Postal Service
Resume:
State of Alabama
Department of Human Resources
Food Assistance Application
AGENCY USE ONLY:
Expedite Screening: Entitled Yes No
Screener Signature and Date
FS Case Number
Check digit Processing standard
Name
IEVS Function
PA Case No.
Appointment Date Time Date Received
1
EXPEDITED SERVICES
You may get food assistance benefits within 7 calendar days if your food assistance household has less than $150 in monthly gross income and liquid resources (cash, checking or savings accounts) of $100 or less; or your rent/mortgage and utilities are more than your household’s combined monthly income and liquid resources; or a member of your household is a migrant or seasonal farm worker. Failure to answer the questions on this application may result in our inability to determine your eligibility for expedited services. 1. How much money do the members of your household have in cash or in a bank account? $ 2. What is the total amount of income you expect your household to receive this month? 3. What is your current monthly rent/mortgage payment? $ Utilities other than phone? $ 4. Is anyone in your household a migrant or seasonal farm worker? Yes No If yes, answer these questions: Did all of your household income stop recently? Yes No Does anyone in your household expect to receive income from a new source this month? Yes No If yes, how much?
Have you or anyone in your household received or do you expect to receive Food Assistance benefits from any other county in Alabama or any other state this month? Yes Where No Did anyone in your household receive food assistance last month? Yes No Have you or anyone in your household been convicted by a state or federal court of making a fraudulent statement about your identity or residency in order to receive food assistance in more than one state at the same time? Yes No If yes, member’s name Have you or any member of your household been convicted of a felony under Federal or State law for possession, use or distribution of a controlled substance (felony drug conviction) after August 22, 1996? Yes No Have you or any member of your household been convicted of buying or selling food assistance benefits over $500? Yes No Have you or anyone in your household received lottery or gambling winnings of $3,750 or more this month? Yes No If you are a resident of an institution, and file a joint application for SSI and food assistance before leaving the institution, if eligible, you will receive benefits from the date you were released from the institution. YOUR NAME (First, Middle, Last)
Mailing Address
Signature Date Birth date (Month, Day, Year)
Street Address, if different
City County State Zip Daytime Phone
Social Security Number**
(Applicants Only)
Food Assistance Case Number
**Providing a SSN for each household member is voluntary. However, failure to provide a SSN for each household member will result in disqualification of that member. Your household’s eligibility for food assistance benefits will be determined separately from any other programs and will not be denied solely because benefits from other programs have been denied. Your application for food assistance will be processed in accordance with Food Assistance Program regulations; timeliness, notice, and fair hearing requirements, even if you apply for other programs. DHR-FSP-2116 (12/21)
Check here if you prefer a telephone interview or a face-to-face interview.
Telephone Interview
or
Face-to-Face Interview
● You have the right to file an application the same day you contact your county office.
● To file an application, you need only complete your name, address, and signature.
● Mail, fax, e-mail or take this application to the Food Assistance Office in the county where you live. You may also apply online at www.dhr.alabama.gov. If eligible for food assistance, you will receive benefits from the date we received your signed application.
● To get the address or phone number of your local county office, call toll free: 1-833-***-**** or online at www.dhr.alabama.gov . Do you need help filling out this application due to disability? Do you need an interpreter? Do you need translated materials? If yes, please ask for help at your local Food Assistance Office. Individuals who are deaf, hard of hearing or have speech disabilities can call 1-833-***-**** using the Alabama Relay Service at 711 or 1-800-***-****
(TTY) for assistance contacting your local Food Assistance Office. 2
Household Members
INSTRUCTIONS: Please print clearly. Please list everyone who lives in your household and answer all questions for each household member that you are asking to get food assistance benefits. You only have to give social security numbers (SSN) and citizenship/immigration information for those household members that you are asking for food assistance benefits. You will have to give information such as income for household members who are not seeking benefits to determine if the persons for whom you are applying are eligible to receive benefits.
(Use another sheet of paper to add members if there is not enough spaces below.) Some of the things you should bring to your interview include: proof of identity (driver’s license, birth certificate), proof of income (check stubs, award letter, child support statement, signed statement from person that gives you money), and proof of expenses (rent receipts, mortgage, property tax, house insurance premium, day care receipts, child support orders and receipts, and medical bills for disabled and aging members). If you have expenses that you do not report and/or provide proof of, you will not receive the deduction for the expense. We will tell you what we need to finish your application during your interview. Name Age Relation to you
Does this person give you or anyone listed
above any money?
