Colorado Food stamp Application form pdf download

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Hello, if you need Colorado Food stamp Form PDF then you can download Colorado Food stamp Form PDF from here. Here you can generate the application in PDF form by clicking on the download button and use the application form to apply for Colorado SNAP Program. To do this, you need a PDF form which is downloaded and submitted by the applicant by filling his information in the form, after that the eligibility is checked accordingly and the benefit is given. So let's download Colorado Food Stamp Form PDF.

A Revised 0 7 /2022 Ap plication for Public Assistance State of Colorado Departments of Health Care Policy and Financing and Human Services Please remove pages A - F to keep for your records You have the option to answer only those questions relevant to the program for which you are applying . S upplemental Nutrition Assistance Program (S NAP ) - previously known as Food Assistance Questions marked with a ◼ are NOT required for SNAP . • You have the right to file your application today. You can start the process by filling out your name, address , and signature or that of an authorized representative on this form and turning it into a county office. You can give us your application in pers on, by fax, through the mail or you can apply through PEAK. An interview will be required before receiving SNAP and you may be required to provide proof of some information given on the application. Benefits will begin from the date any county office receives your signed application. • You may receive SNAP within 7 days if the household has less than $100 in assets and less than $150 income per month , OR if your monthly shelter costs are more than your monthly income plus any cash on hand or in the bank , OR if anyone in the home is a migrant or seasonal farm worker and the household has less than $100 in cash on hand and in the bank. • If you do not qualify for expedited SNAP processing , benefits can begin within 30 days if all requested proof of the information that was given on your application was provided. If expedited assistance is denied, you may ask for an inform al hearing. Cash Programs Questions marked with a ⧫ are NOT required for Cash Assistance. • Colorado Works (CW), known federally as Temporary Assistance for Needy Families ( TANF ) – For households with a child or a pregnant mother. Provides a cash benefit to families in need. With a few exceptions, parents must participate in work activities. A referral may be made to Child Support Services based on your household circumstances . If you feel this could cause hard ship to you or your child (ren) , you may request good cause for waiving this referral. • Colorado Supplement to SSI – Provides an additional cash supplement to eligible persons not rece iving the full SSI grant from the Social Security Administration. • Aid to the Needy Disabled (State AND) – Provides a cash benefit for persons ages 18 - 59 who have been determined totally disabled for at least six months or persons under the age 59 who m eet the definition of a person who is blind. • Old Age Pension (OAP ) – Provides a cash benefit for low - income persons age 60 or over. • Home Care Allowance (HCA) - For persons who need help on a regular basis with some or all of their daily self - care (such a s bathing, dressing, eating, getting around, and using the bathroom). Provides a cash benefit that used must be to pay the provider for services. A functional assessment is required. Medical Assistance Questions marked with a ⚫ are NOT required for Medical Assistance. Medical Assistance includes free or low - cost insurance from Health First Colorado (Colorado’s Medicaid Program) or the Child Health Plan Plus Program (CHP+). It also includes affordable private health insurance plans that offer you comprehensive coverage through Connect for Health Colorado (the Marketplace). This includes tax credits that can immediately lower your premiums for health coverage. It also include s assistance for paying your Medicare Premiums. Instructions: List EVERYONE in your home and on your federal tax return , even if you are not applying for them. Use more paper if necessary. If you are a non - citizen who has a sponsor, you will list the sponsor’s information in a question later in this application. If you are applying for benefits and you have a Social Security Number (SSN), we need this information. If you provide your SSN, it may speed up the application process. We use SSNs to c heck income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1 - 800 - 772 - 1213 or visit socialsecurity.gov. TTY users should call 1 - 800 - 325 - 0778. Providing a SSN or immigration status is optional for SNAP . If a SSN or immigration status is not provided for a person, that person will not receive benefits . Even if the person’s SSN or proof of immigration status was not provided, they must provide their income , resources, and expenses t hey pay because that information will be used to determine eligibility and benefits for eligible household members. B Revised 0 7 /2022 What I Should Know B y c o m pl e tin g a n d s i g ni ng th e S t a t e o f C olor a d o Appli c a tio n f o r P ubli c A ss i s t a n c e a n d oth e r do c u me nt s r e quir e d t o d e t e r m in e wh e th e r I’ m e li g ibl e fo r p u bli c a ss i s t a n c e b e n e fit s A N D b y a cc e ptin g b e n e fit s th a t I a m e li g ibl e t o r e c e i ve , I und e r s t a n d th e follo w in g infor m a tio n a n d a g r e e t o th e followi n g r e quir eme nt s : • I m u s t t e l l th e tr u th ; i t i s a c ri m e t o li e o n thi s a p p li c a tion . • I ma y h a v e t o g i ve p a p e rs th a t s ho w w h a t I’ v e tol d y o u i s tru e . • I m a y h a v e t o t e l l y o u o f a n y c h a n g e s t o th e info rm a tio n I g a ve y o u o n m y a ppli c a tion . I f I t h in k y o u m a d e a m i s t a k e , I c a n a s k fo r a n a p p e a l o r f a i r h e a rin g . • Th e d e p a rt me n t wil l no t di sc ri m in a t e . • Th e d e p a rt me n t wil l c o n fir m c itiz e n s hi p a n d i mm i g r a tio n s t a tu s fo r eve r y on e a ppl y in g fo r b e n e fit s . • The department will tell you i f y ou r b e n e fit s c h an ge . • Th e d e p a rt me n t or relevant federal agency wil l t a k e b a c k a ny b e n e fit s y o u s houl d no t h a v e r e c e i v e d . 1. T h e D ep a rt m e n t o f He a l th Ca re P o l i cy a n d F in a n c in g ( H C PF ) i s t h e s t a te a gen c y r e s p o n s ibl e f o r M ed i cal A s s i st a n ce P r o g r a ms i n C o l or a d o . T h e D e p a rt m e n t o f Hu m an S e r v i c e s i s t h e s t a te a ge n cy r e s p o n s ibl e f o r t h e o t h e r publ i c a ss i s t a n ce p r o g r a m s. T h e C o u n ty D e p a r t m e n t s o f H u ma n / S o c i a l S e rv i c e s a n d M e di cal A s s i s t a n ce S i t e s a r e t h e a ge n c i e s t h at r e c e i ve a n d p ro c e s s a ppl i c a t i o n s f o r a l l publi c a s s i s t a n c e p r o g r a m s. In t h i s s t a t e m e n t, t h e t e r m “ de p a r t m e n t ” i s u s e d t o r e f e r to a l l a ge n c i e s. 2. I m u st g i v e t h e de p a rt me n t a l l nee d e d p r o o f a n d d o c u m e n t s b e f o re q u a l i fy i n g f o r b e n e f i ts . 3. T h e i n f o r m a t i o n I g i ve o n t h e a p pli c ati o n a n d i n t h e a p p li c a t i o n i n t e r v i e w i s c o n f ide n t i a l . However, t h e de p a rt m e n t c an u se o r s h a re t h e i n f o r m a t i o n w i t h another program t h a t a n y o f my f a m i l y and/or household m e m b e r s a r e g e t t in g o r a re a pp l y i n g fo r. T h e in f o r m a t i o n c an o nl y b e u s e d f o r p u r p o s e s o f t r e a t m e n t , p a y m e n t , d e t e r m inin g eligibil i t y , o t h e r p r o g r a m an d a d m i n i st r a t i v e op e r a t i on s , o r o t h e r p u r p o s e s pe r m i t t e d b y l a w f o r my f a m il y and/or household m e m b e r s o r m e . Additionally, this information may be disclosed to other Federal and State agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. It will also be determined if the information is factual. If any information is incorrect, SNAP may be denied and the applicant may be subject to criminal pr osecution for knowingly providing incorrect information. 4. It i s a c r i me to li e o n t h e a p pli ca t i o n o r to t a k e ben e f i t s t h at I kn o w t h at my f a m i l y a n d I a re n o t eligi b l e to r e c e i ve a n d I m ay b e s u b j e c t to c r i m i n al p r o s e c u t i o n f o r kn o w i ngl y p r o v i d in g f a l s e i n f o r m a t i on . G i v i ng f a l s e i n f o r mat i on may be p u n i s hed by a fi ne of up to $250 , 000 o r a j a i l term of up to 20 yea rs , o r b o th. 5. A per s on f o u nd to have i ntent i o n a ll y g i ven f a l s e i n f o r mat i on can n ot g et SNAP a n d/or Cash Programs f or 12 mo n ths f or the f i r s t o ff en s e, 24 mo n ths f or the s eco n d o ff en s e, a n d permanent l y f or the th i rd o ff en s e . If a person is found to have intentionally violated program rules in SNAP or Cash Programs, that person is also disqualified from Cash Programs for the same period of time. A c o u r t can a l so s t o p a pe r s o n fr o m g e tt i n g SNAP f o r a n o t h e r eig h t e e n m o n t h s . T h i s c r i me i s s u b j e ct to p r o s e c u t i o n unde r o t h e r s t a te a n d f ed e ral l a w s. R e c e i v i ng d u p l i c a t e b e n e f i ts of SNAP b y lyi n g ab o u t i d e nt i t y o r r e s i d e n c e w i l l re s u l t i n a ten (10) ye ar d i s q ua lif i c a t i o n f or t h e fi r s t offense, a ten (10) year disqualification for the second offense , a nd a pe r m a n e n t d i s q ua lif i c at i on f or t h e th i rd o ffe n s e. If I omit or provide any information (other than lying about identity or residence) that leads to duplicate benefits being issued, I can be disqualified for 12 months for the 1st offense, 24 months for the 2nd offense , and permanently for the 3rd offense. A person convicted by a court or whose disqualification was obtained through an Intentional Program Violation (IPV) waiver for misrepresenting their residence in order to obtain assistance in two states at the same time will have their Colorado Works assistance denied for ten (10) years. 