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DHS-5223-ENG 1-14
Combined Application Form
Apply online at www.applymn.dhs.mn.gov
This application can be used to apply for
any of the following programs:
Supplemental Nutrition Assistance Program (SNAP).
helps low income Minnesotans get the food they need for
good nutrition and well-balanced meals. If you are age
60 and older and are applying for SNAP only, please use
the “Supplemental Nutrition Assistance Program (SNAP)
Application for Seniors” (DHS-5223F).
Cash assistance programs.are provided to help families
and individuals meet their basic needs until they can
support themselves. Cash assistance programs include:
Diversionary Work Program (DWP)
Emergency Assistance (EA)*
General Assistance (GA)
Group Residential Housing (GRH)
Minnesota Family Investment Program (MFIP)
Minnesota Supplemental Aid (MSA)
Refugee Cash Assistance (RCA).
If you need help paying for child care, ask your worker
how to apply for the Child Care Assistance Program.
Need to apply for Health Care coverage?.
Apply for free or low-cost coverage at MNsure,
Minnesotas online health insurance marketplace.
Go to www.mnsure.org or call 855-366-7873.
How to fill out this application
Read all of the information in this application. Tell someone
if you need help filling out this application. Complete and
turn in pages 1 - 10 as soon as possible. We can set your
application date if we have your name, address and signature
(page 1), but we must have the complete application to
decide if you can get help.
For your application to be complete, you must answer
all questions and have certain information verified. SNAP
and cash programs require an interview with a worker.
For SNAP, this can be a phone interview.
If you miss your interview appointment, you must
reschedule. If you do not reschedule, we may stop or not
approve your benefits.
You may need to provide proof of the information you
report on this application. Your worker may ask for
additional proofs. You may not get help until we get proof of
this information. Bring the required information with you
to the interview or send the information to your worker as
soon as you can.
Recertifications. Report all changes in the past 12 months
on this application. You may need to provide proof of the
reported information.
* Before applying for Emergency Assistance, check with your agency regarding funding and specific eligibility criteria.
** Wage stubs from the last 30 days if you are employed or federal income tax records if you are self-employed.
*** Your SNAP benefits may increase if you also provide proof of these expenses: child support paid for children not living with you; housing costs; medical
expenses (including prescriptions) for people with disabilities or who are age 60 or older. Your DWP benefits may increase if you provide proof of your
housing and utility costs.
Required Information
Cash
Programs
SNAP
Identity of applicant or authorized representative (driver’s license, state ID, passport, etc.)
3 3
Social Security numbers of all people applying for help
3 3
Residency in Minnesota (state ID, lease agreement, etc.)
3 3
Income** (paystubs, pension, etc.) or any other money coming into your household
(unemployment, sponsor income, etc.). The agency will verify Social Security income.
3 3
Housing costs*** (rent/house payment receipt, mortgage, lease, etc.)
3 3
Medical costs*** (prescription and medical bills, etc.)
3
Relationship to other household members (birth certificates, marriage licenses, court documents, etc.)
3
Checking and savings accounts (bank statement, etc.)
3
Value of vehicles (cars, trucks, motorcycles, boats, etc.)
3
Current value of stocks/bonds, certificates of deposit, life insurance, trusts (statement, etc.)
3
Utility costs (utility statement, phone bill, etc.)
3
Proof of illness or disability (doctors statement, etc.)
3
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Important Information
Do you have to answer the questions we ask?. You do
not have to give us your personal information. Without the
information, we may not be able to help you. If you give us
wrong information on purpose, you can be investigated and
charged with fraud.
Denial or changes. The state may deny or change your cash
or SNAP assistance because of information you give on the
application. The state may make changes without giving you
10 days advance notice for cash assistance and SNAP. The
state will send you written notice no later than the effective
date of the change for cash assistance and no later than the
date you receive or would receive your SNAP benefits.
For SNAP only. Household members may choose not to
apply. The amount of SNAP benefits will depend on the
number of people who apply. The Social Security number
and citizenship or immigration questions do not need to be
completed for those who do not apply. Household members
who do apply must provide this information. Household
members who are not applying must give information
on their income and, in some cases, assets because this
information is needed to see if the persons who are applying
can get help.
