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OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 1 OFS 4 I Rev. 0 7 /19 05/18 Issue Obsolete Louisiana Department of Children and Family Services Information about the Application for Assistance What kind of assistance does the Department of Children and Family Services Economic Stability offer? ● Family Independence Temporary Assistance Program (FITAP) – Provides temporary cash assistance to eligible low - income families who need assistance for children. FITAP recipients also receive Medicaid benefits through the Louisiana Department of Health . ● Suppleme ntal Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program) – Provides monthly benefits that help low - income households buy the food they need for good health. ● Kinship Care Subsidy Program (KCSP) – Provides cash assistance for eligible chil dren who reside with qualified relatives other than parents. KCSP recipients also receive Medicaid benefits through the Louisiana Department of Health. ● For more information about programs and services or for specific information about your case, call 1 - 8 88 - LAHELPU (1 - 888 - 524 - 3578). How do you apply for assistance? ● Complete the Application for Assistance, form OFS 4APP. ● The Application for Assistance may be completed online and submitted electronically on the DCFS website at www.dcfs.la.gov . ● You may also apply online or pick up a paper application at one o f you r local community partners. ● Return t he com pleted form to any parish DCFS office, if a paper application is completed. ● One form may be used to apply for the FITAP, SNAP , and KCSP . ● You may file a separate application for SNAP . Whether you file a SNAP application (paper or on line) with another pro gram or separately, your SNAP application will be processed according to the same SNAP procedures, including timeliness, notice, and fair hearing requirements. ● If you file an application for SNAP jointly with another program and are denied benefits from t he other program, you do not have to turn in another application for SNAP . You may not be denied SNAP benefits just because you may not be eligible for benefits from another program. ● We will determine your eligibility for all programs for which you apply . ● You need to be interviewed if you are applying for FITAP, SNAP , or KCSP . ● You need to pro vide verification to the parish DCFS office where you apply. Verification is explained below . If you are applying for: Complete these pages A1 1 - 7 8 - 9 10 - 11 12 - 13 FITAP √ √ √ √ SNAP √ √ √ √ KCSP √ √ √ √ Mail Fax Online In Person Department of Children and Family Services ES (225) 663 - 3164 CAFÉ’ Customer Portal www.dcfs.la.gov/CAFE Any DCFS Office Docu ment Processing Center P. O. Box 260031 Baton Rouge, LA 70826 - 9918 OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 2 Do you need help completing the application form? ● You may ask someone to help you fill out the form, or ● You may ask the worker during your interview to help you fill out th e form. What happens after we receive your application form? ● You will be assigned a worker. ● You will be interviewed, if you are applying for FITAP, SNAP, or KCSP . You may receive an appointment letter for a telephone interview. You may request to have a face - to - face interview instead of a telephone interview . ● You will receive a list of verification that is required. ● Your worker will determine your eligibility within 30 days from the date of application. ● If you applied for FITAP, you may be required to participate in the Strategies to Empower People (STEP) Program. The STEP Program provides opportunities for work - eligible FITAP families to receive job training, employment, and supportive services to enable them to become self - sufficient. What will w e do with the information that you provide? ● Information you give us on your application form will be verified by federal, state, and local offices including computer cross - matching with other agencies. Someone from our agency may contact other people in order to verify your eligibility for benefits. ● The alien status of household members is subject to verification through the United States Citizenship and Immigration Service (USCIS) and may affect eligibility and benefit amount. ● You will not have to prov ide immigration status information or documents for any household members who are not eligible because of immigration status and who are not asking for benefits. If a member of your household does not wish to provide information about his/her citizenship or immigration status, he or she will not be eligible for benefits. Other family or household members may still receive benefits, if they are otherwise eligible. You can apply for and get benefits for eligible household members even if your household inclu des other members who are not eligible because of immigration status. Why do we need your Social Security Number and are you required to provide it? ● The collection of information requested on the application form, including Social Security Numbers (SSNs) of household members, is voluntary and authorized under the Food and Nutrition Act of 2008 , (7 U.S.C. 2011 - 2036), as amended. Failure to provide required information including SSNs or proof you have applied for an SSN for household members may result in that person’s ineligibility for SNAP and cash assistance. You will not have to provide Social Se curity N umbers for any household members who are not eligible because of immigration status and who are not asking for benefits. ● SSNs are used to: o collect in formation from other sources, o check identity of household members, o determine whether your household is eligible, and o prevent households from getting more benefits than they are entitled to receive. ● SSNs are used in state and federal program reviews, au dits, and computer - matching with other agencies such as Louisiana Workforce Commission , Social Security Administration, Internal Revenue Service, etc. , through the State Income and Eligibility