YES or NO. If Yes, reason?
Does this person pay any part of the
household bills?
YES or NO. If Yes, reason?
*This information is voluntary. List all races that apply only if the person is asking for benefits. Your benefits will not be affected if you donʼt answer the ethnicity or race items (the agency will choose for you if you do not answer). Giving us this information will help ensure program benefits are distributed without regard to race, color, or national origin.
**Providing a SSN for each household member is voluntary. However, failure to provide a SSN for each household member will result in disqualification of that member.
***Providing citizenship/immigration information is voluntary. Failure to provide this information for each household member will result in disqualification of that member. List below any other people who live in the same house with you but you do not want included in your food assistance household because they do not purchase and prepare food with you. (Use another sheet of paper to add members if there is not enough space for everyone here.) Authorized Representative
You may appoint someone outside your household to act for your household, to make an application and to be interviewed. This person should know your household’s situation well enough to give any information needed to determine your eligibility for food assistance. You are still responsible for the information that anyone acting as your authorized representative gives, including any information that may be incorrect. If you want to appoint someone for this, write his/her name here: Voter Registration
IF YOU ARE NOT REGISTERED TO VOTE WHERE YOU LIVE NOW, WOULD YOU LIKE TO APPLY TO REGISTER TO VOTE HERE TODAY?
Yes, I would like to register to vote. Yes, I am registered but would like to change my address for voting purposes. No, I do not want to apply to register to vote. If you do not check either box, you will be considered to have decided not to register to vote at this time. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help in filling out the voter registration form, we will help you. You may seek assistance with the application form by seeking assistance at the time of your interview or by calling your local Department of Human Resources located within your county. The decision wheth- er to seek or accept help is yours. You may fill out the application form in private. If you choose to apply to register to vote or if you decline to register to vote, the information on your application or declination form will remain confidential and will be used for voter registration purposes only. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Secretary of State at State Capitol, 600 Dexter Avenue Suite E-208, Montgomery, Al 36130 or by calling 334-***-**** or 1-800-274-VOTE (1-800-***-****). Name
First, Middle, Last
Social Security
Number**
(SSN)
Date
of
Birth
Month
Day
Year
Relation
to you
Working In
school
Sex
M/F
Ethnicity*
Hispanic/
Latino or
Non-Hispanic
HISP NON
(Optional)
Race*
White
Asian
Black or
African American
Native Hawaiian or
Other Pacific
Islander
American Indian or
Alaskan Native
(Optional)
U.S. ***
Citizen
Yes or No
(Applicants
(Applicants Only) only)
Self
Yes or
No
Yes or
No
3
DO NOT REMOVE. This page must be returned to your county office with pages 1 and 2. To get the address or phone number of your local county office, call toll free: 1-833-***-**** or online at www.dhr.alabama.gov Penalty Warnings, Perjury Statement and Signature
When your household receives food assistance benefits, you must follow all the rules. You must provide true and complete information about everyone in your household and you must provide documents to prove what you say if you are asked to by the worker. Any member of your household who breaks any of these rules on purpose can be barred from SNAP for 1 year for first offense, 2 years for second offense, and permanently for third offense; fined up to $250,000, imprisoned up to 20 years or both; and subject to prosecution under other federal laws. She/he may also be barred from the Food Assistance Program for an additional 18 months if court ordered. DO NOT give false information, or hide information to get or continue to get SNAP benefits. DO NOT trade or sell EBT cards. DO NOT alter EBT cards to get SNAP benefits you are not entitled to receive. DO NOT use SNAP benefits to buy ineligible items such as alcohol and tobacco or to pay on credit accounts. DO NOT use someone else’s SNAP benefits or EBT card for your household. Individuals determined by a court to have committed the following program violations will be subject to the following penalties:
● If you are found to have used or received benefits in a transaction involving the sale of a controlled substance, you will be ineligible to receive SNAP benefits for a period of two years for the first offense and permanently upon the second such offense.
● If you are found to have used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you will be permanently ineligible to receive SNAP benefits upon the first occasion of such violation.