Interim Assistance Programs. General Assistance (GA) and
Group Residential Housing (GRH) are “interim assistance
programs.” That means they will help you while you apply
for other benefits. To get GA or GRH you have to apply for
other benefits you may be eligible for, like Social Security
or Worker’s Compensation. If you get other benefits for the
same period of time that you got GA or GRH, you will have
to pay GA and GRH back.
Social Security numbers (SSN). For most programs, you
must provide a Social Security number (SSN) for each
household member applying for benefits.* If you need a SSN
we can help you apply for one. The state uses your SSN:
To check identity, prevent duplicate participation and to
make mass changes
To determine eligibility for programs such as SNAP,
family cash assistance, and the school lunch program
For program reviews and audits to determine household
eligibility, including fraud investigations
To coordinate with other programs or state agencies to
provide more effective and meaningful services to you.
If you are not a U.S. citizen and are applying for Refugee
Cash Assistance (RCA) you do not have to provide an SSN.
* (Food Stamp Act of 1977 as amended by PL 97-98 and the Social Security
Act of 1935 [section 1137] as amended by PL 98-369 and 42 CFR 435.910
[2006]; [Minn. Stat. §256D.03, subd. 3(h); Minn. Stat. §256L.04, subd. 1a])
Non-citizen applicants. To get help from most public
assistance programs, you must be in the United States (U.S.)
legally. Members of your household who are not citizens and
are applying for help must show proof of their immigration
status. Give a copy of both sides of immigration cards or
other documents that show immigration status for every
household member who is not a U.S. citizen and who is
applying for help. You can apply and get help for
other household members, even if you are not applying or
if you are not eligible because of immigration status.
For non-citizen members of your household who apply
and are eligible for help, your worker may do a computer
match with the U.S. Citizenship and Immigration Services
(USCIS) to confirm the immigration status documents you
give us are valid.
We will not share information about you with the USCIS
without your permission. If you get cash it may affect
changes to your immigration status. If you would like more
information about this or would like to know what the
agency might tell or ask the USCIS, talk to your worker.
Immigration. All immigration information you give to us is
private. We use it to see if you can get help. We only share it
when the law allows it or requires it. In most cases, applying
will not affect your immigration status.
You do not have to give us your immigration information if
you are:
Only helping someone else apply
Applying for your children or other household members,
but not yourself.
Family cap information. If you or someone else in your
family has a child while getting cash assistance, your
family might not get more cash for that child. If you have
questions, talk to your worker.
Domestic violence and vulnerable adults. Violence
or abuse is what someone says or does to make you feel
afraid or to control you. People who are elderly, frail, have
a disability, or who depend on others for assistance may
not be able to protect themselves from domestic violence
or abuse. Minnesota has a law to protect and assist adults
who are vulnerable to abuse or who are not able to care
for themselves. The law can help vulnerable adults get the
protection and safety that they need.
Domestic violence. For more information on domestic
violence, read the “Domestic Violence Information
brochure” (DHS-3477). If domestic violence makes it hard
for you to follow program rules, talk to your worker. If you
are in danger from domestic violence and need help, call
the National Domestic Violence hotline at 800-799-7233;
800-787-3224 (TTY) or Minnesota Coalition for Battered
Women at 800-289-6177.
Vulnerable adults. Call the Senior LinkAge Line at 1-800-
333-2433 to report concerns and to help a vulnerable adult
get needed protection and assistance.
Your Responsibilities
You must report changes which may affect your benefits
to the agency within 10 days after the change has
occurred. Applicants - Report these changes to your
worker when the change happens. This includes the
following for everyone in your household:
Employment - Start or stop a job or business; change
in hours, earnings or expenses
Income - Receipt or change in child support, Social
Security, Veteran benefits, Unemployment Insurance,
inheritance, insurance benefits and other payments
Property - Purchase, sale or transfer of a house,
car or other items of value, or as an inheritance or
a settlement
Household - When a person dies or becomes disabled,
moves in or out of your home or temporarily leaves;
pregnancy; birth of a child
Address
Housing costs/rent subsidy
Utility costs
Filing a lawsuit
Absent parent custody or visits
Drug felony conviction
Marriage, separation or divorce
School attendance.
