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Form 297 (Rev. 04 /13) 1 Georgia Department of Human Services Application for Benefits If you need help filling out this application, as k us or call 1 -877- 423- 4746. If you have a hearing impairment, call GA Relay at 1 -800- 255- 0135. Our services are free. What Services Do We Offer at the Division of Family and Childre n Services (DFCS)? DFCS offers the following services: Frequently Asked Questions How long does it take to get benefits? Food Stamps: up to 30 days TANF: up to 45 days Medicaid: 10 to 60 days You may be able to get Food Stamps within 7 days if you qualify. See page 5. How much will I get? Your income, resources, and family size determine benefit amounts. We will be able to give you specific information once we determine your eligibility. How will I get my benefits? For Food Stamps and TAN F, you will get an Electronic Benefit Transfer (EBT) card to access your benefits. For Medicaid, you will receive a Medicaid card for each eligible member. What information will I need to provide ? It is a good idea to provide the following: • Proof of ident ity for the applicant if applying for Food Stamps and/or TANF. Proof of identity for everyone requesting Medicaid if applying for Medicaid. Ex : A n identification card (ID) or driver’s license (DL) • Proof of US citizenship/ qualified immigrant status for ever yone requesting benefits • Social Security numbers of eve ryone requesting assistance • Proof of income for example , pay stubs, child support payments , and income award letters • Proof of expenses like child care receipts, medical bills , medical transportation co sts, and child support payments You will be given time to return any information to our office. If you need help getting this information, please tell us. How do we use the applicant’s personal information? You only have to provide Social Security Numbers (SSN) and citizenship or immigration status for persons who want to apply for benefits. This information will be used to check the income and eligibility verification system (IEVS). We will also match your information against other Federal , state and loc al agencies to verify your income and eligibility. If a household member does not want to give us information about their SSN, citizenship, or immigration status, other household members may still receive benefits . Can someone else apply for me? Yes, fo r Food Stamps and Medicaid, you may ask someone to apply for you. For TANF, anyone can apply but the parent or caretaker must be interviewed. Food Assistance Food Stamps are benefits that you can use to buy food at any store that has the EBT/ Quest sign. We will subtract the price of your food purchas e from your Food Stamp account. Cash Assistance/Employment Support Services Temporary Assistance for Needy Families (TANF) provides cash assistance to families with dependent children for a limited time . Parents or caretakers who are included in the grant are required to participate in a work program. Cash Assistance program also provides financial assistance to refugee households who are not eligible for the TANF program . Medical Assistance Medicaid, for those who are eli gible, may help pay medical bills, doctor’s visits, and Medicare premiums. Community Outreach Services For more information about Community Outreach Services, please visit our website at: http://www.dfcs.dhr.georgia.gov or call 1-877- 423-4746. How Do I Apply for Benefits? Step 1. Fill out the application. Read the questions carefully and give accurate information. Sign and date the application. Step 2. Turn in the application. Yo u will need to tear off pages 1 -3 and keep it for yourself. Mail, fax, or bring in pages 4-8 of this application to your local Division of family & Children Services (DFCS) office. If you or the person for whom you are applying is eligible for benefits , Food Stamps or TANF benefits will be provided from the date that we receive the application with your name, address, and signature on it. If you apply for Food Stamps, and/ or Medicaid you can file an application for benefits with only your name, address and signature. However, it may help us to process your application quicker if you complete the entire form. Step 3. Talk with us. You may need to complete an interview with a case manager. If so, we will give you an appointment. This interview can be completed by phone. Form 297 (Rev. 04 /13) 2 Georgia Department of Human Services Application for Benefits “In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, co lor, national origin, sex, age, or disability. Under the Food and Nutrition Act of 2008 and USDA policy, discrimination is also prohibited on the basis of religion or political beliefs.” To file a complaint of discrimination, you may contact USDA or HHS. Write USDA, Director, Office of Civil Rights , 1400 Independence Avenue, S.W., Washington, D.C. 20250-9411 or call (800) 795- 3272 (voice) or (202) 720 -6382 (TTY). Write HHS, Director, Office of Civil Rights, Room 509-F, 200 Independence Avenue, S.W., Washington, D.C., 20201 or call (202) 619- 0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street, N.W., S uite 19- 248, Atlanta, Georgia 30303 or call (404) 657-3735 or fax (404) 463-3978. Under the Department of Community Health (DCH) policy, Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national origin, or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call the Georgia Department of Community Health’s Office of Program Integrity (local 404 -463- 7590) (toll free) 800- 533- 0686 . What Do the Words Used in this Application Mean? This chart explains the words we have used in this application. Caretaker A parent, relative or legal guardian who applies for and receives TANF with children in his or her care. Grantee Relative A parent, relative