● If you have been found guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently ineligible to receive SNAP benefits upon the first occasion of such violation.
● If you have been found to have made a fraudulent statement or representation with respect to your identity or place of residence in order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the program for a period of 10 years.
● If you are fleeing to avoid prosecution, custody, or confinement, after conviction for a crime or an attempt to commit a crime, which is a felony, or are in violation of probation or parole imposed under a federal or state law, you are ineligible for food assistance.
● If you are convicted of using or receiving food assistance benefits in a transaction involving the sale of a controlled substance, you will be ineligible 24 months for the first violation and permanently for the second violation.
● If you are convicted of a federal or state felony that has an element the possession, use, or distribution of a controlled substance, you may be ineligible for food assistance.
I certify under penalty of perjury that my answers to all questions about each household member, including those about citizenship or alien status, are correct and complete.
Household member signature or mark (X): Date Witness if signed by mark: Date USDA Nondiscrimination Statement
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or 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. Individuals who are deaf, 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.usda.gov/oascr/how-to-file-a-program- discrimination-complaint, and at any USDA office, 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:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
(2) fax: 202-***-****; or
(3) email: *******.******@****.***.
This institution is an equal opportunity provider. 4
State of Alabama Agency-Based Voter Registration Form FOR USE BY U.S. CITIZENS ONLY FILL IN ALL BOXES ON THIS FORM PLEASE USE INK PRINT LEGIBLY To register to vote in the State of Alabama, you must:
Be a citizen of the United States.
Live in Alabama.
Be at least 18 years of age on or before election day.
Not have been convicted of a disqualifying felony, or if you have been convicted, you must have had your civil rights restored.
Not have been declared "mentally incompetent" by a court. NVRA-1B-H
City State ZIP
Current
City
Old
Addresses
Home Address (include apartment or other unit number if applicable) Mailing Address, if different from Home Address
Former Address
Print Your Name:
Print Maiden Name / Former Name (if reporting a change of name) Primary Telephone Email Address
White Black
Asian American Indian
Hispanic Other
I am a U.S. citizen
I live in the State of Alabama
I will be at least 18 years of age on or before
election day
I am not barred from voting by reason of a
disqualifying felony conviction (The list of
disqualifying felonies is available on the
Secretary of State's web site at:
sos.alabama.gov/mtfelonies)
I have not been judged "mentally incompetent"
in a court of law
YOUR SIGNATURE
If you falsely sign this statement, you can be convicted and imprisoned for up to five years. Voter Declaration - Read and Sign Under Penalty of Perjury Date of Birth (mm/dd/yyyy)
Race (check one)
Sex (check one) Place of Birth
11
12 Map / Diagram 13 Did you receive assistance?
If your home has no street number or name, please draw a map of where your house is located. Please include roads and landmarks. If you are unable to sign your name, who helped
you fill out this application? Give name, address, and phone number (phone number is optional).
City County State Country
County
Address where you live:
(Do not use post office box)
Address where you
receive your mail:
Address where you were
last registered to vote:
(Do not use post office box)
REGISTRARS USE ONLY
County Pct
City Pct
DATE APPROVED DENIED
Board member
Board member
Board member
Alabama Driver's
License or Non-
Driver ID Number:
Yes
No Yes
Are you a citizen of the United States of America? No Will you be 18 years of age on or before election day? Å ATTENTION! If you answer "No" to either of these questions, do not complete this application.
STATE NUMBER
Last four digits of Social
Security number:
IF YOU HAVE NO ALABAMA DRIVER'S LICENSE
OR ALABAMA NON-DRIVER ID NUMBER
Â
Ê
I solemnly swear or affirm to support and
defend the constitution of the United States
and the State of Alabama and further disavow
any belief or affiliation with any group which
advocates the overthrow of the governments
of the United States or the State of Alabama
by unlawful means and that the information
contained herein is true, so help me God.
The decision to register to vote is yours. If you decide to register to vote, the office at which you are submitting this application will remain confidential and will be used only for voter registration purposes. If you decline to register to vote, your decision will remain confidential and will be used only for voter registration purposes. John H. Merrill - Secretary of State Questions? Call the Elections Division at 1-800-***-**** or 334-***-**** ID requested: You may send with this application a copy of valid photo identification. You will be required to present valid photo identification when you vote at your polling place or by absentee ballot, unless exempted by law. For more information, go to www.AlabamaVoterID.com or call the Elections Division: 800-***-****. Å
First Middle Last Suffix
I do not have an Alabama driver's license or Alabama non-driver ID or a social security number.