If you have any questions or are unsure about any reporting
rules, contact your worker. If your worker is not available,
leave a message so the worker can get back to you.
The agency, state or federal agency may check any of the
information you give. To get some information we must
have your signed consent. If you don’t allow the agency to
confirm your information, you might not get assistance.
If you give us information you know is untrue or we
get information you did not report, we will investigate
you for fraud.
The state or Federal Quality Control agency may
randomly choose your case for review. They will review
statements you made on forms. They will check to see
if we figured your eligibility correctly. The state agency
may seek information from other sources. The state or
Federal Quality Control agency will tell you about any
contact they intend to make. If you do not cooperate, your
benefits may stop.
Cooperation requirements:.If the agency approves you for
the Supplemental Nutrition Assistance Program (SNAP),
Minnesota Family Investment Program (MFIP) or the
Diversionary Work Program (DWP), you must cooperate
with employment services, unless you are exempt. You
must develop and sign an employment plan or your DWP
application will be denied.
To receive family cash benefits you must cooperate
with child support enforcement for all children in your
household. You have the right to claim “good cause” for
not cooperating with child support enforcement. You
must assign your child support to the State of Minnesota
for all eligible children. If you do not cooperate
or assign your child support, benefits will be denied
or terminated.
After the agency approves your MFIP or DWP, if you
get child support directly from the noncustodial parent,
you must report it to your worker. You must cooperate
with the child support agency in any legal action brought
against a third party for payment of medical expenses,
unless you claim and are granted good cause.
Cash on an Electronic Benefit Transfer (EBT) card is
provided to help people meet their basic needs. These
basic needs include food, shelter, clothing, utilities and
transportation. These funds are given until people can
support themselves.
It is illegal for an EBT user to buy or attempt to buy
tobacco products or alcohol with the EBT card. If they
do, it is fraud and they will be removed from the program.
Do not use an EBT card at a gambling establishment.
EBT card cash benefits for MFIP/DWP/WB cannot be
used or accessed in any liquor store, casino, gambling
casino, gaming establishment, or retail establishment,
which provides adult-oriented entertainment in which
performers disrobe or perform in an unclothed state
for entertainment.
Each time you use your EBT card for a cash purchase
or sign your check, you state that you have informed the
agency about any changes in your situation which may
affect your benefits.
Each time your EBT card is used we assume you have
received your cash or SNAP benefits, unless you report
your card lost or stolen to the agency.
Your Rights
Your right to privacy. Your private information is
protected by state and federal laws. Your worker will
give you a “Notice of Privacy Practices” (DHS-3979)
information sheet explaining these rights.
You have the right to reapply at any time if your
benefits stop.
You have the right to know why, if we have not processed
your application promptly.
30 days for cash and SNAP
60 days for cash related to disability.
You have the right to know the rules of the program
you are applying for and for us to tell you how we figured
your benefits.
You have the right to choose where and with whom
you live.
Access to free legal services. Contact your worker for
information on free legal services.
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Appeal rights. An “appeal” is a legal process where a
human services judge reviews a decision made by the agency.
You may appeal a decision if you feel the agency did not
act on your request for assistance, or you do not agree with
the action taken. You may represent yourself at the hearing,
or you may have someone (an attorney, relative, friend or
another person) speak for you. For emergency help, when
your case is about an emergency and you need a decision
on your appeal, you can ask for an emergency hearing by
calling the agency or the State Appeals Office. For cash
programs, you may appeal within 30 days from the date
you received this notice by sending a letter saying you do
not agree with the decision. You can send this letter to the
agency, or directly to the State Appeals Office. If you show
good cause” for not appealing your cash assistance within
30 days, the agency can accept your appeal for up to 90
days from the date you received this notice. “Good cause”
is when you have a good reason for not appealing on time.
The human services judge will decide if your reason is a
good cause reason. You can ask to meet informally with
agency staff to try to solve the problem, but this meeting
will not delay or replace your right to an appeal. For SNA P,
you may appeal within 90 days by writing or calling the
agency or the State Appeals Office.
