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470 - 0462 (Rev. 0 9 / 2 3 ) Page 1 of 1 6 Iowa Department of Health and Human Services Food and Financial Support Application This form is to apply for Supplemental Nutrition Assistance Program (SNAP) , Family Investment Program (FIP) , or Refugee Cash Assistance (RCA). If you would prefer to comp l ete an onl ine application, please visit http://h . Anyone may fill out an application. You may apply for one or both programs on this application. You only need to complete the sections for the program(s) you wa n t to ap ply for . Pages 1 and 2 , and 13 through 16 are for you to keep for your records. Part A – Everyone must complete this section to get either SNAP or FIP . Part B – SNAP : Th is p rogram helps you buy food for good health . Part C – FIP or RCA : FIP p ro v ides temporary cash assistance to children and families. The Family Investment Program is also known as Temporary Assistance for Needy Families (TANF) . Refugees who do not get FIP may get Refugee Cash Assistance You can turn in your application by mail or ema il or fax or drop it off at any local H HS office. If mailing application, use this address: Cedar Rapids Service Area Imaging Center 4 PO Box 2027 Cedar Rapids IA 52406 - 2027 If emailing application, use this email address: [email protected] If faxing application, use this number: 515 - 564 - 4017 The date we receive Page 3 with your name, address, and signature is your application date . This starts the time we have to work on your appli c at i o n . It is also the date your SNAP may start. An interview will be set up for you if you need to have one. The interview will likely be held over the phone. There is information we must verify before we can process your application. You will be given ti m e t o provide that information . If you can’t get proof of the information , you can ask H HS to help you get the information. Before we can process your application, we may ask for proof of the following : ▪ Y our identity, as well as the people who are applyin g f o r benefits . Examples of that proof include: a driver’s license, social security card, or alien documentation card. ▪ That you and the people you are applying for are U.S. citizens or nationals. ▪ T he money you have gotten in the last 30 days such as check s tu b s, self - employment records, child support payment printouts , or award letters (such as disability benefits, Veterans benefits or financial aid) . ▪ Assets you have, such as bank accounts, trust accounts, stocks, or bonds. ▪ E xpenses you have, such as shelte r , u tilities, day care, and child support. Information About Immigration Status You can apply for part of your household even if some members do not have lawful immigrant status . For example, parents who do not have lawful immigrant status may apply for th e i r children who are U.S. citizens or qualified lawful immigrants . You need to give proof of immigration status or U.S. citizenship for each person in your household for whom you apply. Your household’s alien status may be checked with the United States Ci t i z e nship and Immigration Service s (USCIS ) . Any information we get from USCIS may affect your household’s benefits . We will not contact the Citizenship and Immigration Service about the people you don’t apply for . However, we may use their income and as s e t s t o see if the rest of the household can get help. 470 - 0462 (Rev. 0 9 / 2 3 ) Page 2 of 1 6 Emergency Service - SNAP This is who can get SNAP in seven days: ▪ Households with gross monthly income less than $150 and with assets, such as cash or bank accounts, of $100 or less; or ▪ Households wit h r e nt , mortgage, and utilities that are more than the household’s gross monthly income and assets; or ▪ Households with a migrant or seasonal farm worker and with assets of $100 or less whose income is stopping or starting. SNAP in 30 days If you don’t get E m e r ge n cy Service, you will get SNAP within 30 days if you are eligible, or a letter telling you why you are not eligible. FIP or RCA Y ou will get FIP or RCA within 30 days if you are eligible, or a letter telling you why you are not eligible. We use the f o l l ow i ng terms on the application . This is what they mean : Alien A person who is not a U.S. citizen. Appeal A request for hearing based on a decision made by the Department. EAC E lectronic access card (Mastercard debit card) for getting your cash ben e f i t s . EBT card Electronic benefit transfer card is a plastic swipe card that you use to buy food. Eligible