Applicant for Illinois ABE Benefits (SNAP) Verification

Location:

Chenoa, IL

Salary:

0pen

Posted:

February 10, 2026

Contact this candidate

Resume:

**Do not mail this information. Your application was submitted electronically.**

Thank you for using ABE to apply for benefits!

Dawn Sargeant, your application was submitted on October 17, 2023 at 03:51 P.M. If your application was received outside of normal business hours, your application date will be the next business day. Mailing Address

Your application tracking number is T27242736. You will need this number to check the status of your application.

You may also need to give your worker proof of some of the things you told us in your application. We will send you a letter with a list of the items you need to provide in order for us to process your application. Once you have gathered the items, you can fax, mail or bring them to the office listed above. If you cannot find something, your worker may be able to help you get the proof you need.

Application Summary

Here is a summary of what you told us, as well as important information about your rights and responsibilities. Office Information

Original Suggested Office: McLean County FCRC, 72

Office of Choice: McLean County FCRC, 72

Basic Information

McLean County FCRC

501 W WASHINGTON

BLOOMINGTON IL 61701-3809

Phone Number: 309-***-****

Your Name Date of Birth Gender Language Preference County Dawn Sargeant 10/24/1977 Female McLean

Where You Live Mailing Address

410 W.Owsley St.

Chenoa, IL 61726

410 w. Owsley St.

Chenoa, IL 61726

How many days a month you live at this address? 31 Currently homeless?

Contact Information

Home Phone 815-***-****

Work Phone

Cell Phone 815-***-****

Alternate Phone 815-***-****

ABE Application for Benefits Eligibility Page 1 http://abe.illinois.gov Expedited SNAP Screening

People In Your Home

You have told us that there is/are 2 person(s) in the household. Best way to get in touch during weekday Home Phone Phone Type (if Deaf or Hard of Hearing)

Best time to call during weekday Early Afternoon

Phone for Text Reminders Cell Phone

Email Address *************@*****.***

Application Programs Requested

SNAP

Healthcare Coverage

Are you getting SNAP benefits this month? No

Are you residing in a shelter for abused women?

Total amount of income your household will get this month $2260.00 Total value of your household's resources $7.00

Total amount your household will pay for housing this month $2400.00 Total amount of child support expenses paid by members of your household this month

$0.00

Countable income for your household this month $2260.00 Did anyone receive a payment of $21 or more this month or in any of the last 12 months from the Low Income Home Energy Assistance Program

(LIHEAP), (in Chicago paid through CEDA)?

Utilities your household will pay for this month Heat/Air Conditioning, Non-Heat Electric, Water/Sewer, Telephone,

Garbage Removal

Is anyone in your home a migrant or seasonal farmworker? No ABE Application for Benefits Eligibility Page 2 http://abe.illinois.gov Person

Dawn Sargeant

Age: 45

Date of Birth Gender Marital Status Language

10/24/1977 Female Never Married

Benefit Selection Medical Benefit choice

SNAP Yes No

Healthcare Coverage - Ongoing Yes No

Backdate Month 1 SEP Yes No

Backdate Month 2 AUG Yes No

Backdate Month 3 JUL Yes No

Family Planning Program Yes No

Cash Assistance Yes No

Medicare Savings Program Yes No

No Preference

Is this person planning to file taxes this year?

SSN SSN Application

Date

US Citizen?

***-**-**** Yes

In the military or spouse or child of

person in the military?

Ethnicity Race

White

Is this person a

resident of Illinois?

Job commitment or looking for work? Migrant or Seasonal Farm Worker?

Yes No No

Where does he/she live? Moved and received assistance from another state?

In this Home N/A

ABE Application for Benefits Eligibility Page 3 http://abe.illinois.gov Questions About the People In Your Home

Tax Information

Person

Joseph P Grabon

Age: 47

Date of Birth Gender Marital Status Language

07/18/1976 Male Never Married English

Benefit Selection Medical Benefit choice

SNAP Yes No

Healthcare Coverage - Ongoing Yes No

Backdate Month 1 SEP Yes No

Backdate Month 2 AUG Yes No

Backdate Month 3 JUL Yes No

Family Planning Program Yes No

Cash Assistance Yes No

Medicare Savings Program Yes No

No Preference

Is this person planning to file taxes this year?