Write:
Minnesota Department of Human Services
Appeals Office
P.O. Box 64941
St. Paul, MN 55164-0941
Call:
Metro: 651-431 3600 (Voice)
Outstate: 800-657 3510
TTY: 800-627 3529
Fax: 651-431 7523
If you want to keep getting your benefits until the hearing,
you must appeal within 10 days of the date on the agency’s
notice of action letter or before the proposed action takes
place in order to keep benefits in place. For most programs,
if you file your appeal on time, you will get your benefits
until a human services judge decides your appeal. If you lose
your appeal, you will have to pay back the benefits you got
while your appeal was pending. You can ask the agency to
end your benefits until the decision. If you end your benefits
and then win your appeal, you will be paid back for benefits
that you should have received. Ask your agency worker to
explain how the timing of your appeal could affect your
present or future assistance.
Your right to file a
discrimination complaint
If you feel that your county human service agency or the
Minnesota Department of Human Services discriminated
against you in the handling of your public assistance
application or benefits because of your race, color,
national origin, political beliefs, religion, creed, sex,
sexual orientation, public assistance status, age, or disability,
you have the right to file a discrimination complaint with
your county agency or any of the following agencies. Your
county agency or the Department of Human Services may
refer your complaint to another agency if it does not have
authority over it. You can also go directly to one of the
federal agencies listed below to file your discrimination
complaint.
Minnesota Department of Human Services
Equal Opportunity and Access Division
P.O. Box 64997
St. Paul, MN 55164-0997
651-431-3040 (Voice)
711 or 800-627-3529 Minnesota Relay
651-431-7444 (Fax)
Minnesota Department of Human Rights
Freeman Building
625 Robert Street North
St. Paul, MN 55155
651-539-1100 (Voice)
651-296-1283 (TTY)
800-657-3704 (Toll-Free Voice)
651-296-9042 (Fax)
The Minnesota Department of Human Rights prohibits
discrimination in public services programs because of race,
color, creed, religion, national origin, disability, sex, sexual
orientation, or public assistance status.
U.S. Department of Health and Human Services
Office for Civil Rights
Region V
233 North Michigan Avenue
Suite 240
Chicago, IL 60601
312-886-2359 (Voice)
800-368-1019 (Toll-Free)
800-537-7697 (TTY)
The U.S. Department of Health and Human Services’ Office
for Civil Rights prohibits discrimination in its programs
because of race, color, national origin, disability, age,
religion, or sex.
U.S. Department of Agriculture
Director
Office of Adjudication
1400 Independence Avenue S.W.
Washington, D.C. 20250-9410
866-632-9992 (Toll-Free Voice)
800-877-8339 (Federal Relay Service)
800-845-6136 (En Español)
The U.S. Department of Agriculture prohibits
discrimination in its programs because of race, color,
national origin, sex, age, religion, disability, or
political beliefs.
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Notice about the Income and
Eligibility Verification System and Work
Reporting System
What is the Income and Eligibility Verification System
(IEVS)?.
The government has a way to check income.
It is the “Income and Eligibility Verification System
(IEVS). The law has us check your income with other
agencies. We have to check income for all who ask for or
get cash assistance benefits. This includes your children.
We need Social Security numbers (SSN) for anyone wanting
help. If you have no SSN, you must apply for one. Apply
with your human services agency. You must report all
SSN’s to your worker.
What is the Work Reporting System?.Minnesota
employers must tell us when they hire someone. This
information is used by the Child Support Program. We
also use this information to see if a new employee is getting
help from any of the programs listed on the first page of
this application.
What facts will we get and how will we use them?..
We check with other agencies about your income, assets
and health insurance. If you did not tell us about all of your
income or assets, we will refigure your aid. Your aid might
go lower or stop. If you get aid you should not be getting,
we may use these facts in civil or criminal lawsuits.
How do we use it?.If the employee is getting help from any
of these programs, the worker gets a notice. If the client did
not report the new job, the worker will contact the client.
The worker may ask the client to show proof about the job.
The client may need to give the agency permission to check
the facts with the employer. If a client does not help us
check the information, they will lose benefits.
Agencies we get information from. We must trade facts
with these agencies:
United States Social Security Administration (SSA) -
We get records of self-employment earnings, retirement
income, survivor’s benefits, disability payments, Social
Security (RSDI), Supplemental Security Income (SSI).