or legal guardian who applies for and receives TANF in his or her name on behalf of the children. Disqualified The action taken to remove an individual from a Food Stamp or TANF case because they did not tell the truth and received benefits that they should not have received. Electronic Benefit Transfer (EBT) The system used in Georgia to pay benefits to individuals who are eligible for Food Stamps. Individuals receiving assistance are issued an EBT debit card, which is used to access their food stamp accounts . EPPICard debit MasterCar d New debit card issued by Xerox for individuals receiving cash assistance in Georgia. The EPPICard debit MasterCard will be accepted for purchases and cash withdrawals anywhere the MasterCard is accepted. Household Members Individuals who live in your home . For Food Stamps, individuals who live together and purchase and prepare their meals together. Income Payments such as wages, salaries, commissions, bonuses, worker’s compensation, disability, pension, retirement benefits, interest, child support or any other form of money received. Migrant Farm Workers Individuals who are seasonal farm workers and move from one home base to another to work or look for farm work . Resources Cash, property, or assets such as bank accounts, vehicles, stocks, bonds, a nd life insurance. Seasonal Farm Workers Individuals who work at certain times of the year planting, picking or packing produce. They are hired on a temporary basis when a job requires more workers than the farm employs on a regular basis . Form 297 (Rev. 04 /13) 3 Georgia Department of Human Services Application for Benefits What Do the Words Used in this Application Mean? (cont ’d) This chart explains the words we have used in this application. Trafficking in the SNAP/Food Stamp Program Trafficking SNAP benefits means: (1) Buying, selling, stealing, or ot herwise exchanging SNAP benefits issued and accessed via EBT cards, card numbers and PIN numbers or by manual voucher and signature, for CASH or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone; (2) The exchange of firearms, ammunition, explosives, or controlled substances; (3) Purchasing a product with SNAP benefits that has a container requiring a return deposit with the intent of obtaining cash by discarding the product and retur ning the container for the deposit amount, intentionally discarding the product, and intentionally returning the container for the deposit amount; (4) Purchasing a product with SNAP benefits with the intent of obtaining cash or consideration other than eligible food by reselling the product, and subsequently intentionally reselling the product purchased with SNAP benefits in exchange for cash or consideration other than eligible food; (5) Intentionally purchasing products originally purchased with SNAP benefits in exchange for cash or consideration other than eligible food. Qualified Alien/Immigrant A qualified alien/immigrant is a person who is legally residing in the U.S. who falls within one of the following categories: a person lawfully admitted for permanent residence (LPR) under the Immigration and Nationality Act (INA); Amerasian immigrant under section 584 of the Foreign Operations, Export Financing and Related Program Appropriations Act of 1988; a person who is granted asylum under section 208 of the INA; Refugees , admitted under section 207 of the INA; A person paroled into the US under section 212(d)(5) of the INA for at least one year; A person whose deportation is being withheld under section 243(h) of the INA as in effect prior to April 1, 1997 , or section 241(b)(3) of the INA, as amended; a person who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April 1, 1980; Cuban or Haitian immigrants as defined in section 501(e) of the Refugee Education Assistance Act of 1980; victims of human trafficking under section 107(b)(1) of the Trafficking Victims Protection Act of 2000; battered immigrants who meet the conditions set forth in section 431 (c) of the Personal Responsibility and Work Opportunity Reconcil iation Act of 1996, as amended; Afghan or Iraqi immigrants granted special immigrant status under section 101(a)(27) of the INA (subject to specified conditions ); American Indians born in Canada living in the U.S. under section 289 of the INA or non- citize ns of federally -recognized Indian tribe under Section 4(e) of the Indian Self -Determination and Education Assistance Act and Hmong or Highland Laotian tribal members that rendered assistance to U.S. personnel by taking part in military or rescue operation during Vietnam Era (8/05/1964 – 5/07/1975). Applicant An individual who chooses to apply for or to receive public assistance/benefits Non -applicant An Individual who choose s NOT to apply for or to receive public assistance/benefits; non -applicants are not required to provide an SSN, citizenship or immigration status. Assistance Unit An assistance unit includes eligible individuals who live together and receive public assistance/ benefits together. Form 297 (Rev. 04 /13) 4 Georgia Department of Human Services Applicati on for Benefits What Am I Applying For? C heck all that apply:  Food Stamps The Food Stamp program helps meet the food and nutritional needs of eligible households.  Temporary Assistance for Needy Families (TANF) Temporary Assistance for Needy Families (TANF) provides temporary monthly cas h payments, single cash payments, or other support services, to strengthen eligible families with children. If you are the child’s parent, or the caretaker who would like to be included in the grant, we will require you to participate in a work program.  Refugee Cash Assistance The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible for the TANF program. The term refugee includes refugees, Cuban/ Haitian Entrant s, victims of human trafficking, Amerasi ans, and unaccompanied refugee minors.  