Fillable Application for Food Stamp benefits (City of Oakland)

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Application for Food Stamp benefits (City of Oakland)

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To apply: You have the right to apply for Food Stamp benefits at any time.
• Benefits are provided from the date Family Support Division (FSD) receives your application which must contain your
name, address and signature. Please complete sections 2 through 6 to help FSD process your application faster.
• You can drop off, mail or fax your application. Interviews can be completed face-to-face or by phone. Call the Family
Support Division (FSD) at 855-FSD-INFO (855-373-4636) or visit an FSD office to complete this as soon as possible. We may
ask you for proof of some of the information you give to FSD.
Date of application: If approved, your Food Stamp benefits are provided from the date FSD receives your application. This is
your filing date. If you are in an institution and apply for Food Stamp benefits and Supplemental Security Income (SSI) at the
same time, your filing date is the date of release from the institution.
Authorized Representative: You can choose more than one person or facility to complete your application and/or manage
your benefits on your behalf. They will act as your authorized representative. If you want an authorized representative,
complete the Authorized Representative Form (FA-6ARF and FS-6ARI) at http://dss.mo.gov/fsd/fstamp or call FSD.
FAMILY SUPPORT DIVISION
Missouri Department of Social Services
Application for Food Stamp benefits
Section 1 – Tell us about yourself
Your full name (first, middle, last): __________________________________________________ I am homeless
Home address (street, city, state, zip): __________________________________________________________________
______________________________________________________________________ County: __________________
Mailing address, if different: __________________________________________________________________________
______________________________________________________________________ County: __________________
Phone 1: ________________________ Cell Home Work Other
Phone 2: ________________________ Cell Home Work Other
E-mail address:______________________________________________________________________________________
The best way to contact you:   Call      Email      Mail      Text (not available everywhere)
UNDER THE LAWS OF THE STATE OF MISSOURI, AND THE REGULATIONS OF THE UNITED STATES DEPARTMENT OF
AGRICULTURE, I HEREBY APPLY FOR FOOD STAMP BENEFITS.
➡Your signature: __________________________________________________ Date: ________________________
Section 2 – Key questions for faster service
If eligible, you will receive your benefits within 7 days of filing your application if you answer “yes” to any of the questions
below. Otherwise, you will receive your benefits within 30 days of filing your application.
1. Does your household expect to receive less than $150 in income this month and have
$100 or less available in cash and/or in a bank account? Yes    No
2. Does your household have rent/mortgage and/or utility costs that are more than your
total income, available cash, and bank accounts for this month? Yes    No
3. Does your household include a migrant or seasonal farm worker whose income
has stopped and whose available cash and bank accounts do not exceed $100? Yes    No
Help FSD verify your identity for faster service. FSD will try to verify your identity electronically. Please (1) include a copy
of your identification with your application, or (2) bring someone such as a friend, family member, landlord, or employer
to any FSD office, or (3) list a contact below in order to help us verify your identity. FSD will call this person if needed.
Name of person to Phone
verify your identity: Number:
MO 886-0460 (9-16) Page 1 of 8 FS-1 (9-16)
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Section 3 - Household members
Write your information on line 1. Enter the information of all the people who live in your household, including your
spouse, any children under age 22 who are in your household at least half (50%) of the time, and anyone who eats the
majority of their meals in your household. Include all household members regardless of their citizenship or
immigration status.
Citizenship or immigration status does not automatically disqualify an applicant from receiving Food Stamp benefits.
Racial and ethnic information is collected to assure that program benefits are distributed without regard to race, color,
or national origin. Providing this information is optional and does not affect your eligibility or the amount of Food
Stamp benefits you receive.
Providing the Social Security Number (SSN) and immigration status of each household member is voluntary.
However, you will not receive Food Stamp benefits for individuals who do not provide a SSN and/or immigration status.
Immigration status of applicant household members may be subject to verification by U.S. Citizenship and Immigration
Services (USCIS). Information provided by USCIS may affect your eligibility and benefit level.
Sex Relationship
Hispanic or Race
Full Legal Name
Date of birth SSN
** to applicant
Latino? *
1.