United States Internal Revenue Service (IRS) - We get
records of unearned income (like interest and dividends).
Minnesota Department of Employment and Economic
Development (DEED) - We get records of wages and pay
and facts on Unemployment Insurance.
Minnesota Office of Child Support Enforcement
Agencies in other states that manage:
Unemployment Insurance
Cash assistance
SNAP
Child support enforcement
SSI state supplements.
These agencies have the right to get certain facts from us
about you. They have to use those facts for programs like
RSDI, child support enforcement, cash assistance, SNAP,
Unemployment Insurance, and SSI.
We will tell you if facts from other agencies are not the same
as the facts you gave us. We will tell you what facts we got,
the kind of income or assets, and the amount. We give you
10 days to respond in writing to prove if our facts are wrong.
We will ask you to show proof of income, assets, or health
insurance you did not report or that we could not verify.
You may need to give us permission to check the facts with
the source of data. We will tell you what happens if you do
not sign for permission or do not help us.
The law limits who gets facts about you. The law limits
the facts about you that we get from other agencies and
the facts we give them. Contracts with the Minnesota
Department of Human Services and those agencies also
protect you. Only those agencies, the state, and the county
agency where you apply for and get program benefits can
use the facts about you. No one else can get the facts about
you without your written permission.
Your duty to report. You must report all of your income
and assets:
If you receive cash assistance, report any changes within
10 days of the change, or, if you report on a Household
Report Form (DHS-2120), complete the form and return
it by the 8th of the month.
If you receive SNAP, report required changes by the 10th
of the month following the month of the change. For
example, if a change happens in March, you must report
the change by April 10.
You must still report all of your income, assets and other
information on redetermination forms we send you.
You must help the agency check your income and assets.
IEVS is one way of proving your income and asset amounts.
What if you do not help. You must help us check your
income and assets to get cash assistance and SNAP. If you
dont, you and your family will not get help.
Legal Authority.IEVS - 7 CFR, parts 271, 272, 273, 275;
42 CFR, parts 431, 435; 45 CFR, parts 205, 206, 233 Work
Reporting - Minnesota Statute, section 256.998, subd.10.
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Attention. If you need free help interpreting this document, ask your worker or call the number below for
your language.
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ati dubbattuuf bilbilli 1-888-234-3798.
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

weydiiso ama wac lambarka 1-888-547-8829.

o llame al 1-888-428-3438.

1-888-554-8759.
LB1-0001 (3-13)
This information is available in accessible formats for individuals with disabilities by contacting your county worker. For other
information on disability rights and protections to access human services programs, contact the agency’s ADA coordinator.
ADA5 (12-12)
-vi-
-1-
Combined Application Form
Apply online at: www.applymn.dhs.mn.gov w
CASE NUMBER
The application date or the day your SNAP (food) or cash benefits can start is the date the agency gets your application.
We can set your application date if we have your name, address and signature on page 1. For your application to be complete,
answer all questions on the application. Tell someone if you need help filling out this
application. Be sure to sign and date the application on pages 1 and 9.
PERSON 1 APPLICANT’S LEGAL NAME (last/first/middle)
OTHER NAMES YOU USE (maiden name, nickname, etc.) BIRTH DATE(mm/dd/yy)
GENDER
M F
ADDRESS WHERE YOU LIVE (If you do not have an address, write “homeless.”)
APT. NUMBER
CITY COUNTY STATE ZIP CODE
MAILING ADDRESS
(If different from address where you live)
CITY COUNTY STATE ZIP CODE
PHONE NUMBER WHERE YOU CAN BE REACHED
(include area code)
Home: Other:
DO YOU LIVE ON A RESERVATION?
Yes No If yes, which one?
DO YOU NEED AN INTERPRETER?
Yes No
WHAT IS YOUR PREFERRED SPOKEN LANGUAGE? WHAT IS YOUR PREFERRED WRITTEN LANGUAGE?
MARITAL STATUS
*
SOCIAL SECURITY NUMBER
MOST RECENTLY MOVED TO MINNESOTA
(mm/dd/yy)
Date: From:
U.S. CITIZEN OR U.S. NATIONAL? Yes No
ETHNICITY (optional)
Hispanic?