Meeting all of the program rules to get benefit s from H HS. Household A group of people who live together. M igrant Farm Worker A person who trav e l s t o f ind work harvesting crops on a seasonal basis. PROMISE JOBS A work and training program for the Family Investment Program (FIP). Quality Control A H HS unit that might review your case to see if you are getting the correct assistance . If your cas e i s c ho s en, the Quality Control unit will contact you. Refugee A person who enters the U.S. with a refugee status. Seasonal Farm Worker A person who works on a farm on a seasonal basis within driving distance of the ir home. Stocks, bonds, savings certi f ic a t e s, annuities, IRAs, Keogh These are different types of financial investments and that may be considered resources/assets for SNAP and FIP. 470 - 0462 (Rev. 0 9 / 2 3 ) Page 3 of 1 6 Iowa Department of H e alth and Human Services Food and Financial Support Application Check the box next to the p r o g ra m ( s ) you want to apply for :  SNAP  Family Investment Program ( FIP)  Refugee Cash Assistance ( RCA) You do not need to apply for programs you already get. If you can’t fill out the whole application today at least fill out your name, address, and s i gnature a n d t u rn in this page . If you only fill out your name, address, and signature, then please fill out and turn in the rest of the application as soon as you can to help us get your application processed . If you need help filling out this form, cal l y our loc a l H H S office. Name Telephone Number ( ) Is morning or afternoon the best time to call you? Social Security Number Birth Date Street Address City State Z IP Code Mailing Address (if different) City State Z IP Code County Y ou L ive I n: Em a il Addr e s s : D o you need an interpreter? If yes , which language? I authorize H HS to communicate confidential information with me by email at the email address I provided above. Confidential information includes any thing needed for H HS to process my app l ication . By giving HHS my email address, I u n de rstand that it is my responsibility to tell my H HS worker if my email address changes or to stop c ommunicating with me by email. I certify, under penalty of perjury, that: ▪ The answers I am about to give are c orrect and complete to the best of my kn o w l e d ge . ▪ My answer about citizenship or alien status of each person applying for assistance is correct. Your Signature or Mark Today’s Date Signature of Person, If Any, Who Helped Complete th e Form Today’s Date P rint Name of Person Who Helped Complete F o r m Ph one Number Mailing Address of Person Who Helped Complete Form City State Z IP Code 470 - 0462 (Rev. 0 9 / 2 3 ) Page 4 of 1 6 Social Security Number Information We can give help only to people who give us their social security n umber (SSN) or proof o f application fr om the Social Security o f f i c e . You don’t have to give us the SSN for people in your household who you do not want help for, but you can choose to give us their SSN . However, we will use any SSN given to us the same way we use the SSN of pe o ple getting assistance. If you do not gi v e u s a SSN for people in your household, we will deny assistance to those people. There are some exceptions to this. Please ask your worker. We will not give any SSN to the Citizenship and Immi gration Service. Peo p le in Your Home Part A List all people w h o l iv e in your home and mark the box yes or no if you are applying for that person . If you choose no, you only need to list their name, relationship to you , and their birth date. *Only require d if applying for FIP . We have to ask your ethnicity and race, b u t y ou do not have to answer . The reason for the information is to assure that program benefits are distributed without regard to race, color, or national origin . Your answer won’t affect how much you get or how s o on . If you choose to answer, use the fol l o w ing codes: * *Ethnicity * **Race (Choose all that apply) H = Hispanic or Latino N = Not Hispanic or Latino W = White B = Black or African American A = Asian I = American Indian or Alaskan Nati ve N = Native Hawaiia n or other Pacific Islander Apply for? Y e s / No Name (First, MI, Last) Relationship to You Birth Date SSN Citizen Yes/No If Not a Citizen, What is Your Alien Status Birth State* Last Grade in School* Ethnicity ** Race *** Self Grandparents and others applying for children who are not your own: If you are applying for FIP only for the children, answer the remaining questions only about the child ren . If you are apply i ng for SNA P or want FIP for yourself, a n s w e r the questions about everyone in your home. List anyone in your home who is disabled: List anyone age 18 or over who is in college or trade school: List anyone getting benefits from an other state: Which state? List anyone who is on strike o r g ets regular meals in stead of paying rent : List anyone who is in the military, a veteran, or a spouse of a ve teran: 470 - 0462 (Rev. 0 9 / 2 3 ) Page 5 of 1 6 List anyone in your home who is pregnant: Criminal Actions and Disqualifi cations Part A Is anyone fleeing to avoi d prosecution, custody, or jail for a felony crime?  