Self
2.
3.
4.
5.
6.
7.
8.
*List ALL that apply:
**Not required for Food
1 - White 2 - Black/African American 3 - American Indian/Alaska Native
Stamp eligibility
4 - Asian 5 - Native Hawaiian/Pacific Islander
determination
If you do not have enough space for all household members, attach an additional list with their information.
1. Do you and all the people in your household buy and eat (cook) meals together? Yes    No
If no, who does not buy and eat (cook) with your household?____________________________________________
2. List anyone who is a boarder in your household: ______________________________________________________
3. List anyone who is a foster child or foster adult in your household: ________________________________________
4. List anyone who is not a U.S. citizen in your household:__________________________________________________
5. Is English your preferred language? Yes    No
If no, what is the language spoken most often in your home? ____________________________________________
MO 886-0460 (9-16) Page 2 of 8 FS-1 (9-16)
Section 4 - Household declarations
Answer “yes” or “no” to each of the questions in this section. For each question you answered “yes,” explain in the
space provided. A “yes” response to any of the questions in this section may result in a disqualification for Food
Stamp benefits for the person in which the “yes” answer applies.
1. Have you or any member of your household been convicted of buying or selling Food Stamp
benefits of $500 or more after 9-22-96? Yes    No
If yes, who? __________________________________________________________________
2. Are you or any member of your household hiding or running from the law to avoid prosecution,
custody, or jail for a crime (or attempted crime) that is a felony? Yes    No
If yes, who? __________________________________________________________________
3. Are you or any member of your household violating a condition of probation or parole? Yes    No
If yes, who? __________________________________________________________________
4. Have you or anyone in your household made false statements about your identity or address
to receive Food Stamp benefits in 2 or more households at the same time? Yes    No
If yes, who? __________________________________________________________________
5. Have you or any member of your household been convicted in a federal or state court of a
felony committed after 8-22-96 related to illegal possession, use, or distribution of a controlled
substance? Yes    No
If yes, who? __________________________________________________________________
6. Have you or any member of your household ever been convicted of fraudulently receiving
duplicate Food Stamp benefits in any state after 9-22-96? Yes    No
If yes, who? __________________________________________________________________
7. Have you or any member of your household been convicted of trading Food Stamp benefits for
guns, ammunitions, or explosives after 9-22-96? Yes    No
If yes, who? __________________________________________________________________
8. Have you or any member of your household ever been convicted of trading Food Stamp benefits
for drugs after 9-22-96? Yes    No
If yes, who? __________________________________________________________________
Section 5 - Household information
Answer these questions for yourself and all of the people who live with you (as listed in Section 3).
1. Has anyone received Food Stamp benefits in a state other than Missouri within the past 30 days? Yes    No
If yes, who?__________________________________ State: ____________________________
2. Is anyone disabled?    Yes    No
If yes, who?______________________________________________________________________
3. Is anyone age 18 to 49 and enrolled in school? Yes    No
If yes, who?__________________________________ School:____________________________
If yes, who?__________________________________ School:____________________________
MO 886-0460 (9-16) Page 3 of 8 FS-1 (9-16)
Resources
Resources are bank accounts and other types of money you own by yourself or with other people.
1. Does anyone have a bank account or is anyone’s name on a bank account?    Yes    No
If yes, who? __________________________ Balance: $ ____________ Bank name: ______________________
If yes, who? __________________________ Balance: $____________ Bank name: ______________________
2. Does anyone have any other cash?     Yes   No
If yes, who? ___________
_______________ Balance: $ ____________
If yes, who? __________________________ Balance: $____________
3. Does anyone have stocks, bonds, and/or retirement accounts such as an IRA?    Yes    No
If yes, who? ___________
_______________ Cash Value: $ ______________
If yes, who? __________________________ Cash Value: $______________
Income
Income is money that’s paid to you, such as earnings from a job or payments from Social Security or child support.