6. T h e depa r t m ent w i l l n o t if y me i n w r i t i ng o f h o w and when to te l l t h e depa r tme n t o f a n y cha n g e s . If I am receiving Cash Programs , I know that I must tell the organization providing the assistance if the information I listed on this application changes by the 10 th of the month following the change . I am aware I have 10 calendar days to report any changes if I am enrolled in Health F irst Colorado or Child Health Plan Plus (CHP+). Changes are to be reported to my local county office for Health First Colorado or to CHP+. I am responsible for paying fees, premiums and co - payments for myself and my family if they are required for Medical Assistance benefits . I know I have 30 calendar days to report any change to Connect for Health Colorado if I am receiving Advance Premium Tax Credits, Reduced Co - Pays or Deductibles, or I am enrolled in a Qualified Health Plan. If my family is enrolled in multiple insurance affordability programs, I must report changes to each organization in the appropriate time frame. I understand that a change in information could affect my eligibility and eligibility of member(s) of my household. 7 . If I d o n o t t el l t h e t r u th o n m y a ppl i c a t i o n o r i f i n f o r m a t i o n i s l e f t o f f o f t h e a ppl i c a t i o n , o r i f I d o n o t r ep o rt c h a nge s to t h e d ep a r t m e n t , a s r e q ui r e d , I m ay l o se my a s s i st a n c e , a n d I may h ave to p a y back t h e d ep a rt m e n t f o r t h e a ss i s t a n ce r e c e i v e d w he n I w a s n o t eligi b le . If I h a ve to p ay b a ck m o n e y to t h e de p a r t m e n t , I unde rs t a n d t h at st ate o r f ed e r al sa l ar i e s , r e b a t e s, o r t a x r e f un d s t h a t wo ul d b e r e c ei v e d b y me o r a n o t h e r pe r s o n o n t h i s a p pli ca t i o n m ay b e t a ke n . 8 . T h e l a w s a y s t h e de p a rt m e n t m u s t c he c k t h e i m m i g rat i on st a t u s a n d c i t i z e n s hi p of a n yo n e w h o i s a p p l yi n g . T he y w il l n o t c h e ck the i mm i g r a t i o n stat u s o f fam i l y m e m b e rs w h o a re n ot a p p l yi n g for ben e f i ts. I may b e r e q ue st e d to g i v e p roof o f n o n - c i t i z e n r eg i str a t i on d o c u m e n t a t i on r e c e i v e d fr o m t h e U n i t e d St a t e s C i t i z e n a n d I mm ig r a t i on S e rv i ce (US CI S) f o r e v e ry n on - c i t i z e n m e m be r i n my h o u se w h o i s a ppl y in g f o r b en e f i ts. T h e de p a rtm e n t w i l l c o n f i rm i n f o r m a t i o n w i th U S C I S a n d a n y in f o r m a t i o n r e c e i v e d f r o m US C IS m ay a ff e c t my elig i bil i ty a n d be n e f i t s. F e d e ral l aw ( P ubl i c L a w 9 7 - 9 8 ) r e qu i r e s me to g i ve t h e de p a r t m e n t t h e S o c i al S e c u r i t y nu m b e r a n d /o r a l ie n r e g i st r a t i o n n u m b e r o f a l l p e r s o n s w h o a re a pp l y i n g f o r public a s s i s t a n c e . I m u st a l so p ro v i d e t h e S o c i al S e c u r i ty n u m b e r a n d/ o r a lie n r eg i s t r a t i o n n u m b e r f o r a l l s p o n s o rs . For A d u l t F i na n c i al and Colorado Works p r ograms, s p o n s or i n f o r mat i on w i l l be co n fi rmed w i th U SCIS a n d the i n f o r mat i on r ece i ved f r o m U SC IS may a ff e c t s p o n s or r epay m ent f or my e li g i b ili ty a n d b ene f i t s . My s p o n s or and I may be re s p o n s i b l e for r e i mb u r si ng the s tate f or the bene fi ts that I rece i ve. C Revised 0 7 /2022 9 . The following applies to all qualified non - citizens applying for Cash Programs : As a condition of my eligibility for financial assistance programs , I agree that, during the time I am receiving such assistance, I will not sign an Affidavit of Support to sponsor a non - citizen who is seeking permission to enter or remain in the United S tates. I understand that any Affidavit of Support signed prior to July 1, 1997 does not affect my eligibility for assistance. If I do not agree, I will no longer be eligible for financial assistance from the State of Colorado. 10 . I d o n o t h ave to b e a U . S. c i t i z e n to a ppl y f o r a s s i s t a n c e . P l e a s e do n ot l e t t h e f ear a b o u t i mm i g ra t i on s t a t us s t o p y ou f r o m s e ek i n g b e n e f i ts f or yo u r f a m i l y. 11 . If I a m a r e s id e n t o f an i n s t i t u t i o n a n d j o i n t l y a pp l y i n g f o r SS I a n d SNAP p r i o r to le a v in g t h e i n s t i t u t i o n , t h e f ilin g d ate o f t h e a p p li c a t i o n i s my d a t e o f r el e a se f r o m t h e i n st i t u t i o n . Pr o c e s s in g t i me w i l l b egi n f r o m t h e d a te t h e a ppl i c a t i o n i s r e c e i v e d i n t h e SNAP o f f i c e . 12 . P r i v acy A ct I n f o r m a t i o n : T h e d e p a rt m e n t i s a u t h o r i z e d to c o ll e c t i n f o rm ati o n o n t h e a ppl i c a t i o n , in c ludin g S o c i al S e c u r i t y n u m b e r s , a n d w il l c o n f i r m i n f o r m a t i o n t h a t m ay a f f e c t in i t i al o r o ng o i n g e li gibil i ty a n d p ay m e n ts fo r a l l p e r s o n s l i s t e d o n my a p p li c a t i o n . I am a l l ow i ng t h e d e p a r t me n t to u s e S o c i al Se cu r i t y n u m b e rs (SSN) and o t h er i n f o r ma t i on f r o m m y ap p lic a t i on to r e q u e s t a n d r e ce i v e i n f o rm a t i on or r e co r ds to co n f i rm t h e i n f o r m a t i on i n m y a p p l i c at i o n . SNAP w il l b e denie d to ind i v id u a l s t h a t d o n o t p ro v id e a S o c i al S e c u r i t y n u m b e r , a n d S o c i a l S e c u r i t y n u m b e r s w i l l b e u s e d a n d di s c l os e d i n t h e s a m e m a nn e r f o r b o th eligib l e a n d i nelig i bl e m e m b e r s. I r e l e a s e t he d e p a r t me nt f r o m a l l li ab il i t y f or s ha r i ng th i s i n f o r m a t i o n w i th o t h er a g e n c i es f o r t h i s p u r p o s e . F o r e x a m pl e , t h e d e p a rt m e n t m a y g e t a n d s h a re i n f orm at i o n w i th a n y o f t h e f o ll o w in g a ge n c i e s: S o c i a l S e c u r i ty A d m in i s tr ati o n ; I n t e r n al R e v enu e Se rv i c e ; U n i t e d S t a t e s C u s t o m s a n d I m m i g r a t i o n S e rv i c e s; C ol o r a d o D e p a r t m e n t o f L a b o r a n d E m pl o y m en t ; f i n a n c i a l i n s t i t u t i o n s ( b a n k s, s a v in g s , a n d l o a n s , cr e d i t un i o n s , i n s u r a n ce c o m p a ni e s , l a nd l o r d s, l e a s in g a ge n t s , e t c . ) ; c hil d s upp o rt services ; e m pl o y e r s; c o u rt s; a n d o t h e r f ed e r al o r s t a te a ge n c i e s; a n d f o r SNAP , l a w e n f or c e m e n t o f f i c i a l s f o r t h e pu r p o s e s o f a p p r e hend i n g p e r s o n s f lee i n g to av o i d t h e l a w. 13 . If a SNAP , Colorado Works, and/or Adult Financial o v e r - p a y m en t o cc u r s a g a i n s t my h o u s eh o ld , t h e in f o r m a t i o n o n t h i s a p p li c a t i o n , i n c l udin g a l l S o c i a l S e c u r i t y n u m b e rs , m ay b e r e f e rr e d to F e d e r al a n d S t a t e a gen c i e s , as w el l as p r i va te c l a i m s c o ll e c t i o n a gen c ie s f o r c l a i m s c o ll e cti o n a c t i o n. 14 . T h e EB T ( o r Q u e s t ) c a r d i s u s e d to p ay me mos t o f m y p ubl i c a s s i s t a n ce ben e f i ts . I c a nn o t t r a d e o r s el l EB T c a r d s . The only people allowed to use my household’s EBT card are members of my household, my authorized representative(s), and individuals outside my household that have my permission to use my EBT card to access benefits for the people in my household . I cannot use my EBT card to access my cash benefits at locations identified as prohibited locations including licensed gaming establishments, in - state simulcast facilities, tracks for racing, commercial bingo facilities, stores or establishments in which th e principal business is the sale of firearms, retail establishment licensed to sell malt, vinous, or spirituous liquors, establishments licensed to sell medical marijuana or medical marijuana - infused products, or retail marijuana or retail marijuana produc ts, establishments that provide adult - oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment. C ontinued misuse of my EBT card at prohibited locations will cause my cash benefits to be suspended on my EBT card and/or my cash benefits to be terminated for a period of 30 days requiring a new application. 