SSN SSN Application

Date

US Citizen?

***-**-**** Yes

In the military or spouse or child of

person in the military?

Ethnicity Race

White

Is this person a

resident of Illinois?

Job commitment or looking for work? Migrant or Seasonal Farm Worker?

Yes No No

Where does he/she live? Moved and received assistance from another state?

In this Home N/A

Person Pregnant

during last 3

months?

Blind or

Disabled?

Convicted of a

Drug Felony?

Drug

Treatment

Program?

Violation of

Parole/Probation?

Getting Other

SNAP

Benefits?

Dawn Sargeant

Age: 45

No Yes No No No No

Person Pregnant

during last 3

months?

Blind or

Disabled?

Convicted of a

Drug Felony?

Drug

Treatment

Program?

Violation of

Parole/Probation?

Getting Other

SNAP

Benefits?

Joseph P

Grabon

Age: 47

No No No No No No

Person Will they be claimed as a

tax dependent?

Name of the Tax Filer Relationship with the tax

filer:

Dawn

Age: 45

No No N/A

ABE Application for Benefits Eligibility Page 4 http://abe.illinois.gov Relationship Information

Blind or Disability Information

Additional Household Information

Healthcare Coverage Information

Joseph

Age: 47

No No N/A

Person

Joseph Grabon

Age: 47

Relationships Do they buy food and eat

meals together?

Can they buy food or meals

separately?

is Not related to Dawn(Age: 45) Yes Yes

Person Has the SSA

made an official

decision for

blindness?

Date became

blind

Has the SSA

made an official

decision for

disablility?

Date became

disabled

Does this person

need help with

activities of daily

living through

personal

assistance

services, a

nursing home, or

other medical

facility?

Dawn Sargeant

Age: 45

No Waiting for

Decision

05/28/2022 No

Person

Dawn Sargeant

Age: 45

Is Victim of Domestic Violence? No

Is going to an Alcohol and Drug

Treatment program?

Is working with Rehabilitation

services?

Is caring for a child, spouse or other

person with disability in the home?

Has Healthcare coverage? No

Person

Joseph Grabon

Age: 47

Is Victim of Domestic Violence? No

Is going to an Alcohol and Drug

Treatment program?

Is working with Rehabilitation

services?

Is caring for a child, spouse or other

person with disability in the home?

Yes

Has Healthcare coverage? No

ABE Application for Benefits Eligibility Page 5 http://abe.illinois.gov You have told us that no one we asked about has this Healthcare Coverage other than Medicaid. Disability

You have told us that no one we asked about is receiving disability benefits but has applied or been denied. Liquid Resources - Cash

You have told us that no one we asked about has this type of resource. Checking Account Information

Person

Dawn

Age: 45

Value Account Number

$1.00

Bank Name Bank Address

Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

Person

Joseph

Age: 47

Value Account Number

$1.00

Bank Name Bank Address

Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

ABE Application for Benefits Eligibility Page 6 http://abe.illinois.gov Savings Account Information

ABE Application for Benefits Eligibility Page 7 http://abe.illinois.gov Person

Dawn

Age: 45

Value Account Number

$1.00

Bank Name Bank Address

Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

Value Account Number

$1.00

Bank Name Bank Address

Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

Value Account Number

$1.00

Bank Name Bank Address

Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

Value Account Number

$1.00

Bank Name Bank Address

ABE Application for Benefits Eligibility Page 8 http://abe.illinois.gov Other Liquid Resource Information

You have told us that no one we asked about has this type of resource. Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

Value Account Number

$0.00

Bank Name Bank Address

Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

Person

Joseph

Age: 47

Value Account Number

$1.00

Bank Name Bank Address

Other Owners

Has the resource been sold/given away within the last 60 months? No

Please print this

screen now to save

the list of the

documents you

uploaded.