1. Does anyone earn income or money from working?    Yes    No
If yes, list who gets it, their employer, and monthly gross income before taxes or deductions:
Who earns income from working? Employer Monthly amount
$
$
$
$
2. Does anyone receive income or money from the following sources?    Yes    No
If yes, check the source and list who gets it and the monthly amount:
Source Who gets it? Monthly amount
Social Security Income (Retirement,
$
Disability or Survivor’s)
Supplemental Security Income (SSI)
$
Veteran’s Administration (VA)
$
benefits
Child support
$
Unemployment benefits
$
Gifts or donations
$
Student loans, grants, scholarships
$
Other sources—list here:
1.
1.
$
2.
2.
$
3. Has anyone’s income stopped or been reduced in the last 30 days? Yes    No
If yes, whose? _______________________________ Date and amount of last check _______________________
MO 886-0460 (9-16) Page 4 of 8 FS-1 (9-16)
Expenses
Expenses are the bills you are responsible for paying.
1. Does anyone pay rent or a house payment for the home you live in?    Yes    No
If yes, list the total monthly amount: $ __________________ Who pays? ____________________________
2. Does anyone pay the following utility expenses for the home you live in? (check all that apply)
Electric: Does it heat or cool your home? Yes    No Who pays? ________________________
Gas: Does it heat or cool your home? Yes    No Who pays? ________________________
Other fuel: Does it heat or cool your home? Yes    No Who pays? ________________________
List the fuel: _______________________________
Phone Who pays? ________________________________
Trash Who pays? ________________________________
Water Who pays? ________________________________
Sewer Who pays? ________________________________
3. Does anyone pay court-ordered child support and/or alimony?    Yes    No
If yes, list the total monthly amount: $ ________________________________
4. Does anyone who is either disabled or age 60 and older have medical expenses such as insurance
or Medicare premiums, doctor visits, in-home care, transportation for medical care, or eyeglasses? Yes    No
If yes, list the total monthly amount: $ ________________________________
Section 6 - Notices (Please read and sign page 8)
USDA NON-DISCRIMINATION STATEMENT: In accordance with Federal civil rights law and U.S. Department of
Agriculture (USDA) Civil Rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions
participating in or administering USDA programs are prohibited from discriminating based on race, color, national
origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation 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 may 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: http://www.ascr.usda.gov/complaint_filing_cust. html, and at any USDA office, or write a letter
addressed to USDA and provide in the 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: program.intake@usda.gov. This institution is an
equal opportunity provider.
DSS NON-DISCRIMINATION STATEMENT: The Missouri Department of Social Services (DSS) is committed to the
principles of equal employment opportunity and equal access to services. Accordingly, DSS employees, applicants for
employment, and contractors are treated equitably regardless of race, color, national origin, ancestry, genetic
information, pregnancy, sex, sexual orientation, age, disability, religion, or veteran status.
MO 886-0460 (9-16) Page 5 of 8 FS-1 (9-16)
FSD FAIR HEARING RIGHTS: You have the right to a hearing if you have applied for or are receiving Food Stamp
benefits, and the following happens:
• FSD decides that you are not eligible and you think you are.
• FSD provides you with Food Stamp benefits and then reduces or stops the benefits and you think the reasons are
wrong.
• You disagree with the information used to determine the benefit amount or disagree with the benefit amount.
• FSD refuses to take your application.
• FSD does not act promptly on your request for help and you think that they have had enough time to do so.
If your application has been refused or rejected or any action on your case has already been taken, you may request a
hearing within 90 days of the refusal or action. If the proposed action will change or stop your benefits and you request
a hearing within ten days from the date of the notice, you may continue to receive the same benefits until the hearing
decision. You or your representative may request a hearing by phone, in-person, or in writing. Your case can be
presented by a household member, or a representative such as legal counsel, relative, friend or other spokesperson.
YOU MAY BE DISQUALIFIED FROM RECEIVING FOOD STAMP BENEFITS IF YOU:
• Sell your Food Stamp benefits for cash or consideration other than eligible food, either directly, indirectly, in
complicity or collusion with others, or acting alone.
• Lie or hide information to get Food Stamp benefits that your household should not get.
• Use Food Stamp benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit accounts.