(mm/dd/yyyy)
DATE(mm/dd/yyyy)
Female Male
First Middle Last Suffix
City State ZIP
State ZIP
2019.06.27
FOR USE BY AGENCY OFFICIAL ONLY
Check one (1) box:
Registrars
Motor Voter
State Designated Agency
Agency-Based
Disabilities Services Office Business Phone of Agency Representative Signature of Agency Representative
6
IMPORTANT INFORMATION ABOUT FOOD ASSISTANCE
You have the right to have your application acted on within thirty days without regard to race, sex, religion, national origin, age, handicap or political belief. You have the right to know why your application is denied, or your benefits reduced or terminated. You have the right to request a conference or fair hearing either orally or in writing if you are not satisfied with any decision of the county department. You have the right to be represented by any person you choose. You have the right to examine your food assistance case file in relation to any hearing you may have.
You have the right to confidentiality. The use or disclosure of information will be made only for certain limited purposes allowed under State and Federal laws and regulations. Information may also be disclosed to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
The information provided in connection with this application will be subject to verification by Federal, State and local officials to determine if such information is true. If any information is found to be untrue or incorrect, food assistance benefits may be denied to the applicant and the applicant may be subject to criminal prosecution for knowingly providing incorrect information. Any person authorized to act on behalf of the household may be barred from participation as a representative for up to one year or may be subject to fines and/or prosecution if s/he breaks any rules on purpose.
If a food assistance claim arises against your 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. SOCIAL SECURITY NUMBERS: The collection of a Social Security Number (SSN) for each household member is authorized under the Food & Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036, to determine eligibility for food assistance. The Social Security Number will be used in the administration of the Food Assistance Program to check the identity of household members to prevent duplicate participation and to facilitate making changes. Your SSN will also be used in computer matching and program reviews or audits to make sure your household is eligible for food assistance. This may result in criminal or civil administrative claims against persons fraudulently participating in the Food Assistance Program. Providing a SSN for each household member is voluntary. However, failure to provide a SSN for each household member will result in disqualification of that member. You will still have to give information such as income for this member. VERIFICATION: To determine eligibility, you may have to provide documents to prove what you have stated on the application. If you are unable to provide proof, you may request help from your worker. The information given on this application will be checked by using the State Income and Eligibility Verification System, other computer matching systems, program reviews and audits. This includes such information as receipt of Social Security benefits, Unemployment benefits, unearned income such as interest and dividends, and wages from employment. When discrepancies are found, verification of this information may be obtained through contact with a third party such as employers, claims representatives or financial institutions. This information may affect your eligibility and level of benefits. In addition, any information given may also be checked by other Federal Aid Programs and Federally Aided State Programs such as school lunch, Family Assistance, and Medicaid. If you give false information on purpose, legal or administrative action may be taken against you. You may have to repay food assistance benefits that you receive to which you are not entitled. Some elderly and/or disabled household members are allowed certain medical expenses as a deduction if these expenses are reported and proof of the expense is provided to us. Allowable medical expenses include expenses such as the following: prescription drugs, hospital and nursing home bills, doctor, dentist, or other health care professional visits, over the counter medication prescribed by a doctor, Medicare premium, hospital insurance premium, insurance for prescription drug coverage, transportation expenses for travel to doctors, hospitals, drugstores such as amount charged for transportation or for the number of miles driven in your personal vehicle, medical appliances or equipment such as hearing aids, wheelchairs, artificial limbs, eye glasses, contact lenses, dentures, etc., attendant care or homemaker services, service animal expenses such as animal food and veterinary care. CITIZENSHIP AND IMMIGRATION STATUS: Citizenship/immigration information is used to determine eligibility for food assistance. Only U. S. citizens and eligible immigrants may participate in the Food Assistance Program. Any household member who is not a citizen or permanent resident alien may be left out of your food assistance household. Providing citizenship/immigration information is voluntary. Failure to provide this information for each household member will result in disqualification of that member. You will still have to give information such as income for this member. The Food Assistance Division will check with U. S. Citizenship and Immigration Service (USCIS) on all non-citizens that you are asking to get food assistance benefits. We will not check on the non-citizens you choose not to include in your food assistance household.