Yes  No Is anyone violating a condition of probation o r parole?  Yes  No I s anyone in or expecting to go to jail or prison ?  Yes  No Has anyone bee n disqualified from SNAP in any state for fraud or a program violation?  Yes  No Income Part A You must tell us about all money the people in your household get . If yo u l e a ve a space blank, we will take that to mean no one in your household gets mone y of this kin d . Please u se an additional sheet of paper, if needed . You may be required to show proof of you r income for the last 30 days. List all jobs th e people in your hou s e h o l d have. Who Works? Employer Name? How Much i s this Person Paid Per Hour? How M any Hours D o es this Pe rson Expect to Work Each Week? How Often is this Person Paid ? Do es this Person Get T ips? $ __________ Regular Hours: _________ __ ____ Overtime Hours: _ _ _ _ _ _____ ___ __  Weekly  Every 2 Weeks  Twic e a Month  Monthly  Other (explai n) ________ _ ____  Yes , Weekly Amount $ ____ ____ __ _  No $__________ Regular Hours: _______________ Ov ertime Hours: _______________  Weekly  Every 2 Weeks  Twice a Mo n t h  Monthly  Other (explain) _____________  Y es, Weekly Amount $ ____ ____ __ _  N o $_____ _ ____ Regul ar Hours: _______________ Overtime Hours: _______________  Weekly  Every 2 Weeks  Twice a Month  Monthly  Other (explain) ___ __________  Yes, We e k l y A mount $ ____ ____ __ _  No $__________ Reg u lar Hours: _______________ Overti me Hours: _ _ __________ ___  Weekly  Every 2 Weeks  Twice a Month  Monthly  Other (explain) ___________ __  Yes, Weekly Amount $ ____ ____ __ _  No 470 - 0462 (Rev. 0 9 / 2 3 ) Page 6 of 1 6 Do es anyone get bonuse s o r c ommissions ?  Yes  No If yes, who? Wi l l the amount of money you get from jobs stay a b out the sa me?  Yes  N o If no, explain : Has anyone been hired for a job but not receiv ed a paycheck yet?  Yes  No If yes, w ho? New e mployer n ame? Rat e o f p ay __________________________ Hou r s worked per week _____________________ Has any o ne reduced their work hours or ended a job in the last 30 days?  Yes  No If yes, w ho? Emplo yer n ame? What Other Money Do People in Your Household Get? Who G e t s t h e Money? How Much Per Month? Self - Em p loyment or Odd Jobs (send the most rece nt feder a l tax form s. If tax return has not been filed, send records that show income and expenses) Une mployment Benefits or Worker’s Compensation Social Security or S S I Veterans Benefits, Pensions , or Retir e ment Child Support or Alimony Mon ey from F riends or Relatives Other: (Including irregular or one time payments) Explain: Will the am ount of other money people in your household ge t stay about the sam e ?  Yes  N o If no, explain : Expens e s Part A If you have day care expenses for a c h ild or a d isabled adult who lives with you, tell us how much you are responsible to pay below. We need proof of how much you are responsible to pay to see if you can get a deduction. Proof can be receipts or statement of expenses from the provider. Who ge t s care: Amount you pay $ per month If anyone pays court - ordered child support , tell us how much you pay below . We need proof of how much you pay to see if you can get a deduction. Who pays: Amount y ou pay $ per month 470 - 0462 (Rev. 0 9 / 2 3 ) Page 7 of 1 6 Resources (A s se t s ) Part A D oes anyone have a car, truck, boat, camper, motorcycle, or other veh icle?  