Verification System. ● Under the Privacy Act of 1974(P.L. 93 - 579 ), SSNs may be released for various reasons including those directly connected to the administration of the Child Support Enforcement Program. OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 3 What type of verification do you need to provide? Verification means proof of the information you report. The following table lists the information that must be verified by each program and the examples of the proof that is required. Let your worker know if you have any questions about what you must provide or if you need help in getting the proof. It is our responsibility to help you get the proof that you need. What Must be Verified and Examples of Proof SNAP FITAP (Cash) KCSP (Cash) Identity – driver’s license, work or school ID, ID for health benefits or another social services program, voter’s regist ration card, check stub, or birth certificate √ Age/Relationship - birth certificate, baptismal certificate, or hospital birth records of the person to be included. If not your own child, birth records to prove how the child is related to you √ √ Soc ial Security Number - copy of the social security card or papers you received at the hospital for a newborn . A Social Security number is not required for any household member who is not eligible due to immigration status. √ √ √ Alien status - if not a U. S. citizen, forms or cards from USCIS that prove the person is a legal alien (unless you choose not to apply for this person) √ √ √ Wages - last 4 pay check stubs or employer’s statement for each person who works √ √ √ Self - employment - income tax return s, sales records, quarterly tax records, personal wage record √ √ √ Other income such as contributions, child support, alimony, Social Security, SSI, VA, retirement checks, Unemployment Compensation (UCB) - award letters, court orders, statements from con tributors √ √ √ Income that stopped within the last 2 months – pink slip, termination notice, or statement from former employer, termination notice or statement from source of any income that ended √ √ √ Medical expenses - receipts, pharmacy printouts fo r last 3 months, doctor bills or other papers that show medical expenses for household members who are disabled or over age 59 √ Child support payments made to someone outside your home - court order or other legal papers and proof that you are making p ayments such as cancelled checks or wage withholding statements √ Immunization - shot, school, or doctor’s records √ √ C ustody - court order , other legal papers , or provisional custody by mandate √ Home - proof of who lives in the home; such as cur rent school records, landlord’s written statement or the name and phone number of two people (not related to you) who know your situation √ √ OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 4 Rights and Responsibilities When you receive benefits from the Louisiana Department of Children and Family Services, you have certain rights and responsibilities that are explained below. Keep this important information for future reference. What are your rights? This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs. The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex , religious creed, disability, age, political beliefs or reprisal or retaliat ion for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc .), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877 - 8339. Additionally, program information m ay be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form , (AD 3027), found online at: https://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office, or write a letter addressed to USDA and provide in th e letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632 - 9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C.20250.9410 (2) fax: (202) 690 - 7442; or (3) email: [email protected] . For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons shou ld either contact the USDA SNAP Hotline Number at (800) 221 - 5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotlin e numbers by State);found online at: https://www.fns.usda.gov/snap/contact_info/hotlines.htm . To file a complaint of discrimination regarding a program receiving Federal financial as sistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515 - F, 200 Independence Avenue, S.W., Washington, D.C.20201 or call (202) 619 - 0403 (voice) or (800) 537 - 7697 (TTY). This institutio n is an equal opportunity provider. You may file a civil rights complaint with the Department of Children and Family Services (DCFS) by completing the Civil Rights Complaint Form. Turn the form in to a local office; mail it to DCFS Civil Rights Section, P O Box 1887, Baton Rouge, LA 70821;email [email protected] , or; call (225) 342 - 0309. You may file a civil rights complaint with DCFS and USDA or only DCFS. A program complaint may be f iled with the Department of Children and Family Services (DCFS) by emailing [email protected] or by calling 225 - 342 - 2342. OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 5 ● Fair Hearing - If you do not agree with any decision made on your case, you have the right to ask that your case be reviewed. You can tell us that you want a fair hearing in writing, in person, or by calling th e office. You have the right to look at your case record before the hearing. ● Confidentiality – All the information you give us i s confidential. This means that we cannot give information about your case to other people except under special conditions. Examples of those conditions include official review by other State and Federal agencies or Federal, State and private collection agencies for the collection of claims against SNAP benefits. Information from your case may also be given to law enforcement officials for the purpose of catching persons fleeing to avoid the law and for investigation of a felony or prob ation/parole viola tion. ● Voter Registration - If you are not registered to vote where you live now, you may indicate that you would like to apply to register to