Child Care Support
Resume:
Home Phone Number: 785-***-****
Mobile/Cell Phone Number: 785-***-****
Work Phone Number:
Is it ok to call you at work? No
Contact Information:
Email Address: *************@*****.***
I would like to learn that I have important information waiting for me at the message center through: Email
If you select 'Text Message' you may be charged for text messages sent to you. Check with your carrier.
Where are you applying from? Home
Address Line 1: 423 W 8TH ST
Address Line 2:
City: Junction City
State: KS
County: GEARY
Zip: 66441
Address Information :
What is the school district number where you live? 475 Expedite:
PE Determination:
Application Sent To: DCF
Do you want us to send you a voter registration card? Yes No
Applicant's Information:
First Name:
Last Name:
Suffix:
Middle Initial:
Maiden Name:
Donta
Terrell
Miller
Sr.
Miller
Address Line 1:
Address Line 2:
City:
State:
County:
Zip:
Mailing Address (if different):
Office Selection
Your application for Food, Cash, and/or Child Care Assistance will be sent to the service center selected from the list below. If you want your application to be processed at another location, please select a different service center from the list.
Your Physical address as you entered is:
423 W 8TH ST, Junction City, KS, GEARY, 66441
Choose your preferred office location:
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Application Date/Time Stamp: 2022-08-16 14:15:52.321 Page 2 of 21 3325362
Help Completing the Application
Are you filling the application for someone else? No Is someone helping you fill out the application? No Program Information:
CW - TANF
FS - SNAP
Household Members:
First Name MI Last Name Relationship DOB SSN Apply M/F PW Donta Terrell Miller Applicant 05/25/1992 ***-**-**** Yes M Start Application
Expedited Service
If you answer yes to any of the questions below, you may qualify for expedited service. If you qualify for expedited service, you may be able to get your food assistance benefits within 7 days. Expedited benefits cannot be issued until an interview is conducted and you have provided proof of your identity.
Donta Terrell Miller Sr.
Is your total household income this month, before deductions less than $150 and household cash/savings
$100 or less?
Yes
Are your shelter costs (rent/mortgage and utilities) more than your monthly income and resources? No Are any members of your household migrant or seasonal farm workers whose cash and savings is $100 or less?
No
Acknowledgement of TANF Suspicion-based Drug Testing Policy (TANF ONLY) Suspicion-based drug testing is required for Temporary Assistance for Needy Families (TANF) applicants, recipients and payees when there appears to be unlawful use of a controlled substance or a controlled substance analog. I understand that I, or other adults in my household, are required to submit to drug testing if a suspicion of illegal substance use is identified. Donta Terrell Miller Sr.
Signature: Donta Miller
Date: 08/16/2022
Tell Us More
Please give additional information about yourself. Important information about Social Security Numbers- A Social Security Number is required for each person for whom food and cash assistance is requested. If you, without good cause, fail to provide or apply for a Social Security Number, that person will not be able to get benefits. If you are not applying for certain person(s) in your household, you are not required to provide a Social Security Number for that person. We use Social Security Numbers to check income and other information to see who is eligible for assistance. If someone doesn't have a Social Security Number, call 1-800-***-**** or visit www.socialsecurity.gov. Donta Terrell Miller Sr.
Sex: Male
Date of Birth: 05/25/1992
Social Security Number: ***-**-****
Marital Status: Divorced
Are you known by another name? No
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Are you blind or disabled? No
Last grade completed in school: (If applying for Food Assistance only, this is not required.) HS diploma, GED, NEDP Are you attending school? No
Background Information
Please give us additional information about yourself. Telling us your race and/or ethnicity is optional. However, if a Race/Ethnicity option is not selected, one will be selected for you. We are only asking this information for Federal reporting purposes. Answers will in no way affect eligibility or benefits. We ask these questions to ensure that benefits are distributed without regard to race, color, or national origin. Citizenship/immigration status must be provided for all persons for whom you are applying. If you request food and/or cash assistance for a household member who does not meet citizenship/immigration status that person cannot get benefits while the remaining household members who do meet citizenship/immigration status may qualify for benefits. Donta Terrell Miller Sr.