Yes  N o If yes, list make, model, year : ______________________________________________________ _ List the total money anyone h as in: Checking/ savings or other ba n k/ c r e d it union accounts $ Who? Cash $ Who? Stocks, bonds, savings certificate s, annuities, IRAs, Keogh, or other assets $ Who? List anyone who: Owns land, buildings or houses othe r than the house you live in: Owns resources with someone who do e s n o t live in y our househ old: Has a conservatorship or trust: Has sold, traded or given away any resources in the past three months: ____________________________ Help With Your SNAP – Au t horized Representative Part B If you feel like you need help from someone el s e to be at your HHS interviews, complete your HHS documents , answer HHS questions , and buy food for you with your EBT benefits, y ou can tell us who that is. The person who repre s ents you to HHS is called your Authorized Represent ative. It’s very important to pick an Authorized Rep resentative who you trust and can rely on. Any information given to HHS from your Authorized Representative is the same as if that information came from you. If they give wrong information and you get too many benefits, you will h a ve to pay those benefits back. If they use your EBT benefits, you can’t get those benefits replaced. You don’t have to have an Authorized Representative. It’s optional and is yo u r decision. I understand wha t having an Authorized Representative means and I would like to have one. I understand HHS will be able to share my information with th e person I list below . Name: Telephone number: Address: Email address:_______________ _ ________________________ Relationship to you: ___________________ SNAP Part B Wr ite down the names of the people in your househ old who are not a pp lyi n g f or SNAP : Write the names of the people who live with you, but don’t eat wit h you: Does anyone who lives with you already ha ve an Iowa EBT card ? If y es, write their name here : L i st anyone in your home who ag e d out of foster care : _ ___________________________________________ List anyone in your household who is experiencing homelessness : _ ___________________________________ 470 - 0462 (Rev. 0 9 / 2 3 ) Page 8 of 1 6 I s a nyone a migrant o r seasonal farm worker?  Yes  No Have you or an y m e mber of your household been convicted, after September 22, 1996, of: Buying or selling SNAP benefits over $500?  Yes  No Frau d ulently receiving duplicate SNAP benefits in any st ate?  Yes  No Trading SNAP benefits for dr ugs, g u ns, ammun i ti on o r e xplosives?  Yes  No SNAP Expenses Part B To get the most SNAP you c an, please tell us about your bills. You must provide p roof of your expenses. Proof for renters can be a l ease agreement or written statement from the la ndlord or housin g a u th o r i t y. Proof for homeowners can be mortgage, property tax, and insurance statemen ts. Shelter Do you get rent assistance?  Yes  No I f yes, enter the exact amount you are responsible t o pay . Do not estimate . $ _________ per month Te ll us the exact amou nt you are responsible to pay. Do not estimate . R ent $_________ per month Lot rent $ _________ per month Mortgage * $_________ per month If you pay taxes or insurance separate from your mortg age, list the exact amounts you are responsible to pay. D o not esti mate . Property Taxes: $ every  1  3  6  12 months Homeowner’s Insurance: $ every  1  3  6  12 mo nths Ch e c k t he b oxes next to the utility bills you have to pay:  Lights/Ele ctricity  Water and Sewage  Gas  Garbage and Tras h  Telep hone  Garage Rent  Extra charges from your landlord  Pet fees  Other, expl ain Check the boxes if:  A ny of t h e ut ili ty bills y ou have to pay are for heating or air conditioning.  Y ou got energy assistance in the past year.  Your u tilities a re inc luded in your rent.  Anyone helps you pay rent, utilities, or other expense s . Example: roommate, pare n t, friend, e t c . I f yes, wh o helped and which expenses did they pay? __________ ___________________ 470 - 0462 (Rev. 0 9 / 2 3 ) Page 9 of 1 6 Medical Expenses If you have medica l expenses not paid by insurance for anyone who is disabled or over age 59, tell us. These could be doctor or hospital bills, medicine, transportat i on, health insurance premiums, home health costs, health - related supplies, medical equipment, or other medic a l expenses . Send proof if your expenses have changed. Who pays: Amount you pay $ per month H elp Paying Expenses If you get help with your expenses tell us: Which Expense Was Paid Who Paid Amount Paid Family I n ve stment Prog r a m ( F IP) or Refu g ee Cash As sistance Part C If you do not get FIP or Refugee Cash Assistance and want to apply, a nswer the questions in thi s section. Lis t the people in your home who are not applying for FIP : _______ __ ______ _______________________ _ __ L ist anyo n e wh o already ha s an I owa Electronic Access Card ( EAC ) : Does anyone expect to get a one - tim e payment such as an inher i ta nce or insu r a n ce settlement or did anyone get one in the past 30 days?  