vote on the Application for Assistance. Please note that the information you give to the agency will remain conf idential and will be used only for voter registration purposes. Applying to register or refusing to register to vote will not affect the amount of assistance or services that you may receive from the Department of Children and Family Service s. DCFS will a ssist you with completing a Louisiana V oter Registration A pplication unless assistance i s refused. You may fill out the application form in privat e. What are your responsibilities? ● Cooperation - You have to cooperate by providing the information we nee d to determine your eligibility for benefits for you and others for whom you are applying. You also have to provide proof of the information you report. You will be expected to cooperate if a home visit is necessary to determine your eligibility. If your c ase is selected for a quality control review by state or federal reviewers, you have to cooperate with them. ● Report changes – If you receiv e SNAP benefits, you must report if : o Y our household’s monthly income increases to more than the gross income li mit for your household size. This includes reporting the income of a person who moves into your home if that person’s income combined with your SNAP household’s income is more than the gross income limit for your household . o Y our household includes an Ab le - Bodied Adult Without Dependent (ABAWD), you must report changes in work hours of the ABAWD who is subject to the SNAP time limit if the change results in the ABAWD working an average of less than 20 hours per week or less than 80 hours per month. o Your household receive s lottery or gambling winnings of $3500 or more , won in a single game before taxes or other withholdi n gs. These changes must be reported by the 10 th of the month following the month in which the change occurs . In addition, if you are re ceiving: o FITAP - You have to:  Follow the reporting requirements explained in your Family Success Agreement and report these changes within 10 days of your knowledge of the change.  Report within 10 days if the only eligible child receiving FITAP ben efits moves out of your home. o KCSP - You have to report within 10 days if the only eligible child receiving KCSP benefits moves out of your home. If you are not receiving SNAP benefits , and are receiving: o FITAP or KCSP - You have to report within 10 d ays if:  There is a change in the source of any income received in your household. This includes changes in employers and new sources of income such as child support, Social Security, SSI, etc.  The amount of your household’s unearned income changes by more than $50 per OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 6 month.  The amount of your household’s earned income changes by more than $100 per month.  Someone moves into or out of your household.  You move. o FITAP or KCSP - In addition to the changes listed above, you have to report within 10 days any changes in:  School attendance of any 18 year old in your household.  Marital status of anyone in your household. Information on Non - Cash Services Your household may be authorized to receive the following non - cash TANF/MOE funded services. For additional information, please visit our website at www.dcfs.louisiana.gov or contact your local DCFS Office.  Family Violence Prevention and Intervention Program - Provides services for victims of domest ic violence and their children. Services are limited to children and/or parents/caretaker relatives who are victims of domestic violence. Call 1 - 888 - 411 - 1333.  Jobs for America’s Graduates LA (JAGS - LA) Program - Helps keep in school students (age 12 throu gh 21) at risk of failing who face at least two barriers to success which may include economic, academic, personal, environmental, or work related barriers; assists out - of - school youth in need of a high school education; provides an avenue for achieving ac ademically; and assists students in ultimately earning recognized credentials that will make it possible for them to exit school and enter post - secondary education and/or the workforce. Call 225 - 219 - 0368.  Nurse Family Partnership Program - Serves low - inc ome, first - time mothers who are no more than 28 weeks pregnant by providing nurse home visitation services beginning early in pregnancy and continuing through the first two years of the child’s life. Call 504 - 219 - 9520 or 337 - 898 - 6097.  Court Appointed Spe cial Advocates (CASA) - Enhances family stability by facilitating links between the particular child/family and community resources/systems through trained, qualified, and supervised advocates who provide skilled communication, necessary transportation, ef ficient and thorough information gathering, and other services identified in an individual case. Call 225 - 930 - 0305 and 1 - 888 - 567 - 2272.  Drug Court Programs - Combines both treatment and educational components with the ability of a supervising judge to awa rd incentives and sanctions based upon the performance of the clients while in treatment. Treatment is community - based and drug court participants are required to meet with the judge on a regular basis to review progress. Call 504 - 568 - 2020.  Alternatives to Abortion - Provides intervention services including crisis intervention, counseling, mentoring, support services, and pre - natal care information, in addition to information and referrals regarding healthy childbirth, adoption, and parenting to help ensu re healthy and full - term pregnancies as an alternative to abortion.  