Yes No
RACE (optional)*
LAST SCHOOL GRADE COMPLETED
WHAT PROGRAM(S) ARE YOU APPLYING FOR?
SNAP (food) Cash programs Emergency Assistance** None
* See MARITAL and RACE codes on the top of page 2.
** Before applying for Emergency Assistance, check with your agency regarding funding and specific eligibility criteria.
Do you need help right away? Questions 1-4 below will help us decide if you can get help with food right away.
1.
How much income (cash or checks) did or will your household get this month?
$
2. How much does your household (including children) have in cash, checking or savings? $
3. How much does your household pay for rent/mortgage per month? $
What utilities do you pay?
Heat Air conditioning Electricity Phone None
4. Yes No Is anyone in your household a migrant or seasonal farm worker?
5. Yes No Has anyone in your household ever received cash assistance, commodities or SNAP benefits before?
5. Yes No If yes, When? Where? What?
Agency use: MEMB, MEMI, TYPE, PROG, IMIG, SPONN
Eligible for expedited SNAP? l Yes l No
Same-day interview offered? l Yes l No Declined? l Yes l No
Next-day interview offered? l Yes l No Declined? l Yes l No
Intends to reside in MN? l Yes l No
Has sponsor? l Yes l No
Immigration status
Verification: l requested l attached
I have looked over my answers and believe they are all true and correct to the best of my knowledge.
SIGNATURE OF APPLICANT OR AUTHORIZED REPRESENTATIVE DATE AGENCY SIGNATURE DATE RECEIVED
*DHS-5223-ENG*
DHS-5223-ENG 1-14
Clear Form
Mary Margaret
01/19/67
4027 28th Ave S
Minneapolis
MN
55406
(612) 722-5588
English
English
Never married
Pacific Islander
12
$ 500.00
100.00
300.00
Mary
Mary M.
Today
Eligibility Worker Today
List all of the people living in your home even if you are not applying for them and/or the person is not asking for
assistance. Program rules require some people to get benefits together. You have to give a Social Security number only for
people who are applying for help. If anyone in the household uses another name (maiden name, nickname, etc.) list the
other name(s) in the OTHER NAMES boxes below. List in this order: Your spouse, other adult(s), children, all other
people, anyone temporarily away from home. If anyone is pregnant, list unborn child(ren) as “unborn child” and the due
date. The RACE and ETHNICITY questions are optional and used to assure that race, color or national origin do not
affect eligibility or the level of benefits issued.
*Marital status:
*
(choose one)
N = Never married M = Married living with spouse S = Separated (married, living apart)
L = Legally separated D = Divorced W = Widowed
*Race:
*
(choose all that apply)
N = American Indian/ Alaska Native A = Asian B = Black or African American
P = Pacific Islander/ Native Hawaiian W = White
PERSON 2 LEGAL NAME (last/first/middle)
OTHER NAMES GENDER
M F
RELATIONSHIP TO YOU
BIRTH DATE
(mm/dd/yy)
MARITAL STATUS* SOCIAL SECURITY NUMBER LAST SCHOOL GRADE COMPLETED
U.S. CITIZEN OR U.S. NATIONAL?
Yes No
ETHNICITY (optional)
Hispanic? Yes No
RACE (optional)* MOST RECENTLY MOVED TO MINNESOTA (mm/dd/yy)
Date ____________ From: ____________
WHAT PROGRAMS IS THIS PERSON APPLYING FOR?
SNAP (food) Cash programs Emergency Assistance** None
** Before applying for Emergency Assistance, check with your agency regarding funding and
specific eligibility criteria.
Agency use: MEMB, MEMI, TYPE,
PROG, IMIG, SPON
Intends to reside in MN? l Yes l No
Has sponsor? l Yes l No
Immigration status
Verification: l requested l attached
PERSON 3 LEGAL NAME (last/first/middle)
OTHER NAMES GENDER
M F
RELATIONSHIP TO YOU
BIRTH DATE
(mm/dd/yy)
MARITAL STATUS* SOCIAL SECURITY NUMBER LAST SCHOOL GRADE COMPLETED
U.S. CITIZEN OR U.S. NATIONAL?