15 . I c a n n a me s o m e o n e or an organization to b e my r e p r e s e n t at i v e . I m u st d o t h i s i n w r i t i ng . T h e p e r s o n and/or organization I d e s i g n a te to b e my a u t h o r i z e d r e p r e s e n t a t i ve m a y hel p me a p p l y f o r a ss i s ta n c e , g e t m y b en e f i ts , a n d u se my ben e f i ts to b u y f oo d f o r m e . I m ay n a me o n e p e r s o n t o he l p me w i t h e ach s ep a r ate ta sk o r I m a y n a me o n e p e r s o n to hel p m e w i th a l l o f t h e se t a s k s . 16 . If I t hin k t h e d e p a r t m en t ma d e a m i s t a k e , I c a n a sk f o r a F a i r He a r in g . T h e dep a r t m e n t w il l t e l l me i n w r i t in g h o w to m a k e an a p p e a l . I c an a s k f o r a F a i r He a r in g e i t h e r v e r b a l l y o r i n w r i t in g . M y ca se m a y b e p r e s e n t e d b y a m e m b e r o f my h o u s eh o l d o r my r e p r e s en t a t i v e , s u ch as le g al c o u n s e l , f r ie n d , o r r e l at i v e . I m a y r eq u e s t an a pp e al f o r a n y ac t i o n o n a n y p r o g r a m e x c e p t f o r t h e C H P + p r o g r a m 17 . If I t hin k t h e C H P + p r o g r am ma d e a m i s t a k e , I c a n a sk f o r an a p pe a l . CH P+ t e l l s me a b o u t h o w to m a k e an a pp e al i n w r i t in g . 18 . Colorado Works is not an entitlement program and benefits are not guaranteed. To remain eligible, I may be required to complete an assessment and develop a plan. Unless exempted, I will be required to participate in work readiness activities 19 . As an applicant for Colorado Works, if I refuse to cooperate with Child Support Services at the time I apply or while receiving cash assistance through Colorado Works, without good cause, I will not receive assistance or a basic cash assistance grant for my family. Good caus e for not working with Child Support can be but is not limited to; potential physical or emotional harm to a child(ren), parent or caretaker relative; pregnancy or birth of a child related to incest or forcible rape; legal adoption before the court or a parent receiving pre - adoption services; or other reasons determined to be in the best interest of the child . In order to cooperate with Child Support Services, I will be required to complete additional documentation concerning the child(ren), the parentage of the child(ren) , and provide all court documents that concern the child(ren). 20 . If I am an adult between the ages of 18 and 49, with no children under the age of 18 in my SNAP house hold , I will only be eligible to receive SNAP benefits for three month s , unless one of the following applies: I work in a job 80 hours each month and report my hours worked to my local Employment First office, or I meet the Workfare program requirements or work program requirements set by the Employment First office. Additio nally, I may continue to receive my SNAP benefits if I am determined to be physically or mentally unable to work or if the SNAP office identifies other applicable exemptions. If I meet any of these criteria, I will be able to continue receiving SNAP as lon g as I remain eligible. 21 . I u n de rs t a n d a n d a g r e e t h a t to r e c e i ve SNAP , c e r t a i n m e m b e r s o f t h e h o u s eh o l d ne e d to r eg i s t e r f o r w o r k . T h i s m e a n s t h at c e r t a i n m e m be r s o f t h e h o u s e h o l d m u s t: a ) R ep o rt to t h e E m pl o y m en t F i r s t ( w o rk p ro g r a m ) w he n t h e SNAP o f f i ce s c he d ul e s an a p p o i n t m e n t. b ) C o m p l y w i th t h e in s t r u c t i o n s t h e E m pl o y m e n t F i rs t ( w o rk p r o g r a m ) g i v e s in c ludin g r ep or t in g fo r a l l s c hedul e d a pp o i n t m e n t s a n d f o ll o w in g t h r o ug h o n t h e w r i t t e n a g r e e m e n t s s ig ned . c ) P r o v i d e i n f o r m a t i o n t o t h e SNAP o f f i ce o r t h e E m pl o y m e n t F i r st ( w or k p r o g r a m ) a b o u t a n y j o b s I or my household member(s) ge t w h i l e o n SNAP . d ) T e l l t h e SNAP o f f i c e o r t h e Em pl o y m e n t F i r st ( w o rk p r o g r a m ) i f me or my household member(s) a re n o t a bl e to w o rk – I w i l l b e a s k e d to p r o v id e v e r i f i c a t i o n ; wo rk a n y w o r k f a re h o u rs assign e d ; g o to j o b i n t e r v i e ws a r r a nge d f o r me or my household member(s) . A n y o n e w h o d o e s n o t f o ll o w t h e w or k r eq u i r e m e n t s m ay b e d i s q u a l i f ie d fr o m r e c e i v in g SNAP . 22 . I m u st c o o pe r a te f u l l y w i th s t a te a n d f ed e ral st a f f i f my c a se i s r e v ie w e d . M y in f o r m a t i o n o n t h i s a p p li c a t i o n m ay b e r e v i e w e d a n d c o n f i r m e d b y t h e dep a r t m e n t , o r i ts r ep r e s en t a t i v e s . M y ho u sehold w il l n o t b e eligi b l e f o r SNAP i f I r e f u se to c o o p e r a te w i th a n y r e v i e w o f my c as e , in c ludin g a q u a l i t y c o n t r o l r e v i e w . 23 . I ca nn o t u se SNAP bene f i ts to bu y non - food i t e m s , such as al c o h o l o r c ig arett e s. I can b e di s qu a li f i e d f o r u s in g SNAP to p ay f o r i t e ms pu rc h as e d o n cr edi t . If a court of law finds a person gu il ty o f u si ng SNAP bene fi ts to ill ega ll y p u rcha s e or r ece i ve co n t r o ll ed s u bs tances that individual s ha l l be d i s q u a l i f i ed f or two yea r s f or a fi r s t o ff en s e a n d D Revised 0 7 /2022 p ermanent l y f or a s eco n d o ff en s e. In d i v i d u a l s found by a Federa l , St a t e , or l ocal co u rt t o ha v e u s ed o r rece iv ed b e n e fi ts i n a tr a n s act i on i nvo l v i ng the s a l e o f fi r ea r m s , a m mu n i t i o n , o r exp l o si ves s ha l l be permanent l y i ne l i g i b l e to re c e i ve SNAP u p on the f i r s t o cca s i on o f s uch v i o l at i o n . If a court of law finds a person guilty of having trafficked benefits for an aggregate amount of $500 or more, that individual will be permanently ineligible to receive SNAP upon the first occasion of such violation. 24. The trafficking of benefits means: a. The buying, selling, stealing, or otherwise affecting an exchange of SNAP benefits issued and accessed via Electronic Benefit Transfer (EBT) cards, card numbers and personal identification numbers (PINs), or by manual voucher and signature, for c ash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone; or, b. The exchange of SNAP benefits or EBT cards for firearms, ammunition, explosives, or controlled substances; or, c. A SNAP participant, including the participant’s designated authorized representative, who knowingly transfers SNAP benefit to another who does not, or does not intend to, use the SNAP benefits for the SNAP household for whom the SNAP benefits were intended; or d. The reselling of food that was purchased with SNAP benefits for cash; or e. Obtaining a cash deposit when returning water or other containers that were purchased with SNAP benefits. Purchasing water containers is an eligible food item that can be pai d for with SNAP benefits; however, when the container is returned, the deposit should be returned to the client’s EBT card and not given to the client in cash. f. Attempting to buy, sell, steal, or otherwise affect an exchange of SNAP benefits issued and accessed via Electronic Benefit Transfer (EBT) cards, card numbers and personal identification numbers (PINs), or by manual voucher and signatures, for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone. 25 . If I d o n o t r ep o rt a n d p r o v id e p r o o f o f m o r t g a g e , h o u s in g f e e s , p r o pe r ty in s u r a n c e , p r o p e r t y t a x e s, court - ordered c h i l d s u p p or t p a y m e n ts , c hil d o r a du l t c a r e , a n d m e d i c al e x p e n s e s p a i d b y pe o pl e i n my h o u s eh o l d w h o a re el de r l y o r w h o h a ve a d i s a bil i t y , I a m s t a t in g t h at I d o n o t wa n t t h at s pe c i f i c ded u cti o n u s e d to d e t e r m in e my SNAP be ne f i t a m o u n t. 26 . I c an a sk f o r SNAP a p a r t fro m a s kin g f o r ben e f i t s f r o m o t h e r p r o g r a m s. My elig i bil i ty f o r SNAP w il l b e de t e r m i ne d a p a r t f r o m a n y o t h e r p r o g r a ms . T h e SNAP of f i ce s h a l l p ro c e s s a l l SNAP a ppl i c a t i o n s i n a c c or d a n ce w i th SNAP t i m elin e s s, n o t i c in g , a n d f a i r he a r in g r e q u i r e m e n t s , e v e n i f I a m a ppl y in g f o r o t h e r p r o g r a m s . 27 . C olo r a d o r e s i d e n t s w h o h a ve a q u a li f y in g di s a b i li t y , s u ch a s pe rso n s r e c e i v i n g SS I o r SSD I bene f i ts , o r r e s i den t s w h o a r e a t le a s t 6 5 y e a r s o f a g e ( o r a s u r v i v i n g s pou s e a g e 5 8 o r o lde r ) m i gh t a l s o q u a li f y f o r a Pro pe rt y T a x / R e n t/ H e a t R eb a t e fr o m t h e D e p a rtm en t o f R e v e n ue . V i s i t www . T a x C olo r a do . c o m a n d c l i c k o n t h e PT C bu tt o n a t t h e t o p o f t h e p a g e o r c a l l 303 - 238 - 737 8 f o r d e t a i l s . 