Person Value Date

ABE Application for Benefits Eligibility Page 9 http://abe.illinois.gov Vehicle Resource Information

Real Property Information

You have told us that no one we asked about has this type of resource. Burial Resource Information

You have told us that no one we asked about has this type of resource. Life Insurance Information

You have told us that no one we asked about has this type of resource. Additional Resource Information

You have told us that no one we asked about has this type of resource. Person

Joseph

Age: 47

Type Year Make Model

Other Vehicles 1998 Dodge Van

Fair Market Value How much owed?

$1500.00 $0.00

Other Owners

Type Year Make Model

Other Vehicles 1998 Dodge Van

Fair Market Value How much owed?

$1500.00 $0.00

Other Owners

Type Year Make Model

Other Vehicles 1998 Dodge Van

Fair Market Value How much owed?

$1500.00 $0.00

Other Owners

ABE Application for Benefits Eligibility Page 10 http://abe.illinois.gov Other Resource Summary Questions

Job Income Information

Current or Recent Job Information

You told us that no one in your home has this kind of income, benefit, or bill. Self Employment Information

Other Information Questions

Additional Information

Dawn

Age: 45

Bring/

Buy

Food?

Buys

Unifor

ms/Sp

ecial

Tools?

Cost

purcha

sing

meals,

unifor

ms,

and

tools

Freque

ncy of

purcha

sing

meals,

unifor

ms,

and

tools

Transp

ortatio

n type

to and

from

work

Miles

per

day to

and

from

work

Bus

Fare to

and

from

work

Expens

amount

0.00

< click

here to

choose

0.00 Expens

amount

0.00

If other, daily

cost of

transportation

to and from

work

Pays union dues, group life

insurance premiums, group

health insurance premiums, or

retirement plan with-holdings?

Monthl

Amou

Expense

amount0.00

Expens

amount

0.00

Person In School? Highest Grade

Completed?

Type Of School College, University or

Vocational School

Dawn

Age: 45

Full time GED Program

Joseph

Age: 47

Not in school

Person Does anyone applying

receive or has anyone

applied for services

through the Department on

Aging's Community Care

Program?

Former Foster Care Status Adoption Subsidy

Payments

Dawn

Age: 45

No No No

Joseph

Age: 47

No No No

ABE Application for Benefits Eligibility Page 14 http://abe.illinois.gov Interview Status No

Reason unable to come to interview Problems with health, transportation or ongoing severe weather.

Comments

Dawn is not working. Workman's comp case. Waiting on my disability application is in for review. Joe helps pay all bills for Dawn that's it. Dawn can only do house work. And takes care of self getting ready for the day. ABE Application for Benefits Eligibility Page 15 http://abe.illinois.gov l

Electronic Attestation

I have agreed to submit this application by electronic means. By submitting this application electronically, I declare under penalties of perjury that my answers are correct and complete to the best of my knowledge and belief. I also declare the following:

I understand the questions and statements on this application. I have read and understand my Rights and Responsibilities in the box above. I understand the penalties for giving false information. I understand that upon verification of my information, this attestation will have the same legal effect and can be enforced in the same way as a written signature.

By checking this box and typing my name below, I am electronically attesting to the information in the application. Dawn M Sargeant

Healthcare Coverage Rights and Responsibilities

Read Carefully - These are your Rights and Responsibilities as an applicant for Healthcare benefits. 1. We will keep what you tell us private as required by law. Be sure to answer the questions correctly. We may check all information on your application. You must help us if we ask you to prove that your information is correct. 2.

We will use the information you provided as well as information from other sources such as Social Security benefits, unemployment insurance, unearned income and wages from employment to decide if you qualify. 3.

You agree the state may seek reimbursement for services the state covered for your family if those services should have been paid for by any other health coverage your family may have. 4.