What language do you speak at home? English
What language do you read at home? English
Do you have other communication needs? Not Applicable What city were you born in? kinston
What state were you born in? North Carolina
Are you Hispanic or Latino? No
What is your race? Mark all that apply. Black or African American What is your citizenship or non-citizenship status? US Citizen Job/Wages
Job Information
Next we will ask you some questions about the people in your home who have, or have had a job. Self-employment means that you are your own boss and can include earnings from odd jobs, childcare, lawn mowing, snow removal, cosmetic sales, etc. Donta Terrell Miller Sr.
Has anyone lost or quit a job in the last 60 days? Yes Donta Terrell Miller Sr.
Name of the Company: Interstate glass
Company Phone Number:
Last Day Worked: 07/29/2022
Last Paycheck Received Date: 08/01/2022
Last Paycheck Amount (Before Deductions): 321.94
Do they get tips? No
Does this person get commissions? No
Does this person get bonuses? No
Is anyone currently working (or has been hired but not yet paid)? No Is anyone Self-Employed? No
Other Income
Income Information
In the next few pages we will ask you about the people in your home who may earn or get money. Donta Terrell Miller Sr.
Is anyone getting child support or spousal support? No Is anyone getting Social Security or SSI benefits? No Is anyone getting unemployment benefits? No
Is anyone getting money from family, friends or others? No Page 4 of 21 3325362
Is anyone getting or going to get money from any of these? This includes children. Veterans Administration payments such as Disability, Education, Aid and Attendance Railroad Benefits
Retirement
Other pension or disability
Legal or Insurance settlements/ court actions pending Trusts or annuities
Contract Sales
Oil Royalties/Mineral Rights
Rental Income
Strike Pay/Benefits
Per capita payments or Tribal payments
Workers Compensation
Training Allowances
Other
No
Resources
Resources Information
In the next few pages we will ask you about the people in your home who have resources.Check the boxes if anyone in the home has that resource.
Donta Terrell Miller Sr.
Has anyone sold, traded, given away or changed ownership of any property such as a house or money, or any other property in the last 90 days?
No
Does anyone own a home? Is anyone buying a home or other property such as land, buildings, or mobile homes?
No
Does anyone own a vehicle? No
Does anyone have any cash, stocks, bonds or bank accounts? Cash
Checking account
Savings account
Credit Union account
Certificate of Deposit (CD)
Money Market
Stocks/Bonds
Other Accounts
No
Does anyone have any retirement plans?
Pension
IRA, Keough, or 401(K)
Deferred Compensation Plan
Annuity
Other Retirement plan
No
Does anyone have any of these types of property?
Life Insurance
Life Estate
Burial/Funeral Plan
Oil/Mineral Rights
Trust Fund
Promissory note or loan
Reverse mortgage
Other Property
No
Does anyone have any of these types of personal property? Boats, 3-Wheelers, off-road vehicles, snowmobiles, mobile homes, campers or trailers Business equipment, inventory, etc.
LivestockOther property
No
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Expenses
Expense Information
In the next few pages we will ask you about the expenses of the household. Donta Terrell Miller Sr.
Is your household responsible for paying any of the following Rent
Lot Rent
Mortgage
Property taxes
Homeowner's insurance
Medical expenses for persons 60 and older or disabled Yes
Donta Terrell Miller Sr.
Housing Expense Type: Rent
How much does the household pay for rent? 900
How often? Monthly
Landlord Name: Na
Landlord Address: Na
Landlord City: Junction city
Landlord State:
Landlord Zip: 66441
Landlord Phone:
Do you get help with your rent from Section 8, HUD, or others? No Is your household responsible for paying any of the following Child or Dependent Care
Child Support
Yes
Donta Terrell Miller Sr.
Child Expense Type: Child Support
How much does the household pay for child support? 77 Are the payments court ordered or voluntary? Voluntary How often? Monthly
Does the household have Heating and/or Cooling expense? Yes Help with Expenses
Finally, we would like to ask if the household has received any help paying for expenses. Donta Terrell Miller Sr.
Did your household receive LIEAP at this address in the past year? No Does anyone outside the household help pay for the household's expenses? No Other
Authorized Representative
You can have someone fill out your application, answer questions for you or give information at your interview. This person will be your authorized representative. We will be able to share information with this person. * Red Asterisk indicates a required field. Donta Terrell Miller Sr.
Do you want to name someone to be your authorized representative? No Safety
The answers to the following questions will be kept confidential and will not affect your eligibility. Donta Terrell Miller Sr.