Ye s  No Does anyone have life or death benefit insurance?  Yes  No L i st a nyone in yo ur household who has received TANF or other cash assistance b enefits outside of Iowa si n ce January 1, 1 9 97 : Where were the benefits received and for what months ? Child Support Complete this section for each parent who does not live i n the home wit h t he children . Name and Address of Parent Not Living in the Ho me Date of Birth of This P ar ent Social S e c u ri t y Number of This Parent Name of This Parent’s Children Coun ty Where Court Order is Filed, if Any Name and address o f em ployer o f p arent not in the home : If ever married to this parent, lis t the date and place of m a rr iage: 470 - 0462 (Rev. 0 9 / 2 3 ) Page 10 of 1 6 PA G E RE S ERVED 470 - 0462 (Rev. 0 9 / 2 3 ) Page 11 of 1 6 Iowa Department of Health and Human Services Addendu m to Application and Review Forms for Release o f Information OPTIONAL Rel e a se o f Inform a ti on Help Us Help You! You do not have to sign this, but it wi ll help us get information we need t o h e l p yo u , without having to get your signature on specific requests . You should know that: • We may need more inform ation to decide if you can g et a ssistanc e . • If more information is needed from you, you will get a letter telling you what we need and the da t e y o u mu s t get it to us. • You are responsible to get the information or to ask us for help to get it. • If you do not give us the information or a sk f or help b y the due date, your application may be denied or your assistan ce may stop. • We may be able to use t h e r e l e as e below to get the information we need . But you still have t o provide information we request or ask us for help. • We may attach a copy o f th is relea s e to a form that asks other people or organizations (like your employer) for specific information n ee de d a bo u t you or others in your household. Print and sign your name below to give us permission to get needed info rmation. RELEASE OF INFO R M ATIO N I here b y authorize any person or organization to give the Iowa Departm ent of Health and Human Services request e d in f o rm ation about me or other members of my household. A copy of this release is as valid as the original. Th is release does not apply t o pro tected h e al th information. This release is good for 12 months from the d ate signed. ____________________________ _ _ _ _ _ _ __ ____________________________ Your Name (please print cle arly) Other Adult Name (please print clearly) _ __________________________ _ _ ___ ________ _ __ _____________________ Signature or Mark Signature or Mark ___ _____________________________ Date 470 - 0462 (Rev. 0 9 / 2 3 ) Page 12 of 1 6 PA G E RE S E RV ED 470 - 0462 (Rev. 0 9 / 2 3 ) Page 13 of 1 6 You Have the Right to Appeal An appeal is a request for a hearing regarding a decision made by the Department. You can appe al in p erson, b y t elephone, or in writing for SNAP and FIP . To appeal in writing, y ou must do one of the following: ▪ C o m p le t e an appeal electronically at , or ▪ W rite a lette r telling us why you think a decision is wrong, or ▪ Fill ou t an A p peal and Request for Hearing form . You c a n g e t this form at your county H HS office. Send or take your ap peal to the Department of Heal t h and H um an Serv ices, Appeals Sect ion, 321 E . 12 th St . , Des Moines, I A 50319 - 0114 . If you need help fi ling an appe al , ask your county H HS offi c e . Y o u can re p re sent yourself . Or, you can have a friend, relati ve, lawyer, or so meone else act on your be half. You may contact your county H HS office about legal services . You may have to pay for these legal servic es . If you d o, your payment will be base d o n y our i n co me . You may also call Iowa Legal Aid at (800) 532 - 1 275 . If you liv e in Polk County, call (515 ) 243 - 1193. You Will N ot Be Discr iminated Ag ainst It is the policy of the Iowa Department of Health and Huma n Services ( H H S) to provide equal treatm e n t i n employment a n d provision of services to applicants, employ ees and clients w ithout regard to race, co lor, national origin, sex, sexual orientatio n, gender identity, religion, age, disability, political belief o r veteran st at us. I f you feel H HS has di s c r im i nated against or harassed you, please send a letter detaili ng your complai nt to: Iowa Department of Healt h and Human Servi ces, Bur eau o f Human Resources, 321 E. 12 th St . , Des Moines, IA 50319 - 0114 or via email in clusion@ dh s.state.i S NAP In accordance with f ederal civil rights l aw and