LA 4 Public Pre - Kindergarten Program - Provides high quality early childhood education for low income 4 - year - olds in participating public school districts and Charter schools. OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 7 Penalti es If you knowingly report incorrect information, your SNAP benefits or cash assistance may be denied, reduced, or ended and you may be subject to criminal prosecution. What penalties apply in SNAP ? If you do the following: You will: ● Hide information o r give false information ● Trade or sell SNAP benefits or EBT cards ● Use SNAP benefits to buy ineligible items, which includes alcohol , tobacco , hot food, and any food sold for on - prem i s e s consumption. Nonfood items are also not allowed. ● Use someone else’s S NAP benefits ● Pay for food purchased on credit with SNAP benefits Lose your SNAP benefits for: ● 1 year for the first violation ● 2 years for the second violation ● Permanently for the third violation You may also be fined up to $25 0 ,000 or impri soned for up to 20 years or both. ● Trade SNAP benefits for illegal drugs Lose your SNAP benefits for: ● 2 years for the first violation ● Permanently for the second violation ● Trade SNAP benefits for firearms, ammunition, or explosives ● Trade, buy, or sell SNAP benefits of $500 or more ● Lose your SNAP benefits permanently ● Give false information about who you are or where you live in order to receive benefits in more than one case at the same time ● Lose your SNAP benefits for 10 years What penalties apply in FITA P and KCSP? If you do the following: You will: ● Hide information or give false information Lose your benefits for: ● 1 year for the first violation ● 2 years for the second violation ● Permanently for the third violation You may also be fined up to $ 5 0,00 0 or imprisoned for up to 20 years or both. ● Use your EBT card:  in a liquor store,  in a gambling casino or gaming establishment,  in a retail establishment that provides adult entertainment in which performers disrobe or perform in an unclothed state for e ntertainment purposes,  at any adult bookstore, any adult paraphernalia store, or any sexually oriented business,  at any tattoo, piercing, or commercial body art facility,  at any nail salon,  at any jewelry store,  at any amusement or video arcade,  at any bai l bonds company,  at any night club, bar, tavern, or saloon,  on any cruise ship,  at any psychic business; or  at any establishment where persons under age 18 are not permitted, or  at an ATM in any of these establishments . Lose your benefits for: ● 1 year for the first violation ● 2 y ears for the second violation ● Permanently for the third violation OFS 4I – Rev. 0 7 /19 05/18 Issue Obsolete 8 ● Use your EBT card:  at any retailer for the purchase of an alcoholic beverage,  at any retailer for the purchase of tobacco products, or  at any retailer for the purchase of lottery tickets ,  at any retailer for the purchase of jewelry. ● Give false information about where you live in order to receive benefits in two or more states at the same time ● Lose your benefits for 10 years OFS 4APP – Rev. 08 /1 9 A 1 12/17 Issue Obsolete OFS 4APP Rev. 08 /19 05/18 Issue Obsolete II Louisiana Department of Children and Family Services OFFICE USE ONLY Date Received Application for Assistance Assigned to Is an EBT card needed? Yes No Check only those programs for which you are applying: Family Independence Temporary Assistance Program (FITAP) Kinship Care Subsidy Program (KCSP) Supplemental Nutr ition Assistance Program (SNAP) (formerly the Food Stamp Program) You can begin to apply and establish your application date by filling in your name, address and signature below and give this form to us today. It will help us to process your application faster if you also give us a telephone number where you can be reached during the day and p rovide a copy of a photo ID or other proof of identity. Can you read and understand English? (¿Puede leer usted y poder comprender ingles? ) Yes ( S í ) No If No , what language can you read and understand? (¿Si no, qué idioma le puede lee y comprende?) (Last Name ) (First Name) (Middle Name ) Social Security Number Street or Rural Route Apt. or Lot# City and State Zip Code Phone# Mailing Address if different from above: I certify under penalty of perjury, the truth of the information contained in this application, i ncluding the information concerning citizenship and alien status of the members applying for benefits. Your Signature What if you need SNAP benefits right away? We may be able to get SNAP benefits to you within 7 days of t he date you apply if you qualify. You may qualify if:  The total amount of money you have received or expect to receive this month is less than $150 and you have $100 or less in liquid resources such as cash, savings or checking ac counts; or  Your household’s rent/mortgage and utilities are more than your total income and resources; or  Your household includes migrant or seasonal farm workers. If any of the above describes your househ old, answer the following questions: 1. What is the total amount of money that your household will receive this month? Include money from all sources such as earned income, contributions, Social Security, SSI, VA, etc. $ $ 2. How much money does your household have in liquid resources? Include cash on hand, checking accounts, savings accounts, etc. 3. How much is your household’s monthly rent or mortgage? $ 4. Do you pay for utilities, such as electricity, gas, water, etc.? Yes No 5. Do you pay utility costs for heating or air conditioning? Yes No 6. Do you pay telephone expenses? Yes No 7. Is anyone in your household a migrant or seasonal farm worker? Yes No OFS 4APP – Rev. 08 /1 9 A 2 12/17 Issue Obsolete Office Use Only 1. Income $ Is #1 less than $150?  Yes  No + AND 2. Resources $ Is #2 le ss than $101?  Yes  No = Total $ (A) If yes to both, Expedite. If no, consider shelter costs. 3. Rent/Mortgage $ Is B greater than A?  Yes  No + If yes, Expedite. If no, consider migrant or seasonal farm w orker status. Utility Standard * $ Is anyone in the household a migrant or seasonal farm worker?  Yes  No = AND Total $ (B) Is #2 less than $101?  