• Purchase a product with Food Stamp benefits that has a container requiring a return deposit with the intent of
obtaining cash by discarding the product and returning the container for the deposit amount.
• Intentionally purchase products with Food Stamp benefits in exchange for cash. For example, do not purchase food
to make products for resale.
• Pay for food purchased on credit with Food Stamp benefits.
• Use or have in your possession EBT cards that are not yours.
• Trade or sell EBT cards or provide food purchased with Food Stamp benefits to non-household members.
NOTIFICATION AND ACKNOWLEDGEMENT OF FRAUD PROVISIONS
It is against the law to lie to receive Food Stamps or to sell or trade your Food Stamp benefits. Excessive Electronic
Benefit Transfer (EBT) card replacement requests may result in a referral for fraud investigation. 7 USC 2015(b)(1) any
person who has been found by any state or federal court or administrative agency to have intentionally made a false or
misleading statement, or misrepresented, concealed or withheld facts or committed any act that constitutes a violation
of this act, the regulations issued thereunder, or any state statute, for the purpose of using, presenting, transferring,
acquiring, receiving, or possessing Food Stamp benefits shall, immediately upon the rendering of such determination,
become ineligible for further participation in the program for a period of 1 year upon the first occasion of any such
determination, 2 years for the second occasion and permanently upon the third occasion.
Applicants cannot violate the Food and Nutrition Act of 2008 which includes the following:
• Any member who breaks any of the rules on purpose can be ineligible from the Food Stamp Program for one year,
up to permanently, fined up to $250,000, imprisoned up to 20 years or both. S/he may also be subject to
prosecution under other applicable Federal and State laws. S/he may also be barred from Food Stamps for an
additional 18 months if ordered by a court.
• Any member of your household who intentionally breaks the rules may be ineligible to receive 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 any household member guilty of using or receiving benefits in a transaction involving the
sale of a controlled substance, you will not be eligible for benefits for two years for the first offense, and
permanently for the second time.
• If a court of law finds you guilty of having used or received benefits in a transaction involving the sale of fire-arms,
ammunition or explosives, you will be permanently ineligible to participate in the Program upon the first occasion
of such violation.
• If you are found to have made a fraudulent statement or representation with respect to the identity or place of
residence in order to receive multiple Food Stamp benefits simultaneously, you will be ineligible to participate in
the Program for a period of 10 years.
• If a court of law finds you guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be
permanently ineligible to participate in the Program upon the first occasion of such violation.
MO 886-0460 (9-16) Page 6 of 8 FS-1 (9-16)
The information you provide on the application will be subject to verification by Federal, State or local officials to
determine if the information is factual; that if any information is incorrect, Food Stamp benefits may be denied and
you may be subject to criminal prosecution for knowingly providing incorrect information.
Information available through the Income Eligibility and Verification System (IEVS) will be requested, used and may be
verified through collateral contacts when discrepancies are found by the State, and that such information may affect
the household’s eligibility and level of benefits.
The collection of information on the application, including the SSN of each household member, is authorized under the
Food and Nutrition Act of 2008 (formerly the Food Stamp Act), as amended, 7 USC 2011-2036. The information will be
used to determine whether your household is eligible or continues to be eligible to participate in the SNAP. We will
verify this information through computer matching programs. This information will also be used to monitor compliance
with program regulations and for program management. This information may be disclosed to other Federal and State
agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to
avoid the law. If a SNAP claim arises against your household, the information on this application, including SSN’s, may
be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.
Pursuant to Section 570.030, RSMo, the stealing of public assistance benefits is a Class C felony if the value of the
benefits is $500.00 or more (after 1/1/17 is a Class D felony and value is $750.00 or more). Punishment includes
imprisonment for up to seven years and a fine not to exceed $5,000.00. If the value of the benefits is less than $500.00,
the crime is a Class A misdemeanor (after 1/1/17 less than $750.00). Punishments and fines may increase for repeat
offenders.