28 . I E V S r e f e r s t o t h e I n c o m e E l i g i b ili ty Ve r i f i ca t i o n S y st e m . I E V S r e po rt s di s c r e p a n c i e s b e tw e e n t h e i n f o rm a t io n y o u p r o v i d e a n d in f o rm a t i o n i n t h e D ep a rtm en t o f La bo r' s s y st e m a s w e l l a s So c i a l S e c u r i t y A d m ini str a t i on ' s va r iou s s y st e ms . I n f o rm a t i o n av a il a b l e t h ro ug h I E V S w i l l b e r e q ue st e d , u s e d , a n d m a y b e v e r i f i e d t h r o u g h c o l l a t e r a l c o n t ac t s w he n di s c r e p a n c ie s a r e f o u nd . T hi s in f o rm a t i o n may a ff ec t y o u r e l i gi bi l i t y a n d b e n e f i t l e v e l . 29 . I will immediately notify the State of any medical claim or lawsuit I have. I will cooperate with the State in collecting the medical bills the State has paid. The state may collect from any insurance company or court settlement for medical bills that th e State has paid. If I am on Medical Assistance and receive money for the same medical bills that the State has paid, I will give the money to the State. I assign to the State all rights to payment for medical expenses and treatment. I also assign my right to appeal a denial of benefits by another party responsible for payment for the benefits to the State. 30. Federal and Colorado state law requires the Department of Health Care Policy and Financing to recover all medical assistance benefits, including ca pitation payments, paid on behalf of Health First Colorado clients from the estates of deceased Health First Colorado clients who were permanently institutionalized. For Health First Colorado clients who were over the age of 55 when benefits were provided, the Department recovers payments for nursing facility services, home , and community - based services, and related hospital and prescription drug services. There are certain exemptions to estate recovery. For further information, please contact your county and request the “Medical Assistance Estate Recovery Program” brochure. 31. I understand that if I get cash assistance under Colorado Works, I must assign the rights to any current and past - due child support due under an existing order to the State, along with any medical support, to reimburse Medicaid for costs paid out for my family. If I receive any current child support, medical support , or spousal support directly while receiving cash assistance, I will give this to the child support unit (CSU). If current child support is collected by the CSU, while I am receiving Colora do Works, I may receive this money through the Pass - Through program. Once I have discontinued Colorado Works, the CSU will continue to collect and send to me any current child support, medical support , and spousal support until I tell the CSU in writing to close my case. E Revised 0 7 /2022 USDA Nondiscrimination Policy Do Not Send Applications Here 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 activ ity. 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 C omplainant should complete a Form AD - 3027, USDA Program Discrimination Complaint Form which can be obtained online at: http s://www.usda.gov/sites/default/files/documents/USDA - OASCR%20P - Complaint - Form - 0508 - 0002 - 508 - 11 - 28 - 17Fax2Mail.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 Medical Assistance Nondiscrimination Policy The Department of Health Care Policy and Financing and Connect for Health Colorado do not discriminate on the basis of race, color, ethnic or national origin and expression, marital status, religion, creed, political beliefs, or disability in any of its programs, services and activities. For further information about the Depart ment’s policy, to request free disability and/or language aids and services, or to file a discriminating complain, contact: 504/ADA Coordinator, 1570 Grant St., Denver, CO 80203, Phone: 303 - 866 - 6010, Fax: 303 - 866 - 2828, State Relay: 711, Email: [email protected] . For information about Connect for Health Colorado’s policy, aids and services or to file a discrimination complaint, contact: General Counsel, 3773 Cherry Creek N. Dr., Suite 1005, Phone: 303 - 590 - 9 640, Fax: 303 - 322 - 4217. Complaints can also be filed with the U.S Department of Health and Human Services Office for Civil Rights at http://www.hhs.gov/ocr/filing - with - ocr/index.html . For Other Programs: For information about the Colorado Department of Human Services policies, to request free disability and/or language aids and services, or to file a discrimination complaint, contact: 504/ADA Coordinator, 1575 Sherman St Denver, CO 80203, P hone: 303 - 866 - 7129, Fax: 303 - 866 - 6080, State Relay: 711, Email: [email protected] . For additional information please visit www.colorado.gov/cdhs . F Revised 0 7 /2022 Civil rights complai nts can also be filed with the U.S. Department of Health and Human Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal available at ht tps://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf or by mail, phone, or fax at: 1961 Stout Street Room 08 - 148 Denver, CO 80294, Telephone: 800 - 368 - 1019 , Fax: 202 - 619 - 3818 , TDD: 800 - 537 - 7697 . Complaint forms are available at http://www.hhs.gov/civil - rights/filing - a - complaint/index.html . Domestic violence information and services are available to me. If I ever feel I am in immediate danger I should cal l 911. If I would like to receive information regarding safety and services in Colorado, I will call the Colorado Coalition Against Domestic Violence at 303 - 831 - 9632 or toll - free at 1 - 888 - 778 - 7091. I may also find the location of services near me by going to www.colorado.gov/cdhs/dvp. The National Domestic Violence Hotline at 1−800−799−SAFE (7233) or TTY 1−800−787−3224 or www.thehotline.org can also provide information. If I am a survivor of domestic viole nce, sexual assault, or stalking , the Address Confidentiality Program (ACP) can provide me with a legal substitute address to use instead of my physical address for use with state and local government agencies. I can find out more about the ACP at acp.colo rado.gov. If I need or receive either of these services, I should tell my department worker . G Revised 0 7 /2022 VERIFICATION OF INFORMATION Please provide as much of the following information as you can. All bills and proof of information must be current. We will tell you if we need any other information at the time your application is processed or at the time of the interview. If you have a s ponsor, you may need to provide proof of your sponsor’s income and resources. 1. PROOF OF ALL INCOME RECEIVED BY YOU OR OTHER MEMBERS OF YOUR HOUSEHOLD Income is any money your household receives. Proof of income may include but is not limited to: • Wages /Tips Retirement/Pension • Gifts/Allowances/Contributions • Self - Employment • Veterans Benefits • Interest from savings, CDs, etc. • Child Support • Military Allotment • Educational Loan/Grant • Unemployment • Rental Income • Social Security • Roomer/Boarder • Alimony /Maintenance Child Support • Colorado Works Cash 2. SOCIAL SECURITY NUMBERS (SSN) The SSN or proof of applying for an SSN should be provided for each member unless the member does not wish to apply for benefits or does not have one. 3. PROOF OF AGE AND IDENTITY You may be required to provide identification for all household members applying for benefits: • Birth Certificate ID for Health Benefits • Baptismal Record Work ID • US Passport Other Documents • Driver’s License • Identification Cards for US Citizens (I - 179 or I - 197) • Certificate of US Citizenship (N - 560 or NH - 561) • Certificate of Naturalization (N - 550 or N - 570) • Certificate of birth abroad of a citizen in the US (Department of State forms FS - 545 or DS - 1350) 4. PROOF OF CITIZENSHIP AND RESIDENCY You may be required to provide proof of citizenship and residence. If you are a US citizen, you may be required to provide proof, such as a: • Birth Certificate • ID for Health Benefits • Client Statement • Work ID • US Passport • Baptismal Record • Driver’s License • Forms from the United States Citizenship and Immigration Services (USCIS) such as: o Identification Cards for US Citizens (I - 179 or I - 197) o Certificate of US Citizenship (N - 560 or NH - 561) o Certificate of Naturalization (N - 550 or N - 570) H Revised 0 7 /2022 o Ce rtificate of birth abroad of a citizen in the US (Department of State forms FS - 545 or DS - 1350) If you are a legal non - citizen, you may be required to provide proof of your status, such as: • USCIS Documents • I - 551 Resident Alien Card • I - 94 Arrival/Departur e Record • I - 688B or I - 766 Employment Authorization Document • A letter from USCIS indicating a person’s status 5. PROOF OF RESOURCES. (Not required for Colorado Works programs) You may be required to provide proof of resources. Proof of expenses may include but are not limited to the following types: • Vehicles • Trust Funds • Checking/Savings • Real Estate • Life Insurance Accounts • Stock and Bonds • Burial Insurance • Retirement Funds • Property where you do not live 6. PROOF OF EXPENSES You may be require d to provide proof of expenses. Proof of expenses may include but are not limited to the following types: • Rent or mortgage • Utilities • Medical • Child support payments • Dependent care payments (adults or children) 7. LIVING ARRANGEMENTS (For SNAP Only) If you are living with other people in the same house, an explanation of your living arrangements will be helpful. The explanation should include who purchases and prepares food together and how expenses are paid. 8. CHILD SUP PORT INFORMATION (For SNAP and Colorado Works Only) If a parent to your child(ren) is out of the home, you must bring copies of any court orders. These court orders include orders involving divorce, child support, or paternity establishment. In addition t o social security numbers for you and your children, please provide social security number(s) for the absent parent(s), if available. 