If we pay medical bills for you, you give your right to collect medical support payments to the State of Illinois. You must help us if we ask you to establish parentage or obtain medical support payments for members of your family. You may not have to do this if you have a good reason not to. Your children can get health insurance even if you do not help us when we ask you to help. 5.

You must apply for other financial benefits for which you may qualify such as Social Security Benefits or Unemployment Insurance.

We will not share any information about immigration of any person who does not have an Alien Registration Number. We will verify the immigration status of any person if you gave us their Alien Registration Number. To do that, we will check the number with the U.S. Citizenship and Immigration Service (USCIS). We may send other information to USCIS, such as copies of proof you sent of an Alien Registration Number and the person's Social Security Number, if they have one.

If you are seeking benefits as a person with a disability, you authorize staff at the Department of Human Services (DHS) to obtain information from your records or copy your records from the Social Security Administration (SSA) with respect to any claims for disability benefits and all related appeals. You certify that you understand that the materials requested may be protected under state and federal privacy laws. You authorize release of any material protected under state and federal privacy laws to the staff of DHS. 8.

9. Some families or individuals have to make a payment each month for this health insurance. This payment is ABE Application for Benefits Eligibility Page 16 http://abe.illinois.gov SNAP Rights and Responsibilities:

Read carefully before signing this application. Ask your caseworker to explain anything you do not understand.

Because the SNAP program requires a social security number (SSN) for every member of your household who is applying for SNAP benefits, we are explaining how your SSN is used by DHS. What does DHS do with your Social Security Number? The SSN will be used in the administration of the SNAP program to check the identity of household members, prevent duplicate participation, and to facilitate making mass changes. If you or any member of your household wants to apply for SNAP benefits, but does not have a SSN, we can help you to apply for one. The SSN will be used in computer matching and program reviews or audits and to make sure the household is eligible for SNAP benefits, other federal assistance programs, and federally assisted state programs, such as school lunch, TANF, and Medicaid. DHS secures and uses information about all clients through the income and eligibility verification system (IEVS). This includes such information as receipt of social security benefits, unemployment insurance, unearned income and wages from employment. When information does not match, we may contact a third party, such as employers, claims representatives or financial institutions to verify the information. This information may affect your eligibility for assistance and the amount of assistance provided. This may result in criminal or civil action or administrative claims against persons fraudulently participating in the SNAP program. We do not require a social security number for any member of your household who is not eligible for the SNAP program or who does not wish to apply. called a premium. The amount of the premium depends on the family's income. Some families or individuals have to pay part of the bill when they visit the doctor, go into the hospital or get a prescription filled. These payments are called co-payments. The amount of the co-payment depends on the family's income.

10.

You must report changes within 10 days if any of the following happens: Your income changes.The number of people in your family who live with you changes.Your address or phone number changes.Someone who gets health benefits moves out of Illinois, dies, or goes to jail or prison.Someone becomes covered by other insurance.

11.

You understand that anyone who knowingly misuses the medical card issued by or on behalf of the State of Illinois may be committing a crime.

12.

You understand that if you have given false information or intentionally failed to disclose information, you may be subject to civil prosecution, criminal prosecution or both. 13.

14. You may withdraw your application or cancel your benefits at any time. The State of Illinois does not discriminate on the basis of race, color, national origin, sex, age, or disability, religion or political belief. The State of Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. 15.

If you are not satisfied with the actions taken on your application, you have the right to a fair hearing. You can ask for a fair hearing by calling 1-800-***-**** (TTY: 1-877-***-****), by writing to the Department of Human Services, Bureau of Hearings, at 401 South Clinton Street, 6th Floor, Chicago, IL 60607, or by emailing your request to ***.************@********.*** . The call is free. Use this phone number, email and address only for appeal-related inquiries. All other inquiries should be directed to 1-800-***-**** (TTY 1-800-***-****). 16.

ABE Application for Benefits Eligibility Page 17 http://abe.illinois.gov Why does DHS collect your Social Security number?