U.S. De partment of Ag ricultur e (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the b a si s o f race, color, nation al orig in, se x (including gen der ident it y and sexual orientation ) , religious creed, d isability, age , politic al be liefs, o r reprisal or retaliation for prior civil rights activity . Program infor mation may be made available in lan gua ge s other than English. Pe rsons with di sabilities who require al ternative mea ns of communication to o btain pr ogram informat ion (e.g. Brai lle, lar ge print, audiotape, American Sign Language ) , should contact the a ge ncy ( s tate or local) where the y a p plied for b e nefits . Indi v id uals w ho are deaf, ha rd of hearing or have s pe ech disab ilities may contact USDA thr ough the Federal Relay Service at (8 00) 877 - 8339 . To f il e a program di scrimination complaint , a Complainant sho uld complete a Form AD - 30 27, USDA P rogra m D is c rimination Co mplaint Fo rm wh ich ca n be o btained online at: - 3027.pdf , from any USDA office, by calling (8 33) 620 - 1071 , or by w riting a l ett er add res se d to USDA . The letter must contain the complainant ’ s name, a ddress, telephone number, and a w ritten descrip tion of the alleged discri mi na to ry actio n in sufficien t d etail to info rm the Assistan t Secreta ry for Civ il Ri ghts (A SCR) about the na tu re an d da te of an alleged civil rights violation. The complet ed AD - 302 7 f o rm or letter must be submitted to: 1. mail: Foo d and Nutrition Service, USD A 13 20 Brad dock Place, Room 3 34 Alexand r ia , VA 22314; or 2. fa x : (8 33) 256 - 16 65 or ( 202) 690 - 7442; or 3. ema i l : FNSCIV ILRIGHTSC OMPLAINTS@ This institution is an equa l opportunity provider. Do N ot M ail Applications to the A bove Address 470 - 0462 (Rev. 0 9 / 2 3 ) Page 14 of 1 6 SNAP , FIP , and RCA We C heck What You Tell Us The information y ou gi ve us may b e checked by federal, st a te , and local officials t o m ake sur e it is true . Things we might check are any lis ted person’s: social securi ty n umber , job and pay, ban k account amount, amounts received from other sou rces like So cial Security or un emp lo y ment , an d alien status . If any i n for mation you give us i s n ot correc t, we may deny your application. We may check r ecords from other states to se e if any person in your h ou sehold can get benefits in Iowa . This may be be cause a pers on was disqualifi ed fr om a progra m in another state. We c h eck and use computer sy stems like t he state Income and Eligibility Verification Sy stem . If something you told us i s different from what t he computer system tells us, we will ch eck to fin d out what i s correct . We mig ht ch ec k your in f ormation by contacting y our employer, your ba nk , or other p eople . S uch information may affect your househo ld’s eligibility and level o f be nefits. Things You Need t o Know ▪ H HS may give yo u r a nswers to l aw en force ment officia ls to catch perso ns fl ee i ng to av o id the law . ▪ The Quality Control unit or Investigations unit may rev iew your case . They may contact other p eople or organizations to ge t pr oof of your information . By signing this applic atio n, you give pe rmissio n to release confidential inf or mat io n to the Q uality Control unit or Investigations unit . You must cooper ate with Quality Control and Investigations to keep your FIP benefits . You mu st cooperate with Quality C ontrol to keep your SN AP b enefits. ▪ W e will use the informat ion you give us t o det er m ine what assistance you are eligible to receive. ▪ You will have to pa y back a ny benefits you got or that was paid to a third party on your behal f fo r which you were not el ig ible. ▪ Section 1128B of the Social S e c u rity Act provides fed eral penalties fo r fra ud u lent act s and false reporting in connection with these programs. ▪ Any one who gets, tries to get, or helps any other person get assistance to whi ch t hey are not entitled, i s guilty of violating th e la ws of the s t ate of Io wa . This inc ludes, but is not l imi te d to, Iow a Code Chapters 239B, 243, 249, and 249A. ▪ Your expenses may be used to figure the amount of assistance you get . You may have expenses i nc lu ded in your benefit cal cu lation by reporting an d gi ving pr o of of your ex penses . If y ou do not report or gi ve proof of your expenses, you choose not to claim the expense . You can report and give proof later, and the expense c an be used for future months . Yo u also have the right t o: ▪ Have someone help y o u co mp l et e