complete the below section for all unearned income that is not listed above. New Unearned Income Details

Household

member

New Income Type Date Started Monthly Amount

Peter

Cole

Benefits/Pension

s

2022-12-01

Peter

Cole

Social Security 2023-05-01

Provide Proof of the unearned income for the past 30 days. (example: award letter) 6. Tell us about the household’s legally obligated child support payment and/or child or adult care expenses. Have you had any changes in the amount you pay for your legally obligated child support payments or your expenses for your child or adult careYes No

Legally Obligated Child Support Payments: $ Child or Adult Care Expense: $

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Provide proof of your monthly legally obligated child support payments and or Child or Adult Care Expenses. (example: court order, receipt, letter from provider)

7. Tell us if anyone in your household is an Able Bodied Adult Without Dependents (ABAWD). An ABAWD is a person between the ages of 18 and 49 who has no dependents and is not disabled. ABAWDs must meet special work requirements to maintain their SNAP eligibility. ABAWD Household Member (s) Employer/Activity # of hours worked per week Do you meet one of the following exemptions for ABAWD? a. Are you 50 years of age or older? Yes No

b. Are you disabled? Yes No

c. Do you have a child under 18 living in your household? Yes No d. Are you receiving any type of disability payment? Yes No e. Have you applied for or are you receiving unemployment benefits? Yes No f. Are you employed/ self-employed and working at least 20 hours per week? Yes No If none of the items apply above you may now be an ABAWD. Complete the section below for all potential ABAWD members. The ABAWD work requirements are as follows:

• Working at least 80 hours per month, averaged to 20 hours per week.

• If self employed, also working at least 80 hours per month, averaged to 20 hours per week. NOTE: Self employed ABAWDs who are working only 20 hours a week must register. Working 20 hours a week meets the ABAWD requirement and the customer is eligible for benefits. Self employed ABAWDs who work 30 hours a week are exempt from work registration

• Participating in and complying with a Workforce Innovation and Opportunity Act (WIOA) program, Trade Adjustment Assistance Act program, or SNAP Employment and Training program (other than job search or job search training program) for 20 hours per week.

• Participating in a work experience program governed by the Fair Labor Standards Act (FLSA) requirements.

• Participating in a Workfare program governed by FLSA requirements.

• Volunteering at a non-profit organization for a minimum of 20 hours per week.

• Any combination of the above for a total of 20 hours per week except Workfare activities governed by the FLSA.

ABAWD Household Member (s) Employer/Activity # of hours worked per week Please Sign Below

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SIGNATURES

I understand that, as required by Maryland law, certain law enforcement agencies that investigate fraud can obtain information about my application, income, benefits, and other documentation as part of their investigation. While access to my application and benefit information is normally limited (under Md. Code Ann. Human Services Article § 1- 201), these limits do not apply to these investigative agencies. Such agencies include the Department of Human Services Office of the Inspector General. I understand that I do not need to provide consent to these agencies in order for them to investigate any allegations of fraud against me. Any information found as a result of the investigation may be used against me if an allegation of fraud is prosecuted. I have read or someone has read and explained the entire application to me. I swear or affirm under penalty of perjury, that all the information I gave is true, correct, and complete to the best of my ability, belief, and knowledge. I received a copy of my rights and responsibilities. I authorize any person, partnership, corporation, association, or governmental agency that knows the facts about my eligibility to give that information to the Department. I authorize the Department to contact any person, partnership, corporation, association, or governmental agency that has given proof of my eligibility for benefits. I authorize the Department to share my information with any person, partnership, corporation, association, or governmental agency that assists the department in providing work, education, or training opportunities that may be available to me. I certify, under penalty of perjury, that by signing my name below, all persons for whom I am applying are U.S. citizens, lawfully admitted immigrants or individuals in satisfactory immigration status.

Customer Signature: Peter Cole or Authorized Representative Signature:

Phone number where you can be reached: Date signed: 05/02/2023 If you have questions or need help filling out this form, please call 1-800-***-****. Please have this letter with your case number ready if you contact us. You can also look at our website mymdthink.maryland.gov for general information.

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Reporting Changes: You must also report all changes in your household circumstances, such as income, resources, health insurance, and household members within ten days of the change. Failure to report these changes may result in cancellation of your eligibility, overpayments, and you may be subject to penalties of fraud. Changes can be reported in person, by mail, or online at https://mymdthink.maryland.gov/. Updating Your Address: It is very important that you notify us if you move. Mail from the Maryland Medical Assistance Program and HealthChoice will not be forwarded to a new address. If we do not have your current address, you will not receive important letters about HealthChoice and continuing eligibility. Address changes can be reported in person, by mail, or online at https://mymdthink.maryland.gov/. Redetermination: Approximately 60 days before the end of your certification, you will receive notification to renew your benefits. After we receive your redetermination, your eligibility will be reviewed. You can complete your redetermination in person, by mail, or online at https://mymdthink.maryland.gov/. If you do not complete this by the established due date, your eligibility will end.

OHEP: Need money to pay your electric and heat bills? If you qualify, the Office of Home Energy Programs (OHEP) can help. For information call 1-800-***-**** or visit us online at ww.dhr.state.md.us/meap/index.htm.

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LANGUAGE ACCESSIBILITY STATEMENT

Interpreter Services Are Available for Free

Help is available in your language:, (MD Relay TTY: 1-800-***-**** or 7-1-1). These services are available for free.

Español/Spanish

Hay ayuda disponible en su idioma: (TTY: 1-800-***-**** or 7-1-1). Estos servicios están disponibles gratis.