Yes  No If yes to both, Expedite. If no, the case is not expedited. * If, on the reverse side, the answer to: #4 is Yes and #5 is No, use BUA. #5 is Yes, use SUA #6 is Yes and #4 and #5 are No, use TEL. Expedited: Yes No If yes, enter “Expedited Date” on CP CA screen of LAMI. Due Dat e * : *The case must be certified and the client must have their EBT card in sufficient time to be able to use their SNAP benefits by the 6 th calendar day after th e date of application. If the 6 th calendar day falls on a weekend or holiday, the due date becomes the previous workday. Expedited status determined by: Signature of Agency Representative Date OFS 4APP - Rev. 08 /19 1 12/17 Issue Obsolete A . Tell Us About You This information is requested solely for the purpose of determining DCFS compliance with Federal civil rights laws. Your response will not affect consideration of your application and may be protected by the Privacy Act. The information is being collected to assure that program benefits are distributed without regard to race, color, or national origin. Do you need a new Louisiana Purchase Card? Yes No First Name Middle Initial Last Name Maiden or Other Name Mailing Address Apt/Lot No. City State Zip Code Home Address (If different from mailing) Apt/Lot No. City S tate Zip Code ( ) ( ) ( ) Home Telephone Number Cell Telephone Number Work or Other Telephone Number Social Security Number Parish of Residence Date of Birth E - mail Address Sex : Male Female Ethn icity: Hispanic/Latino? Yes No Highest grade level completed in school? Marital Status: Racial Heritage (check all that apply): Student? Yes No Married Asian Native Hawaiian/ U.S. Citizen? Yes No Separated White Pacific Islander If no, do you have Divorced Americ an Indian/ immigration papers? Yes No Never Married Alaskan Native Date of entry in U.S.: Widowed Black or African American Would you like a copy of your a pplication? Yes No If yes, what format would you like the copy of your application? Paper Electronic B. Tell Us If You Have An Authorized Representative An Authorized Representati ve is someone you allow us to talk with about your SNAP Program benefits. You can name someone, but it is not required. Would you like to have an Authorized Representative? Yes No If yes , tell us about your Author ized Representative. ( ) Name of Authorized Representative Relationship to Applicant Telephone Number Address City State Zip Code For Office Use Only Rights and Responsibilities discussed with applicant? Yes No Reporting requirements explained to applicant? Yes No Is an EBT card needed? Yes No Is there an authorized representative? Yes No Identity verified by: Driver’s License Identification card Other Residency verified by: Marital status verified by: Reason for application: FITAP/KCSP explained? Yes No Client selected: FITAP KCSP OFS 4APP - Rev. 08 /19 2 12/17 Issue Obsolete C. Tell Us About The Other People In Your Household – Do Not Include Yourself List everyone else who lives in your household, even if you are not applying for them. This information is requested solely for the purpose of determining DCFS compliance with Federal civil rights laws. Your response will not affect consideration of your application and may be protected by the Privacy Act. The information is being collected to assure that program benefits are distributed without regard to race, color, or national origin. Don't miss out on No Cost Health Insurance. If you answer the question below, we will share what you entered on this application with the Louisiana Department of Health (LDH). LDH will sign up anyone who qualifies and send you a letter with more information about the Medicaid program. Children and adults (under age 65 without Medicare) may qualify. PLEASE ANSWER THE QUESTION BELOW. Yes, p lease share my information with LDH so I do not need to complete another application. No, please do not share my information. Do not help me get Medicaid. Household Members (Enter Name) Relation to you (NR=Not Related) Birth Date Soc ial Security Number Sex (M/F) US Citizen? (Yes/No) ED Level * Marital Status Race/ Ethnic Code ** Last First MI Complete these sections only for those who need benefits * * Race : (You may select more than one race) * *Ethnicity: AN = Alaskan Native WH = White BL = Black or African American Y = Hispanic or Latino AI = American Indian AS = Asian PI = Native Hawaiian or other Pacific Islander N = Not Hispanic or Latino *ED Level : List highest grade completed or GED/college If you need more space for additional household members, you can write the information on plain paper or ask for an “Additional Household Members Form.” If anyone for whom you are applying is not a U. S . citizen, your worker will complete an Alien Addendum and Checklist with you during your interview for those for whom you are applying . For Office Use Only Household composition: person household Are all members linked on LAMI? Y es No Enumeration verified by: Age and relationship verified by: Document CR 5 Citizenship: Are all household members U.S. citizens ? Yes No If no, complete Alien Addendum and Alien Checklist for all aliens who the household is applying for benefits. Names of aliens who have opted out of applying for benefits due to immigration status. OFS 4APP - Rev. 08 /19 3 12/17 Issue Obsolete D. Tell Us About Your Household For Office Use Only Please answer the following questions for yourself and everyo ne else in your home. 1. Are you or anyone in your household a fleeing felon? Yes No 2. Are you or anyone in your household in violation of their probation or parole? Yes No 3. Have you or anyone in your household been convicted as an adult for a felony that occurred after February 7, 2014, for one of the following crimes? Yes No Aggravated sexual abuse under section 2241 of title 18, U.S. C.; Murder under section 1111 of title 18, U.S.C.; Sexual exploitation and other abuse of children under chapter 110 of title 18, U.S.C.; A Federal or State offense involving sexual assault, as defined in section 40002(a) of the Violence Against Women Act of 1994 (42 U.S.C. 13925(a)); An offense under State law determined by the Attorney General to be substantially similar to an offense listed above. If yes, who? Is this person in compliance with terms of their sentence? Yes No 4 . Have you or anyone in your household been disqualified or had their benefits reduced or stopped for breaking the rules of SNAP, FITAP, KCSP, or SSI? Yes No 4 . If yes, complete sup plement. 