1 Revised 0 7 /2022 A pplication for Public Assistance State of Colorado Departments of Health Care Policy and Financing and Human Services Check the box for each program you would like to apply for. ❑ Supplemental Nutrition Assistance Program (S NAP) - previously known as Food Assistance Questions marked with a ◼ are NOT required for SNAP . ❑ Cash Programs ❑ Colorado Works - Known federally as Temporary Assistance for Needy Families (TANF) ❑ Adult Financial – Includes Colorado Supplement to SSI, Aid to the Needy Disabled ( S tate AND), Old Age Pension (OAP), and Home Care Allowance (HCA) Questions marked with a ⧫ are NOT required for Cash Assistance . ❑ Medical Assistance - I nclud es Health First Colorado (Colorado’s Medicaid Program), Child Health Plan Plus (CHP+), Tax Credi ts, and Cost - Sharing Reductions Questions marked with a ⚫ are NOT required for Medical Assistance . Your Legal Name (First, Middle Initial, Last) Maiden Name Social Security Number 1 Date of Birth Home address ( N umber, S treet) City State Zip Phone number Mailing address (if different) City State Zip Other phone number Do you speak and read English? ❑ Yes No ❑ If no, what language do you speak? Are you homeless? ❑ Yes No ❑ ◼ Are you a resident of Colorado? ❑ Yes No ❑ Are you currently residing in a nursing home? ❑ Yes No ❑ 1 If you are applying for any program and have an SSN, we need this information. Even if you are not applying for benefits, providing your SSN will help us to quickly process your application. We use SSNs to check income and other information to see what you and your household may qualify for. Under penalties of perjur y, I state that I have examined this application, and to the best of my knowledge and belief , my answers are true, including household composition, citizenship , and non - citizenship information. I have listed all amounts and sources of income and property I receive/own. I have the right to declare an Authorized Representative. If I am declaring an Authorized Representative, by signing below, I allow this person to sign my application, get official information about this application, and act for me on all future matters with this agency. I read, understand , and agree to “What I Should Know.” Your signature Date ◼ ⚫ Spouse’s/Co - Applicants signature (optional) Date Authorized Representative, Conservator, Guardian Printed Name Authorized Representative, Conservator, Guardian Printed Name: ◼ ⚫ Authorized Representative Signature Date ◼ ⚫ Authorized Representative Signature Date Name, address , and phone number of the person who helped you complete this application We can send links that allow you to view electronic notices about your case. You may choose more than one option, but if you do not choose, you will receive paper noti ces by standard mail. I would prefer: ❑ Paper notices ❑ An email with a li nk to view your notices sent to __________ __________@___________________ 2 Revised 0 7 /2022 (For Medical , if you would like to receive notices electronically, please see Instruction Booklet at Colorado.gov/HCPF/Apply or ConnectforHealthCO.com/About - Us/Customer - Resources) Household Demographics Legal Name (First, Middle, Last) Relation to you Birth Date ◼ Male/ Female (M/F) Does this person want benefits? ◼ Married, Civil Union, Domestic Partnershi p , Single, Divorced, Separated, Widowed ⚫ Hispanic or Latino? 1 ⚫ Race 1 ◼ ⚫ Social Security Number 2 US Citizen or US National SELF Provided on Page 1 ❑ Yes ❑ No ❑ Yes ❑ No Provided on Page 1 ❑ Yes ❑ No __/___/___ ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No __/___/___ ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No __/___/___ ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No __/___/___ ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 1 Race and ethnicity information is optional and will not affect eligibility ; rather it is collected to ensure that b enefits are provided to all eligible applicants regardless of race/color/national origin. Race options include : American Indian/Alaskan Native - AI ; Asian - A ; Black/African American - B ; Native Hawaiian/ Other Pacific Islander - NH ; White - W 2 If you are applying for any program and have an SSN, we need this information. Even if you are not applying for benefits, pr oviding your SSN will help us to q uickly process your application. We use SSNs to check income and other information to see what you and your household may qualify for . Is anyone in the home considered a roomer or boarder (they rent a room from you)? ❑ Yes No ❑ If yes, list below Name Amount paid for rent Are meals included with the rent? $ ❑ Yes No ❑ $ ❑ Yes No ❑ Is there any household member temporarily out of the home in any type of facility or institution? ❑ Yes No ❑ If yes, list below . Examples of types of institutions are listed be at the bottom of the table Name Date entered Name of facility Type of facility Is this person pending disposition of charges? Are meals provided? ❑ Yes No ❑ ❑ Yes No ❑ ❑ Yes No ❑ ❑ Yes No ❑ Examples: Nursing home• Hospital • Mental health institution • Incarceration E xpedited SNAP Details Even if you are behind on paying bills, let us know how much you are responsible to pay when answering questions about your expenses. Including yourself, how many people in your home do you purchase and prepare food for? Is anyone in the home a migrant or seasonal farm worker? ❑ Yes No ❑ Total money my household expects to get this month (before deductions) $ Total cash on hand and money in your checking/savings account $ Mortgage per month $ Rent per month $ ⚫ Do you have any of these utilities? If so, cost per month? Electricity ❑ $______ Water ❑ $______ Phone ❑ $______ Trash ❑ $______ Sewer ❑ $______ Other ❑ $______ ⚫ Did anyone in the home get any SNAP or cash benefits in any other state in the last 30 days? ❑ Yes No ❑ ◼ If you are applying for Colorado Works, have you received benefits from any other state since 1996? ❑ Yes No ❑ If yes, list below Name(s) Date of receipt City County State 3 Revised 0 7 /2022 EBT Card ⚫ Does the person completing this application need an Electronic Benefits Transfer (EBT) card? ❑ Yes No ❑ ⚫ How does the person completing this application like to receive an EBT card? By postal mail ❑ In - person at the local office ❑ REGISTER TO VOTE HERE Dependent Children ◼ Do you live with at least one child under the age of 19, and are you the main person taking care of this child? ❑ Yes No ❑ ⚫ ◼ Do any of the children living in the home have a parent living outside the home? ❑ Yes ❑ No If yes, have you tried to get medical support from the child’s parent living outside the home? ❑ Yes ❑ No Name of Parent Address Phone For which child? I would like to apply for good cause from pursuing Child Support Services Assistance allowable under the Family Violence Option Waiver (as described in the “ What I Should Know ” section) ❑ Yes No ❑ ⧫ ◼ Is anyone in the home currently in foster care or has ever been in foster care? ❑ Yes No ❑ If yes, list below Name Age Dates when in foster care Family Planning ⧫ ◼ Does anyone want to apply for Family Planning Benefits? ❑ Yes No ❑ If yes, list below Family planning provides health care and counseling for preventing, delaying , or planning a pregnancy. Name(s): Pregnancy Details ◼ Is anyone in the home pregnant? ❑ Yes No ❑ If yes, list below Name : D ue date : Number of babies expected : ⚫ N ame of the father, if known : ⚫ Would you like to pursue a good cause from pursuing C hild S upport S ervices A ssistance ? ❑ Yes No ❑ Disability Details Does anyone in your home have a disability? ❑ Yes No ❑ Name: ◼ If yes, does this person need help with self - care activities (bathing, dressing, eating, using the bathroom, etc.)? ❑ Yes No ❑ ◼ Does anyone have a medical or developmental condition that has lasted, or is expected to last more than 12 months? ❑ Yes No ❑ Name: If you are not registered to vote where you live now, would you like to register to vote here today? Check YES if you would like to apply to register to vote or update your voter registration information. If you check the NO box or do not check a box, you will be considered to have decided not to apply to register to vote or update your voter reg istration information. Checking YES, NO, or leaving this question blank, will not affect your receipt of benefits. ❑ Yes No ❑ NOTICE OF RIGHTS Help: If you would like help in filling out your voter registration application, we will help you. The decision of whether to seek or accept help is yours. You may fill out the voter registration application in private. Benefits: If you are applying for public assistance from this agency, applying to register, or declining to register to vo te will not affect the amount of assistance you will be provided by this agency. Privacy: Your decision not to register or update your record and the location where you applied to register or update your voter regis tration record is confidential and may o nly be used for voter registration purposes. 