alabama Food stamp Application form pdf download

alabama Food stamp Application form pdf Alabama Food Stamp Application PDF Free Download Food Stamp Form PDF Alabama, mydhr food stamp application pdf, alabama food stamp pdf download, food stamp recertification online pdf, alabama dhr food stamps phone number pdf, mydhr alabama login pdf,

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 iden tity 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 distribu tion of a controlled substance (felony drug conviction) after August 22, 1996? ❏ Yes ❏ No Have you or any member of your household been convicted as an adult of aggravated sexual abuse, murder, sexual exploitation and other abuse of children, a Federal or State offense involving sexual assault, or an offense under State law determined by the Attorney General to be substantially similar to such an offense, after February 7, 2014? ❏ Yes ❏ No If yes, is the convicted member complying with the terms of the sentence? ❏ 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 $4,250 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 (5/23) 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: 1-833-822-2202 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 hear ing or have speech disabilities can call 1-833-822-2202 using the Alabama Relay Service at 711 or 1-800-548-2546 (TTY) for assistance con tacting 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/immigra tion 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 bene fits. (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 insur ance 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 334-242-7210 or 1-800-274-VOTE (1-800-274-8683). 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 only) (Applicants 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: 1-833-822-2202 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 bene fits 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 ineli gible 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 per manently 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 cit izenship or alien status, are correct and complete. Household member signature or mark (X): _____________________________________________________ Date ____________________________ Witness if signed by mark: ________________________________________________________________________ Date ____________________________ Do Not Send Applications Here USDA Nondiscrimination Statement In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity. Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf , from any USDA office, by calling (833) 620-1071, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to: 1. mail: Food and Nutrition Service, USDA 1320 Braddock Place, Room 334 Alexandria, VA 22314; or 2. fax: (833) 256-1665 or (202) 690-7442; or 3. email: [email protected] This institution is an equal opportunity provider. Do Not Send Applications Here 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 ZIP State City 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 Map / Diagram Did you receive assistance? 12 13 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: Ye s No ( ) Ye s No Are you a citizen of the United States of America? 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 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. Questions? Call the Elections Division at 1-800-274-8683 or 334-242-7210 Wes Allen - Secretary of State 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.alabamavotes.gov or call the Elections Division: 800-274-8683. 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 ZIP State City ZIP State 202 2.12.20 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 OPTIONAL: Because of a sincerely held belief, I decline to include the final four words of the oath above. 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 repre sentatives 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 assis tance 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 serv ices, 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 includ ing 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 cir cumstances 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.

Search PDF