5 . Do you or anyone in your household have a disability? Yes No 5 . If yes, complete supplement. 6 . Does anyone in your household attend high school, college, vocational or technical school? Yes No 6 . If yes, is anyone attending an institution of higher education? Yes No If yes , complete the following for each student : If yes, complete supplement. a. Eligible stu dent Ineligible student Name of Student Name of School and Program of study How many hours does the student attend school each week? Is this considered full or part - time? Full - time Part - time b. Eligible student Ineligible student Name of Student Name of School and Program of study How many hours does the student attend school each week? Is this considered full or part - time? Full - time Part - time 7 . Do you usually buy food and prepare your meals with Yes No everyone who lives with you? If no , who buys and prepares their food separately? 8 . Have you or a nyone in your household received cash Yes No assistance or SNAP benefits in Louisiana or from another state? a. If yes , who? b. When? c. What state(s)? 9 . Do you or anyone in your household have an 9 . If yes, what type? application pending for any benefits that you are not receiving yet? Yes No OFS 4APP - Rev. 08 /19 4 12/17 Issue Obsolete E. Tell Us About Your Household’s Work For Offi ce Use Only Tell us about any money received by you or anyone in your household for work including full - time, part - time, temporary, or seasonal jobs, self - employment, training, military reserve pay, or work study. This includes money received from wages, salaries, tips, or commissions. 1. Do you or anyone in your household work? Yes No Complete the following information for each person who works for an employer. If anyone works for more than one employer, complete a separate block for each employer. Use plain paper if you need more space. 2. Person Who Works For An Employer Use OFS 3 Name Start Date Verified by: Employer’s Name Phone # Address How often paid? Weekly Every two weeks Twice monthly Monthly Other Are reimbursements received? Yes No # of hours worked per week Hourly wage # of days worked per week Do you ever work overtime? Yes No Is commission earned? Yes No If yes, how much? How often? Is this piecework? Yes No Rate per piece? If yes , how often? How many hours? Are tips earned? Yes No If yes , how much? How often? Is this Work Study? Yes No 3. Person Who Works For An Employer Name Start Date Use OFS 3 Employer’s Name Phone # Verified by: Address How often paid? Weekly Every two weeks Twice monthly Monthly Other Are reimbursements received? Yes No # of hours worked per week Hourly wage # of days worked per week Do you ever work overtime? Yes No Is commission earned? Yes No If yes, how much? How often? Is this piecework? Yes No Rate per piece? If yes , how often? How many hours? Are tips earned? Yes No If yes , how much? How often? Is this Work Study? Yes No 4. Is anyone on strike? Yes No 5. Has anyone in your household (including you) stopped working in the last 6 0 days? Yes No 5. If ye s, complete supplement. OFS 4APP - Rev. 08 /19 5 12/17 Issue Obsolete Complete the following information for each person who is self - employed. This includes fishermen, child care providers, hair dressers, and people who do odd jobs such as cutting grass, picking up cans, etc. Use plain paper i f you need more space. For Office Use Only 6 . Persons Who Are Self - Employed 6 . Verified by: Prior year’s income tax Name Name return Accountant or Type of Business Type of Business bookkeeper records Personal business Monthly Business Income Monthly Business Income records Monthly Business Expenses Monthly Business Expenses # Hours Worked Per Week # Hours Worked Per Week 7. Is anyone in your household (including y ou) looking for work? Yes No 7. If yes, complete supplement. 8. Is anyone in your household a migrant or seasonal farm worker? Yes No 9. Do you or anyone in your household re nt a room? Yes No 10. Do you or anyone in your household pay someone else in your home for meals? Yes No F. Tell Us About Other Income 1. Do you or anyone in your household r eceive money from a source other than work? Yes No If yes , check each type of income. Annuity Income Roomer/Boarder Child Support Income So cial Security Contributions From Family/Friends Scholarships/Grants/School Loans Disability Insurance Benefits SSI Energy Check Spousal Sup port/Alimony Interest Income Tribal Money Loans Training Allowance (WI O A) Military Allotment Trust Income Oil Lease/R oyalties Unemployment Benefits Railroad Benefits Veterans Benefits Rental Income Workers Compensation Retirement Pension Other For Office Use Only FITAP SNAP Name Age WR Code Reason For Exemption WR Code Reason For Exemption OFS 4APP - Rev. 08 /19 6 12/17 Issue Obsolete 2. For each box checked in #1 of this section on page 5 , complete the following information. Include any money you expect to receive in the next 30 days. For Office Use Only Name Type Of Income Amount How Often (Weekly, Monthly, etc) Do You Expect This Income To End Yes No Verified by: If yes, when? Yes No If yes, when? Yes No If yes, when? Yes No If yes, when? 3 . Is someone court - order ed to pay child support to you or anyone in your household? Yes No 3 . If yes, complete supplement. 