Yes No
ETHNICITY (optional)
Hispanic? Yes No
RACE (optional)* MOST RECENTLY MOVED TO MINNESOTA (mm/dd/yy)
Date ____________ From: ____________
WHAT PROGRAMS IS THIS PERSON APPLYING FOR?
SNAP (food) Cash programs Emergency Assistance** None
** Before applying for Emergency Assistance, check with your agency regarding funding
and specific eligibility criteria.
Agency use: MEMB, MEMI, TYPE,
PROG, IMIG, SPON
Intends to reside in MN? l Yes l No
Has sponsor? l Yes l No
Immigration status
Verification: l requested l attached
PERSON 4 LEGAL NAME (last/first/middle)
OTHER NAMES GENDER
M F
RELATIONSHIP TO YOU
BIRTH DATE
(mm/dd/yy)
MARITAL STATUS* SOCIAL SECURITY NUMBER LAST SCHOOL GRADE COMPLETED
U.S. CITIZEN OR U.S. NATIONAL?
Yes No
ETHNICITY (optional)
Hispanic? Yes No
RACE (optional)* MOST RECENTLY MOVED TO MINNESOTA (mm/dd/yy)
Date ____________ From: ____________
WHAT PROGRAMS IS THIS PERSON APPLYING FOR?
SNAP (food) Cash programs Emergency Assistance** None
** Before applying for Emergency Assistance, check with your agency regarding funding
and specific eligibility criteria.
Agency use: MEMB, MEMI, TYPE,
PROG, IMIG, SPON
Intends to reside in MN? l Yes l No
Has sponsor? l Yes l No
Immigration status
Verification: l requested l attached
-2-
-3-
APPLICANT’S NAME SOCIAL SECURITY NUMBER CASE NUMBER
PERSON 5 LEGAL NAME (last/first/middle)
OTHER NAMES GENDER
M F
RELATIONSHIP TO YOU
BIRTH DATE
(mm/dd/yy)
MARITAL STATUS* SOCIAL SECURITY NUMBER LAST SCHOOL GRADE COMPLETED
U.S. CITIZEN OR U.S. NATIONAL?
Yes No
ETHNICITY (optional)
Hispanic? Yes No
RACE (optional)* MOST RECENTLY MOVED TO MINNESOTA (mm/dd/yy)
Date ____________ From: ____________
WHAT PROGRAMS IS THIS PERSON APPLYING FOR?
SNAP (food) Cash programs Emergency Assistance** None
** Before applying for Emergency Assistance, check with your agency regarding funding
and specific eligibility criteria.
Agency use: MEMB, MEMI, TYPE,
PROG, IMIG, SPON
Intends to reside in MN? l Yes l No
Has sponsor? l Yes l No
Immigration status
Verification: l requested l attached
If more than 5 people, complete DHS-5223S or use back page of application.
Tell us about your household.
(Answer all questions below.)
Yes No
1.
Does everyone in your household buy, fix or eat food with you?
Agency use: EATS
l Confirmed response
Verification: l requested l attached
Yes No
2.
Is anyone in the household, who is age 60 or over or disabled, unable to buy or fix food
due to a disability?
Agency use: EATS
l Confirmed response
Verification: l requested l attached
Yes No
3.
Is anyone in the household attending school?
Agency use: SCHL
l Confirmed response
Verification: l requested l attached
Yes No
4.
Is anyone in your household temporarily not living in your home? (for example: vacation,
foster care, treatment, hospital, job search)
Agency use: REMO
l Confirmed response
Verification: l requested l attached
Yes No
5. Is anyone blind, or does anyone have a physical or mental health condition that limits the
ability to work or perform daily activities?
Agency use: DISA, EMPS, PBEN,
UNEA, WREG
l Confirmed response
Verification: l requested l attached
Yes No
6.
Is anyone unable to work for reasons other than illness or disability?
Agency use: EMPS, WREG
l Confirmed response
Verification: l requested l attached
-4-
Yes No
7.
In the last 60 days did anyone in the household:
•Stopworkingorquitajob? •Refuseajoboffer?
•Asktoworkfewerhours? •Goonstrike?
Agency use: STWK, STRK
l Confirmed response
Eligible for good cause? l Yes l No
Verification: l requested l attached
What kinds of income do you have? (Answer all questions below.)