4 Revised 0 7 /2022 ◼ Have you or anyone in the home applied for Supplemental Security Income (SSI) or other Social Security benefits? ❑ Yes No ❑ If yes, list below Name Program Name ❑ SSI ❑ ______ Application Date ___/_____/___ Application Status ❑ Pending ❑ Approved ❑ Denied ❑ Appealed Name Program Name ❑ SSI ❑ ______ Application Date ___/_____/___ Application Status ❑ Pending ❑ Approved ❑ Denied ❑ Appealed If no, has anyone who is disabled ever received SSI or SSDI? ❑ Yes No ❑ If yes, when did SSI or SSDI end? ___/_____/___ Non - Citizen Details Is anyone who is applying for benefits a non - citizen? ❑ Yes No ❑ If yes, you may be asked to provide a copy of your U.S. Citizenship and Immigration Services card. Non - Citizen 1 Name of Non - Citizen 1: Non - Citizen Status: Alien or I - 94 Number: Card/Passport Number: Document Expiration Date: Country of Issuance: ⧫ ◼ Is the non - citizen’s spouse or parent a veteran or active - duty member of the US military? ❑ Yes No ❑ ⧫ ◼ Has this person lived in the US since 1996? ❑ Yes No ❑ Non - Citizen 2 Name of Non - Citizen 2: Non - Citizen Status: Alien or I - 94 Number: Card/Passport Number: Document Expiration Date: Country of Issuance: ⧫ ◼ Is the non - citizen’s spouse or parent a veteran or active - duty member of the US military? ❑ Yes No ❑ ⧫ ◼ Has this person lived in the US since 1996? ❑ Yes No ❑ ⧫ ◼ Does anyone want to apply for Emergency Medicaid and Reproductive B enefits ? ❑ Yes No ❑ If yes, list below Applicants who are not a U.S. citizen, or a legal resident for at least 5 years, cannot receive full Medicaid benefits, but t hey may qualify for Emergency Medicaid and Reproductive Benefits. Emergency Medicaid and Reproductive Benefits can cover life - threatening emergencies, labor and delivery for pregnant people, and birth control. Name(s): Are any of the non - citizens listed above sponsored to remain in this country ? ❑ Yes No ❑ If yes, list below Sponsor (please add additional pages if there is more than one sponsor) Who is sponsored? Name of sponsor: Name of sponsor’s spouse: Sponsor’s Social Security Number ⚫ Sponsor’s spouse’s Social Security Number Sponsor’s address: Total number of people in sponsor’s household? Does the sponsored individual live with the sponsor? ❑ Yes No ❑ Does the sponsored individual receive free room and board from the sponsor? ❑ Yes No ❑ Does the sponsored individual receive any support from their sponsor? ❑ Yes No ❑ Has the spon sored individual been abandoned, mistreated or abused by their sponsor? ❑ Yes No ❑ Earned Income Does anyone work or is anyone starting a new job? ❑ Yes No ❑ If yes, list below Job 1 : Name of the person who is or will be working: Employer name and p hone n umber: Monthly w ages/ t ips (before taxes): Hourly wage: Average h ours w orked e ach w eek: 5 Revised 0 7 /2022 How often is t his p erson p aid? ❑ Hourly ❑ Weekly ❑ Every 2 weeks ❑ Twice a month ❑ Monthly ❑ Yearly ❑ Daily Is this j ob c onsidered t emporary and e xpected to l ast l ess than 3 m onths? ❑ Yes No ❑ ⧫ Is this income from? ❑ Seasonal Employment ❑ Commission - based Employment (including tip jobs) Job 2 : Name of the person who is or will be working: Employer name and p hone n umber: Monthly w ages/ t ips (before taxes): Hourly wage: Average h ours w orked e ach w eek: How often is t his p erson p aid? ❑ Hourly ❑ Weekly ❑ Every 2 weeks ❑ Twice a month ❑ Monthly ❑ Yearly ❑ Daily Is this j ob c onsidered t emporary and e xpected to l ast l ess than 3 m onths? ❑ Yes No ❑ ⧫ Is this income from? ❑ Seasonal Employment ❑ Commission - based Employment (including tip jobs) Is anyone in the home considered self - employed? This includes, but is not limited to, earning money from babysitting, selling goods such as make - up or kitchenware, selling goods on the internet or selling homemade/homegrown food products? ❑ Yes No ❑ If yes, list below Name of individual that is self - employed: Business name (if applicable) : One m onth’s g ross i ncome $ Month of this income: Type of self - employment: ❑ Sole Proprietor ❑ LLC ❑ S - Corp ❑ Independent Contractor Utilities p aid for b usiness: $_________ Business taxes p aid: $_________ Interest p aid for b usiness: $_________ Gross business labor c osts: $_________ Cost of m erchandise $_________ Other business c ost: Type: $_________ Other business c ost T ype: $_________ Other business c ost: Type: $_________ Total Net Income (Subtract your e xpenses from your g ross i ncome): Has anyone in the home quit a job, lost a job, or reduced their work hours in the past 6 0 days ? ❑ Yes No ❑ If yes, list below Name of person: Employer name and phone number : Start date of job: End date of job: Monthly wages/tips (before taxes): Date and amount of last paycheck: How often was this person paid? ❑ Monthly ❑ Yearly ❑ Hourly ❑ Weekly ❑ Every two weeks ❑ Twice a month Unearned /Other Income Does anyone have other types of income? ❑ Yes No ❑ If yes, list below. Examples of other types of income are listed at the bottom of the table Name Type of Money /Income Monthly Amount Examples include but are not limited to : Unemployment benefits • SSI • Veterans’ benefits • Widow Benefits • Workers’ Comp • Railroad Retirement • ⚫ Child Support • Survivor ’ s Benefits • Dividends/Interest • Rental income • Money from a boarder • Disability benefits • Retirement/pension • SSDI • Alimony • In - kind income (Working for rent) • Social Security benefits • Public Assistance • P lasma donations • Gifts • Loans • Foster Care payments • Tribal Benefits Has anyone who is applying received (or expects to receive) a lump sum payment? ❑ Yes No ❑ If yes, list below . Name Date Received Type of Lump Sum Amount Examples: Lawsuit settlement • Insurance settlement • Social Security, SSI, SSDI Payment • Veterans • Inheritance • Surrender of Annuity • Life Insurance payout • Lottery/gambling winnings Is anyone in the home on strike? ❑ Yes No ❑ If yes, list below Name: Date strike began: Date of the last pay check: Amount of the last paycheck: 6 Revised 0 7 /2022 Expense Detail s Even if you are behind, tell us how much you are responsible to pay when answering questions about your expenses . Rent ⚫ Does anyone pay rent, renter’s insurance, or additional rental fees (pet, washer/dryer, condo or maintenance fees, etc.)? List each rent expense or rent - related fee separately . ❑ Yes No ❑ If yes, list below Expense Type (Rent/Fees) Who Pays Is this person in the home? Who is this expense for? Expense Month Amount Paid ❑ Yes No ❑ $ ❑ Yes No ❑ $ ❑ Yes No ❑ $ ⚫ Are utilities included in the rent you pay or are you billed separately? ❑ Utilities are included Billed separately for utilities ❑ ⚫ Does anyone responsible for rent receive Section 8 or public housing assistance ? ❑ Section 8 Public Housing ❑ Mortgage ⚫ Does anyone pay a mortgage, homeowner’s insurance, property taxes, or HOA fees? List each mortgage or mortgage - related expense separately. ❑ Yes No ❑ If yes, list below Expense Type Who Pays Is this person in the home? Who is this expense for? Expense Month Amount Paid ❑ Yes No ❑ $ ❑ Yes No ❑ $ ❑ Yes No ❑ $ ⚫ Does anyone responsible for the mortgage receive Section 8 or public housing assistance ? ❑ Section 8 Public Housing ❑ Utilit ies ⚫ How do you heat and cool your home? Electric ❑ Gas ❑ Firewood ❑ Propane ❑ Swamp Cooler ❑ Other ( please list type ) ❑ __________ ⚫ Have you received LEAP (energy assistance) at this address in the past 12 months? ❑ Yes No ❑ Additional Expenses ⚫ Does anyone pay child or adult daycare, legally obligated child support, child support arrears, medical expenses 1 , ◼ student loan interest, and/or alimony? ❑ Yes No ❑ If yes, list below Expense Who Pays Is this person in the home? Who is this expense for? Month of expense Amount Paid Legally Obligated Amount ❑ Yes No ❑ $ $ ❑ Yes No ❑ $ $ ❑ Yes No ❑ $ $ 1 For SNAP , medical expenses are only allow able for persons aged 60 or o ld er and persons with disabilities . E xamples of allowable medical expenses : prescriptions, medical/dental/eye, co - pays, insurance premiums , and in - patient care. Amounts reimbursed by a 3 rd party are not allowable . Student 1 Details Does anyone in the home a ttend high school, vocational, trade school , or college? ❑ Yes No ❑ If yes, list below Name ⚫ Name of School ⚫ Last Grade Completed ⚫ Start date ⚫ Expected Graduation Date Full - time student? ❑ Yes No ❑ ❑ Yes No ❑ Is anyone receiving financial aid (grants or scholarships), work - study income, or income through a GI Bill? ❑ Yes No ❑ If yes, list below Who? ◼ What is the amount ($) of Grants, Scholarships, and/or Work Study used for living expenses 2 this month? $_____________ ◼ What is the taxable amount ($) of Grants, Scholarships, and/or Work - Study this person received for the year? $_______________ - If you need Medical Assistance, you will need this information 1 For SNAP , student information i s only required for individuals between the ages of 18 and 49 unless a person under the age of 18 is the head of the household. 