Medicaid Medicaid offers medical coverage to elderly , blind or disabled adults, pregnant women, children, and families. When you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive . Tell Us About The Applicant Does the applicant or person applying on behalf of the applicant need assistance when communicating with us? I f so check all that apply. ( ) TTY ( ) Braille ( ) Large Print ( ) E -mail ( ) Video Relay) ( ) Sign L anguage Interpreter _______________ ( ) Foreign Language Interpreter (specif y language) ______________________ ( ) Other ______________ Please fill out the chart below about the applicant . First Name Middle Initial Last Name Suffix Street Address Where You Live Apt City State Zip Code Mailing Address (if different) City State Zip Code Main Telephone Number Other Contact Number E - Mail address (optional) Signature Date Witness Signature if signed by ‘X’ Date For Office Use Only Date Received By The County Form 297 (Rev. 04 /13) 5 Georgia Department of Human Services Application for Benefits Do I Qualify to Get Food Stamps Faster? Answer these questions about the applicant and all household members to see if you can get Food Stamps within 7 days. 1. Are yo u or any household member a migrant or seasonal farm worker?  Yes  No 2. Total Gross earned income that will be rec eived for this month : $_______________ Employer Name __________________________________ Employment Begin Date _________ ____ Employment End Date_______________ Rate of Pay __________ Hours Worked Weekly _________ wk/bi -wk/semi -mo/mo (circle one) 3. Total Gross unearned income that will be rec eived for this month : $_______________ Type of Unearned Income ____________ Amount _______ wk/bi -wk/semi -mo/mo (circle one) Type of Unearned Income ____________ Amount _______ wk/bi -wk/semi -mo/mo (circle one) 4. Total earned and unearned income for this month: $_______________ 5. How much m oney do you and all household members have in cash or in the bank? $ ______________ 6. How much do you and all household members pay for rent or mortgage? $ ______________ 7. How much do you and all household members pay for electric, water, gas, etc.? $ ______________ Can I Choose Someone to Apply for Food Stamps or Medicaid for m e? Complete this section only if you want someone to fill out your application, complete your interview, and/ or use your EBT card to buy food when you cannot go to the store. If you are app lying for Medicaid, y ou can choose more than one person to apply for medical assistance on your behalf. Name: _______________________________________ Phone: _______________________________ Address: _______________________________________ Apt: _______________________________ City: _______________________________________ State: _______ Zip: ____________________ Name: _______________________________________ Phone: _______________________________ Address: _______________________________________ Apt: _______________________________ City: ________________________________________ State: ________ Zip : _ ___________________ For Medicaid, do you want this individual to have a copy of your Medicaid card?  Yes  No Form 297 (Rev. 04 /13) 6 Georgia Department of Human Services Application for Benefits Tell Us about the Applicant and All Household Members Please fill out the chart below about the applicant and all household members . The following federal laws and regulations: The Food and Nutrition Act of 2008, 7 U.S.C. § 2011- 2036, 7. C.F.R. § 273.2, 45 C.F.R. § 205.52, 42 C.F.R. § 435.910, and 42 C.F.R. § 435.920, authorize DFCS to request your and your household members social security number(s ) .If anyone in your household does not want to give us information about his or her citizenship, immigration status, or social security numbers, then that person can be designated as a non -applicant. Thi s means that the person will not be considered an applicant and will not be eligible for benefits. However, other household members may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any household member s are eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their SSN. You will still need to tell us about your income and resources to determine the eligibility and benefit level of the household. Individuals will not be reported to the United States Citizenship and Immigration Services (USCIS) Systematic Alien Verification for Entitlements (SAVE) system if they do not give us their citizenship or immigration status. However if immigration status information has been submitted on your application, this information may be subject to verification through the SAVE system and may affect the household’s eligibility and benefit level. Tell Us Mor e about the Applicant and All Household Members We need more information about the applicant and all household members in order to decide who is eligible for benefits . Please answer only the questions about the benefits you want to receive on the page below . NAME First Middle Initial Last Relation -ship to You Is this person applying for benefits? (Y/N) Birth Date Format ( - - / - - / - - ) Social Security Number (Applicants Only) Sex (M/F ) Hispanic/ Latino? (Optional) (Y/N) Race Code (Optional) (See codes Below) Are you a U.S citizen , qualified alien/immigrant or Hmong/Highland Laotian Immigrant ? (Applicants only) (Y/N) SELF Race Codes (Choose all that apply): AI – American Indian/Alaska Native AS – Asian BL – Black/African American HP – Native Hawaiian/Pacific Islander WH – White By providing Race/Ethnicity information, you will assist us in administering our programs in a non- discriminatory manner. Your household is not required to give us this information and it will not affect your eligibility or benefit level. Form 297 (Rev. 04 /13) 7 Georgia Department of Human Services Application for Benefits 1. Has anyone received any benefits in another county or state?  