4 . Do you or anyone in your household receive any money from a child’s parent who is not court - ordered to pay? Yes No 4 . If yes, complete supplement. G. Tell Us About Your Expenses Living Arrangement In order to receive the most benefits poss ible, you need to tell us about your household expenses . Failure to report any of the e xpenses listed below will be seen as a statement by your household that you do not want to receive a deduction for the unreported expense. Public housing HUD or Section 8 subsidy Other subsidy No rent subsidy HOUSING EXPENSES 1. Check each type of housing expense that you or anyone in your household has. Rent Electricity Mortgage (s), (if buying) Gas Are insurance and property taxes included in the mortgage payment? Yes No Are any of these bills past due? Yes No Lot Rent Sewer Homeowner’s Insurance Water Flood Insurance Garbage Property Tax Telephone Condominium Fees Other 2. For eac h box checked in #1 of this section, complete the following information. Type Of Housing Expense Name and Phone Number of Person or Company Paid Amount Paid How Often Paid (Weekly, Monthly, Etc.) Indicate how each expense was verified. Eligible for: SUA BUA TEL None OFS 4APP - Rev. 08 /19 7 12/17 Issue Obsolete 3. Do you pay housing expenses for a home you are no longer living in but plan to return to? Yes No For Office Use Only 4. Is your household responsible for paying a utility bill for using a heater or air conditioner? Yes No 5. Does anyone help you pay your housing expenses? Yes No 5. If yes, complete supplement. 6. Do you receive energy assistance? Yes No If yes , is the assistance through the Low - Income Home Energy Assistance Program (LIHEAP)? Yes No 7. Is any of the rent you pay used to pay utilities? Yes No DEPENDENT CARE EXPENSES 1. Do you or anyone in your household pay someone to care for a child, or an adult who is elderly or disabled, so that you or a household member can work, attend training or school, or look for work? Yes N o 1. If yes, complete the OFS 4DC - Dependent Care Expense Worksheet Certified for CCAP? Yes No 2. If yes , complete the following information. Paid For Whom Name And Telephone Number Of Person Paid Amount Paid How Often Paid (Weekly, Monthly, Etc.) What is co - payment amount? CHILD SUPPORT EXPENSES 1. Does anyone in yo ur household pay court - ordered child support? Yes No Court - ordered child support expenses: If yes , complete the following information. Who Pays Paid to Whom Amount Paid How Often Paid (Weekly, Monthly, Etc.) MEDICAL EXPENSES We can allow a medical deduction in your SNAP case for each household member who has a disability or is over the age of 59. A deduction may be given for medical expenses that are more than $35.00 per month. 1. Is there anyone in your household who has a disability or is over the age of 59? Yes No If yes , answer the questions in this section. If no , skip to the Household Resources section on the next page. 2. Does this person have to pa y medical expenses? Yes No a. If yes , do you want to verify these expenses so that you can receive a medical deduction? Yes No Medical expenses: Use form SNAP 1MW b. Check each medical expense that this person has. Dental Bills Prescribed Medicine Hospital Bills Prescription Drug Plan Health Insurance Or Premium Medicare Pr emiums Nursing Home Medical Appliances Other OFS 4APP - Rev. 08 /19 8 12/17 Issue Obsolete 3. For each box checked in # 2 on page 7 , complete the following information. For Office Use Only Names Type of Expense Amount Paid How Often Paid ( Weekly, Monthly, Etc.) Medical Transportation Expense is money spent for trips to the doctor, hospital, drug store, etc. This includes miles driven in your own vehicle. 4. Does any elderly or disabled person listed on previou s page have medical transportation costs? Yes No a. Does this person use their own vehicle or a household member’s vehicle? Yes No b. If yes , complete the following infor mation. Name Of Person List All Places Visited For Medical Purposes (Ex. Doctors, Drug Store, Hospital, Etc.) # Of Miles Traveled Round Trip Number Of Visits Per Month c. Does this person pay someone other than a household member fo r medical transportation? Yes No d. If yes , complete the following information. Name Of Person Who Is Paid Where Does This Person Go How Much Does This Person Pay Per Trip How Many Trips Does This Person Pay For E ach Month If you need more space, you can write the information on plain paper. 5. Will you or anyone in your household be reimbursed for any of the medical expenses listed above? Yes No 5. If y es, complete supplement. 6. Does anyone help pay the medical expenses? Yes No 6. If yes, complete supplement. When management is questionable, use form OFS 4MW. OFS 4APP - Rev. 08 /19 9 12/17 Issue Obsolete H. Tell Us About Your Household’s Resources For O ffice Use Only Resources include cash, money in the bank, Certificates of Deposit, stocks, and bonds. Resources do not include personal property such as jewelry, furniture, electrical equipment, or clothing. 1. Check each resource listed below that you or anyone in your household has. Bank/Credit Union Account Cash On Hand (Checking) Certificate Of Deposit (CD) Bank/Credit Union Account Money Market Accou nt (Saving) Mutual Funds Joint Account Savings Bond Bonds Stocks 2. For each box checked above, complete the following information. In Whose Name Is The Resource Listed Type Of Resource How Much Is It Worth Where Is The Resource (Include Name Of Bank Or Company, Where Money Is Held, Address Of Property, Etc.) Are liquid resources $1500 or less? Yes No 3. Have you or anyone in your household received a Federal tax refund in the last twelve months? Yes No 3. If yes, complete supplement. 4. Have you or anyone in your household received or do you or any one in your household expect to receive a lump sum of money? Yes No 4. If yes, complete supplement. Countable lump sum Non - countable lump sum 5. Does your name or the name of anyone in your household appear on a bank/credit union account with someone else? Yes No How was this verified? Client statement Bank statement Other a. If yes , whose names are on the account? b. Why is this name on the account? c. Does someone else make deposits into this account? Yes No d. If yes , who and how much per month? 6. Have you or anyone in your ho usehold sold, traded, given away, or transferred a resource in the last three months? Yes No 6. If yes, complete supplement. For Office Use Only I F Y OU A RE A PPLYING F OR SNAP B ENEFITS O NLY , S KIP T O P AGE 1 2 . OFS 4APP - Rev. 08 /19 10 12/17 Issue Obsolete COMPLETE THIS PAGE ONLY IF YOU ARE APPLYING FOR FITAP OR KCSP I . FITAP or KCSP For Office Use Only 1. Are you applying for FITAP or KCSP? Yes No If yes , complete this page. If no , skip to page 1 2 . 