2 Student Living Expenses Examples: Food , Clothin g, Housing , Transportation , U tility Costs , Insurance , Other 7 Revised 0 7 /2022 Resources INFORMATION ABOUT RESOURCES IS NOT REQUIRED FOR COLORADO WORKS Does anyone in the home have any resources 1 , including those that are jointly owned with someone else? ❑ Yes No ❑ If yes, list below. Name Type of resource Name of financial institution Account number Current value $ $ 1 Examples: C ash on - hand , Checking and Savings accounts , Stock s, Bonds , Mutual funds , 401Ks , IRAs , Trusts , CDs , Annuities , College funds , PASS accounts , IDAs , P romissory notes , Education accounts ◼ Does anyone own a vehicle, including cars, trucks, motorcycles, trailers, boats, snowmobiles, and other recreational vehicles? ❑ Yes No ❑ If yes, list below Name Year, make , and model Current value $ $ Does anyone have life insurance policies or burial insurance policies? ❑ Yes No ❑ If yes, list below Who Company & Policy Number Type Revocable or Irrevocable? Value ❑ Burial policy ❑ Insurance policy ❑ Revocable ❑ Irrevocable $ ❑ Burial policy ❑ Insurance policy ❑ Revocable ❑ Irrevocable $ Does anyone in the home own any property (including your home)? ❑ Yes No ❑ If yes, list below Name/owner of property Property type Property address Value Primary use for this property (choose one) $ ❑ Primary Home ❑ Rental income ❑ Business/self - employment ❑ Other: $ ❑ Primary Home ❑ Rental income ❑ Business/self - employment ❑ Other: Has anyone in the home sold, transferred , or given away cash, property, or other assets within the last five years ? 1 ❑ Yes No ❑ If yes, list below Name Date of Transfer What Asset? Amount Received Fair Market Value $ $ $ $ 1 If you are only applying for SNAP ; you only need to declare for the last 3 months . For AND , OAP, HCA and CS - SSI , you only need to declare for the last 36 months (3 years). Prior Convictions THESE QUESTIONS ARE ONLY R EQUIRED FOR SNAP , COLORADO WORKS , AND ADULT FINANCIAL If you are applyin g for Medical Assistance, please skip to the next section. 1. Have you or any member of your home been convicted of , or disqualified for, fraudulently receiving duplicate SNAP benefits in any state after 9 /22/1996? ❑ Yes No ❑ Who: 2. Are you or any member of your home hiding or running from the law to avoid prosecution, being taken into custody, or will be going t o jail for either a felony crime , attempted felony crime , or violating a condition o f parole or probation? ❑ Yes No ❑ Who: 3. Have you or any member of your home been convicted of a felony under federal or state law for possession, use, or distribution of a controlled drug substance (felony drug conviction) or for a crime while under the influence of a controlled drug substanc e after 8 / 22/1996? ❑ Yes No ❑ Who: 4. Have you or any member of your home been convicted of , or disqualified for, buying or selling , or attempting to buy or sell, SNAP benefits for more than $500 after 9/22/1996? ❑ Yes No ❑ Who: 5. Have you or any member of your home been convicted of trading SNAP benefits for guns, ammunition , explosives, or drugs after 9/22/1996? ❑ Yes No ❑ Who: 6 . Have you or any member of your home applying for assistance ever been disqualified for an Intentional Program Violation or been convicted of welfare fraud in a criminal case? ❑ Yes No ❑ Who: 8 Revised 0 7 /2022 7 . Have you or any member of your home been convicted of aggravated sexual abuse, murder, sexual exploitation and abuse of children, sexual assault as defined in the Violence Against Women Act of 1994, or similar state law, and is also not in compliance with the terms of their sentenc e? ❑ Yes No ❑ Who: IF Y O U ARE O N LY AP P LYI N G F OR SNAP , YOU MAY S TOP H ER E . Has anyone in the home been in the military? ❑ Yes No ❑ If yes, who? If you need help to pay your burial/funeral costs, would you prefer: ❑ Cremation ❑ Burial ❑ No Preference IF Y O U ARE O N LY AP P LYI N G F OR ADULT FINANCIAL , YOU MAY S TOP H ER E . Lawful Presence Affidavit I, _______________________, swear or affirm under penalty of or perjury under the laws of the State of Colorado that: ❑ I am a United States citizen, or ❑ I am not a United States Citizen but am a legal Permanent Resident of the United States, or ❑ I am not a United States Citizen or a legal Permanent Resident but am lawfully present in the United States pursuant to federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that stat e law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the secon d degree under Colorado Revised Statute 18 - 8 - 503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature: Date: I, _______________________, swear or affirm under penalty of or perjury under the laws of the State of Colorado that: ❑ I am a United States citizen, or ❑ I am not a United States Citizen but am a legal Permanent Resident of the United States, or ❑ I am not a United States Citizen or a legal Permanent Resident but am lawfully present in the United States pursuant to federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that stat e law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I furth er acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the secon d degree under Colorado Revised Statute 18 - 8 - 503 and it shall constit ute a separate criminal offense each time a public benefit is fraudulently received Signature: Date: IF YOU ARE ONLY APPLYING FOR COLORADO WORKS , YOU MAY STOP HERE. Retroactive Medical Coverage Does anyone want help paying for medical bills from the last 3 months? ❑ Yes No ❑ Who Month(s) Household income in that month(s) Tax Filer Information Instructions : Please complete for yourself, your spouse/partner, and children who live with you and/or anyone on the same federal income tax return, if you file one. If you don’t file a tax return, remember to still add family members who live with you. Use more paper if necessary. Do you plan to file a Federal Income Tax Return NEXT YEAR? ❑ Yes No ❑ If yes, list below Filing jointly with a spouse? ❑ Yes No ❑ Name of spouse: Check only one box ⚫ AFFIDAVIT for the Colorado Department of Human Services as Proof of Lawful Presence in the United States Check only one box ⚫ AFFIDAVIT for the Colorado Department of Human Services as Proof of Lawful Presence in the United States 9 Revised 0 7 /2022 Claiming dependent(s)? ❑ Yes No ❑ Name of dependent(s) : Expects to be cl aimed as a dependent on someone else’ s tax return that does not live at your address? ❑ Yes No ❑ If yes, list below Claimed as a dependent? ❑ Yes No ❑ Name of person claiming you: Is this person listed on the application? ❑ Yes No ❑ Is this person a non - custodial parent? ❑ Yes No ❑ If you indicated that you are a tax filer and that you are Married, Filing Separately on your tax forms, do Exceptional Circu mstances (that you have been a victim of domestic violence) apply to your case? ❑ Yes No ❑ Does anyone else in the home plan to file a Federal Income Tax Return NEXT YEAR? ❑ Yes No ❑ Name: Filing jointly with a spouse? ❑ Yes No ❑ Name of spouse: Claiming dependent(s)? ❑ Yes No ❑ Name of dependent(s) : Expects to be claimed as a dependent on someone’s tax return that does not live at your address? ❑ Yes No ❑ If yes, list below: Claimed as a dependent? ❑ Yes No ❑ Name of person claiming them : Is this person listed on the application? ❑ Yes No ❑ Is this person a non - custodial parent? ❑ Yes No ❑ If you indicated that you are a tax filer and that you are Married, Filing Separately on your tax forms, do Exceptional Circu mstances (that you have been a victim of domestic violence) apply to your case? ❑ Yes No ❑ Health Insurance Coverage Does anyone in your home qualify for or have health insurance/coverage? 1 ❑ Yes No ❑ If yes, list below Name(s) Type of Coverage Coverage Dates Is this person enrolled? ❑ Eligible ❑ Enrolled ❑ Eligible ❑ Enrolled ❑ Eligible ❑ Enrolled ❑ Eligible ❑ Enrolled 1 Types of coverage : Medicare •TRICARE • VA Health Care • Peace Corps • COBRA • Retiree Health Plan •Current Employer - Sponsored Health Coverage • Railroad Retirement Insurance If you listed that someone in your home is enrolled in TRICARE, Peace Corps, VA Health Care Program, or other state or Federal Health Benefit Program, complete the table below . Type/Name of Program: Who is currently enrolled in this health coverage? Insurance Company Name: Policy number: If you listed that someone in your home has access to health insurance from a job, complete the table below. This includes if the coverage is from someone else’s job such as a parent or a spouse OR if you have COBRA or a Retiree Health Plan. Employer Na me: Employer Identification Number: Employer Address: Employer Phone: Who can we contact about your coverage? Date you could start coverage: Date you lost coverage: Who else in the Househo ld had access to this coverage? Who else in the Household was enrolled in this coverage? How much would you need to pay in premiums: $ ❑ I don’t know How often would you pay them? ❑ Weekly ❑ Every 2 Weeks ❑ Twice a month ❑ Monthly ❑ Yearly Do you have access to an employee - only health plan that meets the minimum value standard 1 health plan? ❑ Yes ❑ No If Yes, w hat is the name of the lowest - cost plan that meets the minimum value standard offered only to the employee? ❑ I don’t know ❑ No plans meet the mi nimum value standard 1 An employer - sponsored health plan meets the “minimum value standard” if the employer pays for 60% of the allowed health plan benefits. You would pay 40%. Does anyone else in the home plan to file a Federal Income Tax Return NEXT YEAR? ❑ Yes No ❑ Name: Filing jointly with a spouse? ❑ Yes No ❑ Name of spouse: Claiming dependent(s)? ❑ Yes No ❑ Name of dependent(s) : Expects to be claimed as a dependent on