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Are you or your children currently being threatened, hurt or harmed in some way by someone? No Do you need assistance now because working, looking for a job, or going to school may put you or your children in danger of physical, emotional or sexual abuse? No
Do you need assistance now because you are having a hard time dealing with past abuse? No Have you spent time trying to deal with or escape from someone who was threatening, hurting, or harming you or your children?
No
If you have been a victim of domestic violence or sexual assault in the last 5 years, you may be eligible for special considerations and services. Would you like to find out about available services and have a confidential interview?
No
Self-Disclosure
The following questions are required if you are applying for food assistance and/or cash assistance. If you answer yes to any of these questions, the person listed may not be able to get benefits: Donta Terrell Miller Sr.
Have you or any member of your household been convicted of buying or selling food assistance benefits of
$500 or more after September 22, 1996?
No
Are you or any member of your household fleeing to avoid prosecution, custody, or jail for a crime that is a felony?
No
Are you or any member of your household violating a condition of probation or parole? No Have you or any member of you household been convicted of trading food assistance benefits for drugs after September 22, 1996?
No
Have you or any member of your household been convicted of trading food assistance benefits for guns, ammunitions, or explosives after September 22, 1996? No
Have you or any member of your household been convicted of fraudulently getting food or cash assistance benefits from two places at the same time after September 22, 1996? No
For cash assistance, have you or any member of your household been convicted of a drug related felony on or after July 1, 2013?
No
Does anyone in your household have a felony drug related conviction on or after August 22, 1996? No Has anyone in your household been convicted of one of more of the following crimes after February 7, 2014? (1) Aggravated sexual abuse (2) Murder (3) Sexual exploitation and other abuse of children (4) Sexual assault.
No
Facilities and Shelters
In the next few pages we will ask you additional questions about the people in your household. Donta Terrell Miller Sr.
Does anyone live in any of these places?
Shelter for Battered Women
Drug/Alcohol Rehabilitation Center
Correctional Facility/Penal Institution
Psychiatric Hospital/Mental Institution
Assisted Living Facility
Hospital or Nursing Home
Group Home for Persons with Disabilities
College Dormitory
No
Other Information
In the next few pages we will ask you additional questions about the people in your household. Donta Terrell Miller Sr.
Does everyone live in Kansas? Yes
Does anyone own, lease or maintain a home outside of Kansas? No Is anyone currently getting public assistance from Kansas or another state? No Is there anyone planning to leave the home for more than 180 days? No Page 7 of 21 3325362
Have you, or any member of your household, served in the U.S. military? No Are you the spouse or widow of someone who served in the U.S. military? No Are you, or any member of your household, in the U.S. Military? No Do any household members get benefits from the Food Distribution Program on Indian Reservations? No Page 8 of 21 3325362
SUBMIT APPLICATION
Optional Release Of Information For Food Assistance You do not have to sign this, but it will help us get information we need to help you, without having to get your signature on specific request.
You should know that:
• We may need more information to decide if you can get assistance.
• If more information is needed from you, you will get a letter telling you what we need and the date you must get it to us.
• You are responsible to get the information or ask us for help to get it.
• If you do not give us the information or ask for help by the due date, your application may be denied or your assistance may stop.
• We may be able to use the release below to get the information we need. But you still have to provide the information we request or ask us for help.
• We may attach a copy of this release to a form that asks other people or organizations (like your employer) for specific information needed about you or others in your household. Provide your electronic signature below to give us permission to get needed information. Release of Information:
I hereby authorize any person or organization give the Kansas Department for Children and Families requested information about me or other members of my household. A copy of this release is as valid as the original. This release does not apply to protected health information This release is good for 12 months from the date signed. Your Signature:Donta T Miller
Other Adult Signature:Donta T Miller
Date:08/16/2022
Page 9 of 21 3325362
Rights and Responsibilities
Processing times for your application are:
• within 30 days for child care and food assistance;
• within 45 days for cash.
If you are eligible, benefits will start from the date a signed application is received in the DCF office. You may be able to get food assistance within 7 calendar days if you qualify. We will let you know if you qualify for this special processing. The following information applies to all programs: Your Responsibilities
You have a responsibility to:
• Provide all information needed to determine your eligibility;
• Report changes as required - we will tell you what must be reported;
• Turn alimony and child support payments over to DCF if you receive TANF cash assistance, and cooperate with Child Support Services (CSS) if you receive TANF cash assistance, child care assistance, or food assistance;
• Pay your child care provider for services;
• Cooperate with Quality Assurance staff if your case is reviewed; and
• Look for a job and participate in work related services, starting from the date that you apply for TANF cash assistance.