2. Do you or anyone in your household need to get away from an 2. If yes, issue Flyer DV abusive situation? Yes No 3. Are immunizations current on all children? Yes No 3. Verification: OFS IM If no , who? Why: CR9 4. Are you or anyone in your household pregnant? Yes No LINKS If yes, who? Due date: HEALTH INSURANCE 5 . Can you or anyone i n your household get health 5 . If yes, provide BHSF Flyer LaHIPP insurance through an employer? Yes No COLLATERALS 6 . Please complete the following information for two people who are not *Note: If client check ed “ Y es” for #5 on page 3, complete OFS 90 or OFS 90L. related to you who can verify your household situation. Name Address Daytime Phone Number CUSTODY 7 . If you are not the parent of the child(ren) for whom 7 . Custody verified by: you are applying, do you have custody? Yes No a. If yes , complete the following information. Children For Whom You Have Custody Type Of Custody Effective Date Of Custody A non - custodial parent is a parent who does not live in the home with his/her child. Tell us about the non - custodial parent(s) of each child living in your home. This includes both mother and father if you are not the parent of the child(ren). If a child’s biological father and le gal father are not the same person, give the requested information for both fathers. Use plain paper if you need more space. 8 . Non - Custodial Parent Information Name Social Security Number Date of Birth Street Address City State Phone Number Employe r Name(s) of Children Parental Relationship (relationshi p of children’s parents) : Married Widowed Never Married Divorced OFS 4APP - Rev. 08 /19 11 12/17 Issue Obsolete 9 . Non - Custodial Parent Information Name Social Securi ty Number Date of Birth Street Address City State Phone Number Employer Name(s) of Children Parental Relationship (rela tionship of children’s parents) : Married Widowed Never Married Divorced 10 . Non - Custodial Parent Information Name Social Security Number Date of Birth Street Address City State Phone Number Employer Name(s) of Children Parental Relationship (rela tionship of children’s parents) : Married Widowed Never Married Divorced For Office Use Only Living in the home with qualified relative? Yes No Verified by: Landlord statement School records Collateral Other NCP: Complete form 4NCP and 4NCP Supplement, if applicable: OFS 4APP - Rev. 08 /19 12 12/17 Issue Obsolete Read Carefully And Sign Below I certify under penalty of perjury that the information I have given on this application is true, complete, and correct to the best of my knowledge, including the information I have given regarding the felony conviction of certain crimes and the U.S. citizenship or immigration status of all household members. I understand that I and any adult household member will be subject to disqualification and prosecution and will be required to repay ineligible benefits if we knowingly give false, incorrect, or incomplete information in order to obtain or try to obtain financial or f ood assistance. By signing this application, I give permission for the release of information to the Department of Children and Family Services by any persons or agencies who have knowledge of my circumstances. Remember, you must turn in proof of the inf ormation you reported on this application form and verification of your identity. Your Signature (or mark) Date Signed Signature (or mark) of your wife or husband Date Signed Signature of Minor Unmarried Parent Date Signed If you, or you r wife or husband, sign with an “X” mark, ask two people to witness the mark; if applicant is blind, ask three people to witness. Witness Witness Witness Signature of Person Who Helped You Complete this Form and His or Her Relationship to You Signature Relationship Signature of Agency Representative Date I want to withdraw my application because Signature of Applicant Date How to submit the Application for Assistance to the Department of Children and Family Services (DCF S): By Mail: Department of Children and Family Services ES Document Processing Center P. O. Box 260031 Baton Rouge, LA 70826 - 9918 By Fax: (225)663 - 3164 In Person: Any DCFS Office If you have any questions regarding the application process, please c ontact the Customer Service Center at 1 - 888 - LAHELPU (1 - 888 - 524 - 3578). OFS 4APP - Rev. 08 /19 13 12/17 Issue Obsolete Voter Registration If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Check one) I want to register to vote. I do not want to register to vote. IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. Applying to register or declining to register to vote will no t affect the amount of assistance that you will be provided by this agency. Voter eligibility requirements are found on the voter registration application form. Note: If you do register to vote, the location where your application was submitted will rem ain confidential. If you decline to register to vote, this fact will remain confidential. Applying to register or declining to register to vote will be used only for voter registration purposes. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. (Check one) Yes, I would like hel p . No, I do not want help. For assistance in completing the voter registration application form outside our office, contact the Department of Children and Family Services at 1 - 888 - LAHELPU or 1 - 888 - 524 - 3578. If co mpleted outside our office, this declaration form and your completed voter registration application form (if you filled one out) should be returned to the DCFS ES Document Processing Center at P.O. Box 260031, Baton Rouge, LA 70826 - 9918. Signature o r Mark Name Typed or Printed Date Signatures of Two Witnesses If Signed With Mark: 1) 2) COMPLA I NT S If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Louisiana Secretary of State, Commissioner of Elections, P.O. Box 94125, Bat on Rouge, LA 70804 - 9125 or by calling (225) 922 - 0900 or 1 - 800 - 883 - 2805. OFS 4APP - Rev. 08 /19 14 12/17 Issue Obsolete This Page Intentionally Left Blank