Pursuant to Section 578.377 (570.400 effective 1/1/17), RSMo, unlawful receipt of public assistance benefits or EBT
cards, you understand that it is against the law to obtain or attempt to obtain Food Stamp benefits to which you are
not entitled, or obtain, or attempt to obtain Food Stamp benefits in the amount greater than those to which you are
entitled. YOU UNDERSTAND THAT ANY FALSE CLAIM, STATEMENT, OR CONCEALMENT OF ANY MATERIAL FACT
WHATSOEVER, IN WHOLE OR PART, ON THIS FORM OR DURING THE INTERVIEW, MAY SUBJECT YOU TO CRIMINAL
AND/OR CIVIL PROSECUTION. You will be asked to complete an interview with the Family Support Division to complete
this application process. You will be required to provide proof of some of the information you provide on this
application and/or in the interview. Your signature acknowledges that you agreed to the terms outlined in this
application and during the interview.
WORK REGISTRATION
I understand and agree that to receive Food Stamps, certain members of the household need to register for work. This
means that certain members of the household must: A) Register for work at time of application and recertification.
B) Not quit a job of 30 or more hours/week without good cause. C) Not reduce work hours under 30 hours per week
without good cause. D) Not refuse to accept a bona fide offer of suitable employment without good cause. Anyone who
does not follow the work requirements may be disqualified from receiving Food Stamps. This form also acts as a work
registration notice. You, along with other nonexempt household members, will be considered work registered and must
comply with the requirements associated work registration once this form is signed.
WORK AND/OR TRAINING REQUIREMENT (ABAWD)
Individuals identified as Able Bodied Adults Without Dependents (ABAWD’s) are not eligible to participate in the Food
Stamp Program as a member of any household if the individual received Food Stamp benefits for three countable
months during a three year period from January 2016 to December 2018. Countable months are months during which
an individual receives Food Stamp benefits for the full benefit month while not fulfilling the work requirement by
working and/or attending training 20 hours per week, averaged monthly for a total of at least 80 hours.
An ABAWD is 18-49 years old; has no children under age 18 in the Food Stamp household; is not disabled; is not
pregnant; is not a full-time student; not caring for an ill or incapacitated household member; not receiving
unemployment (in any state); and is not attending a drug or alcohol treatment program. The time limit (three months)
applies to ABAWDs only and ABAWDs may regain eligibility by meeting the work/training requirement for at least 80
hours in the last 30 days.
MO 886-0460 (9-16) Page 7 of 8 FS-1 (9-16)
READ THIS PAGE CAREFULLY BEFORE SIGNING.
When you sign, you are certifying you understand the statements on this application. You are certifying, under penalty
of perjury, you understand the information that you provide on this form and during the interview must be true and
accurate, including information concerning citizenship and immigration status. You understand that any expenses you
do not report, and verify when requested, will not be used to determine your Food Stamp benefits.
You are authorizing the Director of Family Support Division or his/her appointee to verify your circumstances and
statements via Federal, State or local officials to determine if the information you provided is factual.
Pursuant to Section 578.385 (570.408 effective 1/1/17), RSMo, under the penalty of perjury, you certify that you have
given true, accurate, and complete statements to the best of your knowledge, for each household member for whom
you are applying including the information concerning citizenship and alien status.
By signing this application on paper or electronically, you are giving us permission to deliver, or cause to be delivered
phone calls to you regarding your case from an automated dialing system at the primary phone number you
provided on page 1. You do not have to consent to this as part of your application. If you want to opt out of getting
these calls, check here:
⬇
SIGN HERE:
Your signature: Date:
Signature of witness (needed if you cannot sign your name): Date
Need help?
• Call 855-FSD-INFO (855-373-4636) Monday through Friday starting at 7:30 AM
• Visit https://dss.mo.gov to find an office location and hours
• Relay Missouri 711
• TTY users can call 800-735-2966
If you are blind or visually impaired and would like information about rehabilitation services for the
blind, please call 800-592-6004.
Establishing paternity is not required for Food Stamp benefits. However, if you want assistance in
establishing paternity, please contact the FSD Paternity Hotline at 855-454-8037.
MO 886-0460 (9-16) Page 8 of 8 FS-1 (9-16)
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Application for Food Stamp benefits (City of Oakland)

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