DCF Rights
DCF has a right to:
• The collection of this information, including the social security number (SSN) of each household member, is authorized under the Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036. The information will be used to determine whether your household is eligible or continues to be eligible to participate in SNAP. 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. This information will also be used to make sure you are getting the correct amount of benefits. For Child Care assistance only, SSN is voluntary.
• Verify the alien status of applicant household members by submitting information from the application to the U.S. Citizenship and Immigration Service (USCIS). The information received may affect the household’s eligibility and amount of benefits.
• Deny benefits to your household if you do not provide requested information;
• Disclose the information on your application to other federal and state agencies for official examination, and to law enforcement officials for the purpose of arresting people who are running from the law;
• Refer the information on this application to federal and state agencies, as well as private claims agencies, for claims collection if overpayments arise against your household;
• Conduct a full investigation of your eligibility including contacting employers, child care providers, banks, doctors, or by visiting your home;
• Deny your application or prosecute you for fraud if you knowingly give us false information so you can receive assistance.
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Your Rights
You have a right to:
• Have an interpreter provided at no cost if English is not your primary language
• Have information given to DCF kept confidential, unless directly related to the administration of DCF programs
• Withdraw your application at any time
• Request a fair hearing within 30 days for cash assistance and child care assistance, or within 90 days for food assistance if you disagree with the decision. For food assistance, you may request a fair hearing verbally or in writing. Your case may be presented by a household member or by a representative such as legal counsel, a relative, a friend or other spokesperson
• Know that if you apply for food assistance benefits, your application for food assistance may not be denied solely because benefits have been denied for other programs
• Have your benefits determined from the date this application is received by DCF
• Special considerations and confidential services, if looking for a job or pursuing child support puts you in danger of domestic violence or sexual assault.
CIVIL RIGHTS PROVISION:
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 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.ascr.usda.gov/complaint_filing_cust.html, 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: *******.******@****.***
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at 800-***-****, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: https:// www.fns.usda.gov/snap/contact_info/hotlines.htm
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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 for 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. Page 12 of 21 3325362
Penalties
Families may lose benefits for not cooperating with the following agency programs: I. Work Programs - looking for work, preparing for employment and keeping a job. (Does not apply to child care.)
A. For TANF cash assistance, the following penalties apply for failure to cooperate with work Programs without good cause:
1st Penalty
Your family will not get TANF cash assistance benefits for a minimum of 3 months. 2nd Penalty
Your family will not get TANF cash assistance benefits for a minimum of 6 months. 3rd Penalty
Your family will not get TANF cash assistance benefits for a minimum of 1 year. 4th and subsequent penalties
Your family will lose TANF cash assistance benefits for a period of 10 years. To get your TANF cash reopened, you must reapply and the penalized individual must cooperate with Employment Services. These penalties will not carry forward if children in your family become adult TANF cash recipients.
B. For Food Assistance, a comparable penalty as described above will be applied only against the person who failed to cooperate. The rest of the food assistance household can get benefits if otherwise eligible. Eligibility will be redetermined at the end of the penalty period. II. Child Support Services - establishing a child's paternity and collecting child support. A. For TANF cash assistance and, child care assistance, the following penalties apply for failure to cooperate with Child Support Services without good cause: 1st Penalty
Your family will not get TANF cash assistance or child care benefits for a minimum of 3 months. 2nd Penalty
Your family will not get TANF cash assistance or child care benefits for a minimum of 6 months. 3rd Penalty
Your family will not get TANF cash assistance or child care benefits for a minimum of 1 year. 4th and subsequent penalties
Your family will lose TANF cash assistance or child care benefits for a period of 10 years. To get your TANF cash and/or child care assistance reopened, you must reapply and the penalized individual must cooperate with Child Support Services. B. For food assistance, any adult household member who fails to cooperate with Child Support Services without good cause will be ineligible for food assistance benefits until DCF determines the household has cooperated. The rest of your food assistance household can get benefits if otherwise eligible.
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III. Fraud Penalties
A. Food Assistance - Any member of your household who breaks any of the following rules on purpose can be barred from the food assistance program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. The individual may also be subject to prosecution under other applicable Federal and State laws and may also be barred from the food assistance program for an additional 18 months, if court ordered.
• Do not lie or hide information to get benefits that your household should not get.