You will be ineligible for benefits if you refuse to cooperate in completing the application process or in subsequent reviews of eligibility including reviews resulting from reported changes, recertification, or as a part of a State or Federal Quality Control Review. Your signature on the application will serve as authorization for State and Federal Quality Control Reviewers to verify your household circumstances for food assistance eligibility purposes. You or any member of your household may be disqualified from receiving benefits if you or the member voluntarily quits a job or reduces the number of hours worked without good cause.
Your household will not receive an increase in food assistance benefits if anyone in the household fails to comply with the requirements of another income based (means tested) program such as Family Assistance. You are not to use food assistance benefits to buy ineligible items such as alcoholic drinks or tobacco or pay on credit accounts. Continued on page 2
DEPARTMENT OF HUMAN RESOURCES
Food Assistance Program
Summarized Eligibility Requirements
If you have difficulty communicating with us because you do not speak English or have a disability, we can provide free language assistance or other aids and services to assist you. These services are available by phone or in person upon request. Households applying for or receiving food assistance benefits must meet all applicable eligibility requirements based on food assistance policies. Time limits and requirements of other programs do not affect a householdʼs eligibility for food assistance benefits. A household may still qualify for food assistance benefits even if eligibility ends in another program. Households must cooperate with the agency in establishing eligibility for food assistance. Failure to meet these requirements can result in a denial or termination of the food assistance case. TECHNICAL REQUIREMENTS
1. Household Members. The food assistance household is composed of individuals who live together and purchase and prepare their meals together for home consumption. Certain individuals, such as spouses and children under age 22, must be included in one food assistance household regardless of their method of buying food and preparing meals. 2. Strikers. Households with striking members shall be ineligible to participate in the Food Assistance Program, unless the household was eligible for benefits the day before the strike and is otherwise eligible at the time of application. However, the household shall not receive an increased allotment as a result of a decrease in income of the striking household member(s). 3. Citizenship and Alien Status. Citizenship/immigration information is used to determine eligibility for food assistance. Only U.S. citizens and eligible aliens may participate in the Food Assistance Program. Any household member who is not a citizen or permanent resident alien may be left out of your food assistance household. Providing citizenship/immigration information is voluntary. The Food Assistance Division will check with the U. S. Citizenship and Immigration Service (USCIS) only for those household members that you are asking for food assistance benefits. We will not check on the non-citizens you do not include in your food assistance household but their income may count in determining the eligibility and food assistance allotment for the other people included in the food assistance household. Failure to provide this information will result in ineligibility (no benefits) for these members.
4. Social Security Numbers. The collection of a Social Security Number (SSN) for each household member is authorized under the Food
& Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036, to determine eligibility for food assistance. The Social Security Number is used in computer matching and program reviews or audits to make sure the household is eligible for the food assistance benefits it receives. The SSN will be used to check the identity of household members to prevent duplicate participation and to facilitate making changes. Providing a social security number for each household member is voluntary. However, failure to provide a SSN for each household member will result in disqualification of that member. You will still have to give information such as income for this member. The household must furnish a Social Security Number for each household member that you are asking for food assistance benefits. If a household member does not have a number, s/he must apply for one. 5. Residence. Households must apply for food assistance in the county in which they live. They cannot receive food assistance in more than one county or state in a month.
6. Work Requirements. Unless exempt from work registration, each member of your household must meet the following work requirements:
● must be registered for work
● must not quit a job voluntarily
● must not voluntarily reduce hours at a job
● must accept a suitable job that is offered. (The job must be 30 hours weekly or equal to 30 hours X minimum wage). If a non-exempt member of your household fails to meet work requirements, [s]he cannot get food assistance. This could reduce or stop your household’s food assistance.
Able-Bodied Adults Without Dependents (ABAWDs)
People between the ages of 18 and 49 (under age 50) who have no children and are not disabled must meet other special work requirements if they want to get food assistance. Federal law calls these people “Able-Bodied Adults without Dependents,” or “ABAWDs.” They may have to work in order to get more than three months of food
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