አማርኛ/Amharic

እገዛ በ ቋንቋዎ ማግኘት ይችላሉ : (TTY: 1-800-***-**** or 7-1-1) እነዚህ አገልግሎቶች ያለክፍያ የሚገኙ ነጻ ናቸው

/ العربيةArabic

هاتف رقم) 1-800-***-**** برقم اتصل .بالمجان لك تتوافر اللغوية المساعدة خدمات فإن اللغة اذكر تتحدث كنت إذا :ملحوظة 1-800-***-****. ( :والبكم الصم

/文中Chinese

用您的语言为您提供帮助: (TTY: 1-800-***-**** or 7-1-1) 这些服务都是免费的

/ فارسیFarsi

1-800-***-****)ناشنوا افراد تماس خط)1-800-***-**** : کنید می صحبت شما که زبانی به کمک تلفن خط هستند دسترس در رایگان صورت به خدمات این

Français/French

Vous pouvez disposer d’une assistance dans votre langue : (TTY: 1-800-***-**** or 7-1-1).Ces services sont disponibles pour gratuitement.

ગુજર ત /Gujarati

તમ ર ભ ષ મ ં મદદ ઉપલબ્ધ છે: (ટ ટ વ ય: 1-800-***-**** or 7-1-1). સેવ ઓ મફત ઉપલબ્ધ છે kreyòl ayisyen/Haitian Creole

Gen èd ki disponib nan lang ou: (TTY: 1-800-***-**** or 7-1-1). Sèvis sa yo disponib gratis. Igbo

Enyemaka di na asusu gi: (TTY: 1-800-***-**** or 7-1-1). Ọrụ ndị a dị na enweghi ugwo i ga akwu maka ya.

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한국어/Korean

사용하시는 언어로 지원해드립니다: (TTY: 1-800-***-**** or 7-1-1) 무료로 제공 됩니다 Português/Portuguese

A ajuda está disponível em seu idioma: (TTY: 1-800-***-**** or 7-1-1) Estes serviços são oferecidos de graça.

Русский/Russian

Помощь доступна на вашем языке: (TTY: 1-800-***-**** or 7-1-1). Эти услуги предоставляются бесплатно.

Tagalog

Makakakuha kayo ng tulong sa iyong wika: (TTY: 1-800-***-**** or 7-1-1) Ang mga serbisyong ito ay libre.

/اردوUrdu).

) 1-800-***-**** کال ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں بولتے اردو آپ اگر :خبردارTTY: 1-800-***-**** or 7-1-1). کر

Tiếng Việt/Vietnamese

Hỗ trợ là có sẵn trong ngôn ngữ của quí vị (TTY: 1-800-***-**** or 7-1-1). Những dịch vụ này có sẵn miễn phí.

Yorùbá/Yoruba

Ìrànlọwọ wà ní àrọwọtó ní èdè rẹ: (TTY: 1-800-***-**** or 7-1-1). Awon ise yi wa fun o free.

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USDA Nondiscrimination Statement

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex, and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs, reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.) should contact the agency (state or local) where they applied for benefits. Individual who are deap, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at 800-***-****. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint form, AD-3027, found online at: http://www.ascr.usda.gov/complaint_filing_cust.htm at any time or write a letter addressed to USDA and provide in the letter all of the information requested in the form. to request a copy of the complaint form, call 866-***-****. Submit your completed form or letter to USDA by mail, fax or email. Mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW

Washington, D.C. 20250-9410

FAX: 202-***-****

eMail: ad0vla@r.postjobfree.com

For any other information or issue with the Supplemental Nutrition Assistance Program (SNAP), you may contact USDA SNAP Hotline Number at 800-***-**** or call the FNS Information/Hotline number for Maryland 800-***-****. You may access the FNS website for other states hotline number found at http://fns.usda.gov/snap/contact_info/hotlines.htm. To file a complaint of discrimination regarding a program receiving federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office of Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call 202-***-**** (voice) or 800-***-**** (TTY). This institution is an equal opportunity provider.

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Fair Hearing

Any time you disagree with a decision taken on your case, you have the right to request a fair hearing with an official who is required by law to review the facts of every case in a fair and objective manner. You have 90 days from the date of the notice for Supplemental Nutrition Assistance Program (SNAP) benefits and 90 days from the date of the notice for Cash Assistance benefits to request a fair hearing. You can request a hearing by calling the case manager listed on your notice or by calling the Call Center at 1-800-332- 6347. You may have anyone you choose represent you at the hearing or you may represent yourself. If you need free legal help, call your local office or call Legal Aid at 1-800-***-****. What happens to your Supplemental Nutrition Assistance Program (SNAP) and other program benefits while you wait for your fair hearing?

If you request a fair hearing within 10 days from the date of notice and your program certification period has not expired, you can continue to receive benefits unless you opt-out and tell us you do not want them. However, it is important to know that if the case is not decided in your favor, any benefits that you received during this time that you were not entitled to must be paid back. You can opt-out of receiving benefits while you wait for your fair hearing by:

● Checking the box on Question 4 of the Fair Hearing Request form; or

● Notifying your case manager or the Call Center representative who is assisting you request a fair hearing Requesting a Reasonable Accommodation

If you have a disability, you are entitled to reasonable accommodations to help you access DHS’s activities, programs, and services. This applies even if you are working with a vendor who provides services to DHS’s customers. A request can be made any time by you or someone assisting you. The request may be made in person, in writing, or over the telephone. If a reasonable accommodation is needed, speak with your case manager or your local department’s Customer Access Coordinator. You may also request assistance at the front desk of your local department.

Examples of Reasonable Accommodations

● Hearing Impairment: sign language interpreter; providing an assistive listening device

● Visual Impairment: having a qualified reader read to a customer

● Mobility Impairment: mailing forms to a customer; meeting a customer at a more accessible location

● Developmental Disabilities: having things written down; taking breaks; scheduling appointments around a customer’s medical need.

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