the applicatio n. ▪ Have all of your question s ans we r ed. ▪ Get information about programs you applied for and any other H H S progr ams you may be able to get. ▪ Be sent a no tice if you are eligible and w he n your benefits change or stop. ▪ Have informa t i o n a bout you an d your fam ily kept pri vate. To report a cha ng e ▪ Call: 1 - 877 - 347 - 5678 Monday – Friday 7:00 a.m. to 6:00 p.m., exclu ding s tate holidays ▪ Email: IMCS C@ dh SNAP Onl y Follow these R u le s of the SNAP Progr am : ▪ Don’t hide or give wrong informatio n on pu r pose to g et SNAP benefits . ▪ Don’t use SNAP benefits to buy non - food i tems l ike alcohol or tobacco. ▪ Don’t trade, sell , or give away SNAP benefits . ▪ Do n’t use someone else’s SN AP benefits for yo ur s elf. 470 - 0462 (Rev. 0 9 / 2 3 ) Page 15 of 1 6 ▪ Don’t purch ase a prod uct with SNA P benefits that has a container requiring a retur n de posit with the intent o f obtaining cash b y in t entio nally disca rding the product and intentionally ret ur nin g t he conta i ner for the deposit amount . ▪ Don’t buy food on credit and at tempt to pay for it with SNAP . ▪ Don’t buy a prod uct with SNAP benefits so yo u ca n get cash or something o ther than eligi b le f o od by reselling that produ ct. ▪ Don’t fa il to report if y ou r h ou s ehold go e s over its income limit. If you get SNAP , your worker will tell y ou what your household’s income limit is . If your household’s income go es over your limit , or if a nyone in your h ou seh o ld re ceives lott ery o r gam bling winnin gs of $ 4,250 o r m or e i n a ny month , you must tell us by the 10 th day of the next month . If you don’t tell us on time, you might have to pay b ack the benefits. Penalties of t he SNAP Program . Anyone w ho breaks the ab ove r ules: ▪ May not ge t SNAP ben efits for o ne year for the f ir st ti m e, two y ears for the second time, and forever for the third time; ▪ M a y be fined up to $250,000 or jailed up to 20 y ears or both; and may also b e su bject to prosecution un de r other appli c ab le F ederal and State laws. ▪ May be kept off SNAP for an addit io nal 1 8 months, if court ordered. ▪ If a court finds you guilty of trading SN A P ben efits for firearms, ammunition , or explos ives, you will lose benefits fo rever. ▪ If a court finds y ou guilty of b uy ing, sellin g, or trad ing more th an $500 in SNAP benefits, you w ill l o se benef i ts forever. ▪ If a court finds you guilty of trading SNAP ben e fits for controlled substances, you will lose benefits for two years the f i rs t time and forever the s e cond time. ▪ Yo u w ill n ot get SNAP for 10 years if you are fo und guilty of gett in g o r t rying to get SNAP in more than one household at a time . This penalty happe ns if you give wrong information about wh o you are or where you live. Gi ving wrong information o n purpose may re sult i n us t aking lega l action ag ainst you, either criminal or c ivi l . It might also mean we reduce your benefits or take money back from y o u. Th ings You Need to Know ▪ If you have a SNAP overpayment, HHS will give y o ur answers to federal and s t ate age n cies a s well as private clai ms collecti on agencies , to collect the o ve rpa ym e nt. ▪ The S NAP office may contact other people or organizat ions to get proof of your information. ▪ The application fil ing date is different if you r h ousehold is in an insti t u t ion and applyi ng for SNAP and Supple mental Secu rity Income at the same time . I n t hi s case, t h e filing date is the date of release from the in stitu tion. ▪ For information regarding services provided fo r Healthy Marriages contact y o ur local office . ▪ You may n o t be denied SNAP benefits just becaus e you were denied bene fits from other pr og ram s . SNAP ap p l ication s will not be delayed due to requirement s of other p rograms you may apply for. ▪ By having signed thi s application, you agree tha t a ll members of your house h old will register for work and follow all of the work and t raining rules. ▪ To s ee wh a t em p lo y m ent and traini ng opportunities are available, p l ease visit : • SNAP Employment & Training (E&T) Program eith er by phone (515) 281 - 3131 o r o nline at : h tt ps: // h w - assistance/related - programs/employment - and - train ing • Y o ur lo cal IowaWorks Center. You may fin d your local work center at h ttps://www. iowaworkfor ta ct • United Way – 211 ▪ The collection of information on the applica tion, inclu d in g the social security numb er of each h ousehold member, is authoriz e d under the Food and