DHS will only use your SSN for the purpose for which it was collected. DHS will not: Sell, lease, loan, trade, or rent your SSN to a third party for any purpose; publicly post or publicly display your SSN; print your SSN on any card required for you to access our services; require you to transmit your SSN over the Internet, unless the connection is secure or your SSN is encrypted; or print your SSN on any materials that are mailed to you, unless State or Federal law requires that number to be on documents mailed to you, or unless we are confirming the accuracy of your SSN. Right to appeal A fair hearing may be requested either orally or in writing if there is disagreement with any action taken on this case. The SNAP unit's case may be presented at the hearing by any person chosen by the SNAP unit. Non-Discrimination

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 of Illinois Department of Human Services) 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: *******.******@****.***

This institution is an equal opportunity provider. Additional Illinois Nondiscrimination Information

You may also write the Department of Human Services (IDHS) at Department of Human Services, Bureau of Civil Affairs, 401 South Clinton St., 6th Floor, Chicago, Illinois, 60607 or call the IDHS Helpline Number at 1-800-***-**** or 866-***-**** TTY/Nextalk or 711 Relay.

ABE Application for Benefits Eligibility Page 18 http://abe.illinois.gov DHS, HHS, and USDA are equal opportunity providers and employers. The State of Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990

Declaration Regarding Citizenship/Alien Status

I declare, under penalty of perjury, that the statements I have made regarding the citizenship or alien status of each person requesting assistance are true and correct. I understand that the alien status of each person requesting assistance who is not a citizen of the United States will be verified with the United States Citizenship and Immigration Services (USCIS). This will require the disclosure to USCIS of certain identifying information which I have provided. The information received from USCIS may affect eligibility for assistance and the benefit level. I understand that documents may have to be provided to prove what I've said. I agree to do this. If documents are not available, I agree to give the name of a person or organization the FCRC may contact to obtain the necessary proof. The information on this form is subject to verification by Federal, State, and Local Officials. If any information is found to be inaccurate, I may be denied SNAP benefits, and/or be subject to criminal prosecution for knowingly providing false information.

I understand that a change that happens after the eligibility interview and before the notice of decision must be reported within 10 calendar days unless otherwise notified. If I have any doubt about whether to report a change, I will ask my Human Services caseworker. I understand that if I am approved for SNAP benefits and I receive more benefits than I am entitled to, whether an error on my part or an agency error, the amount of overpaid benefits may be subtracted from my monthly benefit amount.

Failure to report or verify above expenses will be seen as a statement by your SNAP Unit that you do not want to receive a deduction for the unreported expenses. Child support payments are subject to verification by computer matching with the records of the Division of Child Support Enforcement.

Penalty Warning - What are the SNAP Program Penalties? IN THE APPLICATION

You Must Report

Child care expenses

Rent or mortgage payment, property taxes and insurance and Utility Expenses

You must report and verify:

Medical expenses

Child support paid to a non-SNAP Unit member

ABE Application for Benefits Eligibility Page 19 http://abe.illinois.gov You can also be fined up to $250,000 and put in prison up to 20 years or both. In addition, you may be barred from SNAP for an additional 18 months if court ordered. You can also be charged under other Federal laws. Persons who are fleeing felons or probation/parole violators are ineligible for SNAP benefits. If you Then you will lose SNAP benefits

Hide or give wrong information on purpose to get SNAP benefits.

Trade, steal or sell SNAP benefits, or resell food bought with SNAP benefits

Use SNAP benefits to buy non-food items like alcohol or tobacco.

Use someone else's SNAP benefits for yourself or

someone else

Throw away beverages purchased with SNAP benefits

just to get money back from a container deposit.

l 12 months the first time

l 24 months the second time

l permanently the third time

Trade SNAP benefits for controlled substances, such as drugs.

l l 24 months the first time

l permanently the second time

Trade SNAP benefits for firearms, ammunition or

explosives

l l permanently

l Buy, sell or trade SNAP benefits of more than $500.00 l permanently Give false information about who you are and where you live so you can get extra SNAP benefits.

l 10 years

ABE Application for Benefits Eligibility Page 20 http://abe.illinois.gov

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