Yes  No If yes: Who: _________________________________ Where: _______________________________ When: _______________________________ 2. Has anyone been convicted of giving false information about where they live and who  Yes  No they are to get multiple FS benefits in more than one area after 8/22/96? If yes: Who: ________________________________ Where: _______________________________ When: _______________________________ 3. Did anyone in your household voluntarily quit a job or voluntarily reduce his/her work hours  Yes  No below 30 hours per week within 30 days of the date of application? If yes, who quit? _______________________________________________________ Why did he/she quit? ____________________________________ ________________ 4. Is anyone pregnant? *Please provide proof of pregnancy if available.  Yes  No (This question does not apply to Food Stamp only applicants) Who: _______________________________________ Due Date: ___________________________________ 5. For Medic aid, does anyone have any unpaid medical bills for  Yes  No the last 3 months? (This question does not apply to Food Stamp or TANF only applicants) 6. Is anyone disqualified from the Food Stam p or TANF Program?  Yes  No If yes: a. Who: ____________________________________ b. Where: __________________________________ 7. Is anyone trying to avoid prosecution or jail for a felony? (Food Stamps and TANF Only)  Yes  No If yes, w ho: _______________________________ _______ Form 297 (Rev. 04 /13) 8 Georgia Department of Human Services Application for Benefits 8. Is anyone violating conditions of probation or parole? (For Food Stamps and TANF only)  Yes  No If yes, w ho: _______________________________________ 9. Does anyone have a felony conviction because of behavior related to the possession,  Yes  No use or distribution of a controlled dr ug substance after 8/22/96 (FS and TANF only ) or a violent felony (TANF only)? If yes: Who: _______________________________________ When: ______________________________________ 10. Have you or any household member been convicted of trading Food Stamp benefits for  Yes  No drugs after 8/22/96? If yes: Who: _______________________________________ When: ______________________________________ 11. Have you or any household member been convicted of buying or selling Food Stamp benefits over $500 after 8/22/96?  Yes  No If yes : Who: ______________________________________ When: ______________________________________ 12. Have you or any household member been convicted of trading Food Stamp benefits for guns, ammunition or explosives after 8/22/96?  Yes  No If yes: Who: ______________________________________ When: ______________________________________ 13. Has anyone used TANF funds or the EPPIC Card at the following establishments , liquor stores, casinos, poker rooms, adult entertainment business, bail bonds, night clubs , salons/taverns, bingo halls, race tracks, gun/ammunition stores, cruise ships, psychic readers, smoking shops, tattoo/piercing shops, and spa/massage salons.? If yes: Who: ________________________________________  Yes  No When: _______________________________________ Form 297 (Rev. 04 /13) 9 Georgia Department of Human Services Application for Benefits Food Stamp Program Penalties Any household mem ber who breaks any of the food stamp rules on purpose can be barred from the Food Stamp Program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. S he/he may also be subject to prosecution under other applicable Federal and State laws. S he/he may also be barred from the Food Stamp Program for an additional 18 months if court ordered. Any household member who intentionally breaks the rules may not get Food Stamps for one year for the first offense, two years for the second offense, and permanently for the third offense. If a court of law finds you or any household member guilty of using or receiving food stamp benefits in a transaction involving the sale of a controlled substance, you or that household member will not be eli gible for benefits for two years for the first offense, and permanently for the second offense. If a court of law finds you or any household member guilty of having used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you or that household member will be permanently ineligible to participate in the Food Stamp Program upon the first offense of this violation. If a court of law finds you or any household member guilty of having trafficked benefits for an aggregate amount of $500 or more, you or that household member will be permanently ineligible to participate in the Food Stamp Program upon the first offense of this violation. If you or any household member is found to have given a fraudulent statement or rep resentation with respect to identity (who they are) or place of residence (where they live) in order to receive multiple Food Stamp benefits, you or that household member will be ineligible to participate in the Food Stamp Program for a period of 10 years. For All Medicaid, Food Stamps and TANF Applicants: I have read and completed everything on this form that applies to the applicant and the applicant’s household. I certify, under penalty of perjury, all the information that I provided is true and complete as far as I know. I understand I can be punished by law if I do not tell the complete truth. _______________________________________________________________ ________________________________________________ Applicant’s Signature Date ______________________________________________ ___________________________________ Authorized Representative ’s Signature Date ______________________________________________ _____________________ ______________ Case Manager ’s Name and Signature Date