Nutri t ion Act of 2008 (formerly the Food St amp Act of 1977), as a mended, 7 U.S.C. 2011 - 2 036 . The in f ormation will be used to determine whether your househ old i s eli g i b le or continues to be eligi ble to parti cipate in the SNAP program . W e will verify this informa t ion through computer 470 - 0462 (Rev. 0 9 / 2 3 ) Page 16 of 1 6 matching program s . This inf ormation wi ll also be used to mo ni tor c omplia n ce with program regulations and for program management . ▪ A h ous e ho l d consi sting of only Supplem ental Securi ty Income (SSI) applicants o r r ecipients is entitled to apply for SNAP recertification at a S ocial Secur ity Adminis tration office. FIP o r Ref ug ee Cas h Assistance (RCA) Only Within 10 days of the date th e chan ge ha p p ens, yo u must tell HHS abou t changes, su ch as: ▪ Income, when it start s o r stops, including getti n g an inheritance or a one - time paymen t of past d ue child su pport ▪ Resources or as se ts ▪ So meone m oving in or out of your home ▪ Mailing or living addres s ▪ Rece ip t o f a SSN ▪ C hange of school atte ndance of a c hild If you receive FIP or R e fu gee Cash Assistance bene f its, your SNAP may go down or stop. U nless exemp t, all memb ers of your household m ust c oopera t e with the Family Investment Agreement (FIA) you sign ed wit h P RO M ISE JOBS . Talk with your wor ker if you fe el you have a reason not to c oo perate. If you choose no t to participate in your FIA with PROM ISE JOBS, y our FIP ben efits will stop. You mu st co operat e with the Child Support Recovery Unit. While you get FIP, y ou gi v e up you r rights to child su pport for the months you are on FIP . The s ta te of Iowa will keep you r child support to pay back the money you get fro m FIP. Usin g Your FIP/RCA Electr on ic Ac cess C a rd (EAC) or Your Debit Card to Access FIP/RCA Funds from Yo u r Pe r sonal Ba nk Account You cann ot access your cash benefits with your EAC or personal debit card at a : ▪ Liquor store or any place that main ly sells li quor, ▪ Casin o or other gambling o r gam in g esta b lishment, or ▪ Business which provides adult - oriented enterta i nm en t in whic h performers disrob e or perform i n an unclothed state (such a s a strip club). This inclu d es these types of businesses located in Iowa, on tribal lan d, or in any other st at e. If HHS d e termines that you have accessed your cash benefits with you r E A C or perso nal debit card at one of the abov e places you: ▪ Will have comm i tt ed fraud, ▪ Have to repay t he amount of cash accessed at the loc ation, as w ell as any access fees , and ▪ Your f ami ly will n ot get cash benefits for three months with the firs t misuse an d s ix month s fo r each additio nal misuse. By having signed this applicati o n, you agree that no membe r of your household will use the EAC o r your pers onal debit card to access FIP/RC A fun ds at pr o hibited locations. Additional responsibilities: Y ou must: ▪ Ap ply for and accept any benef its that you may be able to get. ▪ Give us in f or mation and provide proof when we ask for it. ▪ Fill out review forms when you are ask ed to. Penalty for Ge tt ing F IP in M ore Than One State You will not get FIP for 10 ye ars if you a re f ound gui lty of getting o r trying to get F IP in more than one state at a time . This penalty happe n s if you give wrong in formation about where you live.

Form NameIowa Food Stamp Application Form
Form TypeFood Stamp Application
Issuing AuthorityIowa Department of Human Services or relevant state agency
PurposeTo apply for food assistance through the Supplemental Nutrition Assistance Program (SNAP) in Iowa
Form VersionLatest available version
FormatTypically available as a downloadable PDF form
AvailabilityOfficial government website of the Iowa Department of Human Services or local Department of Human Services (DHS) offices
Form NumberVaries by form version
File SizeVaries depending on the specific form and its components
RequirementsAdobe Acrobat Reader or compatible PDF reader
Accessible DevicesComputers, smartphones, tablets, and other devices with PDF reader apps
Filling Out MethodPrintable (Handwritten) or Online (Web-based, if available)
SubmissionSubmission through mail, fax, in person at local DHS offices, or online (if available)
FeesNo application fee
Supporting DocumentsSupporting documentation may include proof of identity, income, and household information
Official WebsiteIowa Department of Human Services - Food Assistance
Food Stamp Form PDF

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