someone else’ s tax return that does not live at your address? ❑ Yes No ❑ If yes, list below Claimed as a dependent? ❑ Yes No ❑ Name of the person claiming them : Is this person listed on the application? ❑ Yes No ❑ Is this person a non - custodial parent? ❑ Yes No ❑ If they indicated that they are a tax filer and that they are Married, Filing Separately on your tax forms, do Exceptional Circumstances (that you have been a victim of domestic violence) apply to their case? ❑ Yes No ❑ 10 Revised 0 7 /2022 If you or anyone in your household is enrolled in Medicare, complete the table below. For Part C coverage, please complete if you will be entitled to or enrolled in the month in which you would like to purchase private health insurance. Medicare Part A Medicare Part B Medicare Part C Medicare Part D Are you entitled to or receiving Part A? ❑ Yes No ❑ Are you entitled to or receiving Part B? ❑ Yes No ❑ Are you entitled to or receiving Part C (Medicare Advantage) ❑ Yes No ❑ Are you entitled to or receiving Part D? ❑ Yes No ❑ When did your Part A begin? When did your Part B begin? When did your part C begin? When did your Part D begin? Are you currently enrolled? ❑ Yes No ❑ How much is your Part B premium ? $___________ How much is your Part D Premium ? $_______________ Who pays for your Part A premium ? _______________ Who pays for your Part B premium ? _ ______________ Who pays for your Part D Premium ? _ ______________ Is your Part A Premium Free? ❑ Yes No ❑ Are you or anyone in your home being treated for an injury that you have brought or may bring a legal claim? ❑ Yes No ❑ Name: Individuals that are 18 years or older can get their own mail about their health coverage at a different address. Do any individuals that are over 18 want to receive their own mail? ❑ Yes No ❑ If yes, list below Name Address Expected Income Change Does the income in your household change from month to month? ❑ Yes No ❑ If yes, list below Name Annual income from your job and employer name Will the Annual income be the same or lower in the next calendar year? $ ❑ Yes No ❑ $ ❑ Yes No ❑ Reasons for Income Differences After you submit your application, we will verify your income. Please tell us , if any of the following has happened to you in the past few months to help us with th e verification process: Name What Happened? ❑ Stopped working a job ❑ Hours changed at a job ❑ Change in employment ❑ Married, legal separation, or divorce ❑ Other ❑ Stopped working a job ❑ Hours changed at a job ❑ Change in employment ❑ Married, legal separation, or divorce ❑ Other Does anyone in your household have any job or non - job related deductions? Check all that apply . Provide the amount and how often you pay it. Telling us about these deductions could make the cost of your health insurance lower. You should not include a cost that you already considered in your previous answer to job income and net self - employment. Do the deductions change month to month? ❑ Yes No ❑ If yes, fill out both the current amount and the actual annual amount Deduction Type and How Often Current Amount Actual Annual Amount Type_____________________________________ ❑ One Time only ❑ Weekly ❑ Every 2 weeks ❑ Twice a month ❑ Monthly ❑ Yearly $ $ Type_____________________________________ ❑ One Time only ❑ Weekly ❑ Every 2 weeks ❑ Twice a month ❑ Monthly ❑ Yearly $ $ Type_____________________________________ ❑ One Time only ❑ Weekly ❑ Every 2 weeks ❑ Twice a month ❑ Monthly ❑ Yearly $ $ Example: • Alimony Paid • Capital Losses • Penalty on Early Withdrawal of Savings •Student Loan Interest • Domestic Production Activities • Reimbursement of Expenses • HSA deduction • Moving Expenses •Contribution made to your Traditional IRA •Certain Business Expe nses of Reservists, Performing Artists, or Fee - based Government Officials 11 Revised 0 7 /2022 Did anyone in your household have income and deductions from a past job, self - employment, or other sources during the coverage year which is not listed as current income that you will need to include on your tax return? ❑ Yes No ❑ If yes, tell us the amount of the past inco me and deductions. Do not include any ongoing or future income or deductions. Amount of past Income: $ _________ Amount of past Deductions: $ __________ American Indian or Alaska Native I nformation American Indians and Alaska Natives can get services from the Indian Health Service, tribal health programs, urban Indian hea lth programs , or through a referral from one of these programs. They also may not have to pay cost - sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible. Certain money receive d may no t be count ed as income for receiving insurance affordability programs. List any income that includes money from these sources: •Per capital payments from a Tribe that come from natural resources, usage rights, leases , or royalties •Payments from natural r esources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations) • Money from selling things that have cultural significance Is anyone in your home an American Indian or Alaska Native? ❑ Yes No ❑ If yes, list below Name Tribe Name Tribe State Type of Income Received Frequency and Amount Has anyone in the household ever received a service from the Indian Health Service, a Tribal health program, U rban Indian H ealth program or through a referral from one of these programs? ❑ Yes No ❑ If yes, list below Name: Name: If none, who in the household is eligible to receive services from Indian Health Service, Tribal health programs, U rban Indian H ealth P rograms , or through a referral from one of these programs? ❑ Yes No ❑ If yes, list below Name: Name: Permission to Validate Income As part of the eligibility process, we are required to verify the informa tion that you have provided to us for this applica ti on. By checking the box below, you indicate that Connect for Health Colorado DOES NOT have permission to verify income informa ti on from tax returns. By not allowing the use of this data, you understand that Connect for Health Colorado will send you a le tt er reques ting that you provide proof of informa tion for your household, including your annual income . If you do not prov ide the requested proof of your household’s income tax return informa tio n within 90 days of the request, you will be determined ineligible for Advance Premium Tax Credits/Cost Sharing Reduc ti ons (APTC/CSR). ❑ I DO NOT give Connect for Health Colorado permission to validate my income dat a against federal sources. AUTHORIZED REPRESENTATIVE INFORMATION FOR MEDICAL ASSISTANCE For Medical only y ou can choose an Authorized R epresent ative . An Authorized Representative is a trusted person or organization that you choose to help you with your application. We need your permission in order for your Authorized Representative to talk with us about this application, see your information, and act for you on all issues related to your health coverage. If you ever want to change your Authorized Representative , or no longer want an Authorized Representative , contact Health First Color ado & CHP+ or Connect for Health Colorado. Is your A uthorized R epresentative an: ❑ Individual ❑ Organization Authorized Individual/Organization Name : Company/Organization ID Number (is applicable): Authorized Individual/Organization’s Address: In Care Of (If applicable): City, State, Zip Code, County: Telephone Number: Email Address: 12 Revised 0 7 /2022 Do you want your Authorized Representative to receive copies of your notices/communications? ❑ Yes No ❑ By signing, you allow the Authorized Represen t ative to sign your application, get information about the application, and act for you on all future matters with this agency and/or Connect for Health Colorado. Applicant’s Signature Date: (mm/dd/yyyy) By signing, I agree to fulfill all responsibilities within the scope of the authorized representation that the individual who I represent is required to fulfill. I agree to maintain the confidentiality of any information regarding the applicant or client provided by the agency or Connect for Health Colorado in compliance with state, federal, and all other applicable laws. If an Au thorized Representative is an organization, the signature of an organizational contact who is either a provider, staff member , or volunteer of the organization is required. As a provider, staff member , or volunteer of an organization that is an Authorized Representa ti ve, I affirm that I will adhere to the regula ti ons in 42 CFR §431, Subpart F and to 45 CFR §155.260(f), and 42 CFR §447.10, as well as all other relevant state and federal laws conce rning conflicts of interests and confidentia lity of informa ti on. If you have been given the legal authority to act as an Authorized Representative on the applicant or client’s behalf through some means other than assignment through this Worksheet, you will need to affirm that you have that authority and provide the appropriate documents verifying that you have that authority. I, affirm that I have the legal authority to act on behalf of the applicant or client. (Please provide a copy of the following documents with this application when it is submitt ed: a power of attorney, court order establishing legal guardianship, or other legal documents explicitly stating that you may legally act on behalf of the applicant or client.) Authorized Representative/Organizational Contact Signature Date: (mm/dd/yyyy)