• Do not use, or have in your possession, Kansas Benefits Cards that are not yours.
• Do not trade or sell Kansas Benefits Cards.
• Do not use food assistance benefits to purchase nonfood items, such as alcohol or cigarettes, or to pay on credit accounts.
If you make false or misleading statements and you are found guilty of misrepresentation, or committed any act that constitutes a violation of food assistance, food assistance regulations, or any State statute for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of food assistance benefits or EBT cards, you will not be able to get food assistance benefits:
• For 1 year if your misrepresentation was about something other than identity or residence and it is your first program violation;
• For 2 years if your misrepresentation was about something other than identity or residence and it is your second program violation;
• For 10 years if your misrepresentation was about where you live or who you are in order to get duplicate benefits;
• Permanently if your misrepresentation was about something other than identity or residence and it is your third program violation.
Your food assistance eligibility will be suspended for 2 years for the first offense if you trade benefits for controlled substances such as drugs. You will be permanently disqualified for the second offense. You will lose food assistance permanently if you:
• Trade food assistance benefits for firearms, ammunition or explosives;
• Trade, buy, or sell food assistance benefits for $500 or more;
• Traffic food assistance benefits, including but not limited to:
• Buying, selling, stealing or exchanging benefits for cash;
• Buying soda, water, or other items in a container to get the cash deposit;
• Buying an item with food assistance and then purposely selling the item for cash; and/or
• Trading cash for items paid for with food assistance benefits. In all of these cases, the remainder of your food assistance household can get benefits if they are otherwise eligible, and the rest of the household will still be responsible for repaying the amount of any benefits overpayment that was received by the person disqualified. B. TANF cash assistance and child care assistance - If you or any adult member of your TANF or child care household intentionally break any of the following rules or are otherwise found to have committed fraud (civil, criminal or administrative), in either TANF or child care, all adults in your household are permanently ineligible for TANF cash and child care assistance.
• Do not lie, make misleading statements, or hide information or fail to report changes as required to get benefits that your household should not get. Page 14 of 21 3325362
• Do not use, or have in your possession, Kansas Benefits Cards that are not yours.
• Do not trade or sell Kansas Benefits Cards.
• Do not use TANF cash assistance or transact your Kansas Benefits Card in any liquor store, casino, gambling casino or gaming establishment, jewelry store, tattoo parlor, massage parlor, body piercing parlor, spa, nail salon, lingerie shop, tobacco paraphernalia store, vapor cigarette store, psychic or fortune telling business, bail bond company, video arcade, movie theater, swimming pool, cruise ship, theme park, dog or horse racing facility, parimutuel facility, or sexually-oriented business or any retail establishment that provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment or in any business or retail establishment where minors under age 18 are not permitted.
• Do not use your TANF cash assistance benefits to buy alcohol, cigarettes, tobacco products or lottery tickets, concert tickets, professional or collegiate sporting events tickets, or tickets for other entertainment events intended for the general public or sexually oriented adult materials.
• Do not use your TANF cash assistance benefits for purchases outside of the state of Kansas.
The remainder of your TANF or child care household can get benefits if they are otherwise eligible. Adults in the household will still be responsible for repaying the amount of any benefits overpayment that was received by the person disqualified. A protective payee must be assigned to access your TANF benefits. You and any member of your household may not access your TANF benefits.
IV. Drug Felony Convictions
In a TANF cash assistance household, any individual who is convicted of a state or federal felony offense occurring on or after July 1, 2013, which includes as an element of such offense the manufacture, cultivation, distribution, possession or use of a controlled substance or controlled substance analog is ineligible for TANF cash assistance for five years from the date of the conviction for a first offense. A second drug-related felony conviction will result in that individual being ineligible to receive TANF cash assistance for his/her lifetime. In a food assistance household, any individual who is convicted of a felony offense occurring on or after August 22, 1996 which includes as an element of such offense the manufacture, cultivation, distribution, possession or use of a controlled substance or controlled substance analog, will be ineligible to receive food assistance benefits until the individual participates in an approved drug treatment program and submits and passes an approved drug testing plan. A second drug-related felony conviction will result in that individual being ineligible to receive food assistance for his/her lifetime.
The remainder of your food assistance or TANF cash assistance household can get benefits if they are otherwise eligible.
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Suspicion-based Drug Testing
Kansas requires any adult TANF
Contact this candidate