Yes No
8.
Has anyone in the household had a job or been self-employed in the past 12 months?
Agency use: JOBS
l Confirmed response
Verification: l requested l attached
Yes No
Bring or
send proof.
9.
Does anyone in the household have a job or expect to get income from a job this month or
next month?
If yes, employer/business name: Gross monthly earnings: $
Note: Include income from Work Study and paid internships.
Include free benefits or reduced expenses received for work (shelter, food, clothing, etc.).
Agency use: JOBS, STIN
l Confirmed response
Verification: l requested l attached
How often paid? l Daily l Weekly
l Biweekly l Semimonthly l Other
Yes No
Bring or
send proof.
10. Is anyone in the household self-employed or does anyone expect to get income from self-
employment this month or next month? If yes, gross monthly earnings are:
$
Examples:
•Productsales •ConservationReserveProgram(CRP) •Personalservices •Farming
•Paperroute •In-homedaycare •Roomers/boarders
•Propertyrental •Taxidriver •Other
Agency use: BUSI, RBIC
l Confirmed response
Verification: l requested l attached
Yes No
11.
Do you expect any changes in income, expenses or work hours?
Agency use: BUSI, JOBS, WKEX
l Confirmed response
Verification: l requested l attached
Principal Wage Earner (PWE). SNAP (food) households with children must designate the person they want as the PWE.
Any adult in your SNAP household can be the PWE. Talk to your worker before designating the SNAP PWE.
DESIGNATED PWE SIGNATURE OF APPLICANT
Mary Margaret
Mary M.
-5-
12. Has anyone in the household applied for or does anyone get any of the following types of income each month?
Check yes or no for each item. Bring or send proof.
Yes No Social Security (RSDI)*** $ Yes No Supplemental Security Income (SSI)*** $
Yes No Veteran benefits (VA) $ Yes No Unemployment Insurance $
Yes No Workers’ Compensation $ Yes No Retirement benefits $
Yes No Tribal payments $ Yes No Child support or spousal support $
Yes No Other unearned income (trusts, gifts, gambling, etc.) $
***The agency will verify this income for you.
Agency use: PBEN, UNEA
l Confirmed response
Verification: l requested l attached
Yes No
13.
Does anyone in the household have or expect to get any loans, scholarships or grants for
attending school?
Agency use: STIN
l Confirmed response
Verification: l requested l attached
What kinds of expenses do you have? (Answer all questions below.)
Check yes or no
for each item.
Bring or
send proof.
14. Does your household have the following housing expenses?
Yes No Rent (include mobile home lot rental) Yes No Association fees
Yes No Mortgage/contract for deed payment Yes No Room and/or board
Yes No Homeowners insurance (if not included in mortgage)
Yes No Real estate taxes (if not included in mortgage)
Agency use: SHEL, EATS
l Confirmed response
Verification: l requested l attached
Check yes or no
for each item.
Bring or
send proof.
15. Does your household have the following utility expenses any time during the year?
Yes No Heating/air conditioning Yes No Electricity
Yes No Cooking fuel Yes No Garbage removal
Yes No Water and sewer Yes No Phone/cell phone
Agency use: ACUT, HEST
l Confirmed response
Verification: l requested l attached
Yes No
16. Do you or anyone living with you have costs for care of a child(ren) because you or they are
working, looking for work or going to school? The Child Care Assistance Program may help
pay child care costs. Ask your worker how to apply for the Child Care Assistance Program.
Agency use: DCEX
l Confirmed response.
Verification: l requested l attached
Yes No
17. Do you or anyone living with you have costs for care of an ill or disabled adult because you
or they are working, looking for work or going to school?
Agency use: DCEX
l Confirmed response.
Verification: l requested l attached
Yes No
18.
Does anyone in the household pay court-ordered child support, spousal support, child care
support, medical support or contribute to a tax dependent who does not live in your home?
Agency use: COEX
l Confirmed response
Verification: l requested l attached
-6-
Yes No
19.
For SNAP only: Does anyone in the household have medical expenses?
To get a medical deduction you must provide proof of all medical bills incurred by anyone in
your household who is disabled or 60 years or older. Do not bring medical bills that are being
paid for by any health
care program, insurance or someone not living with you.
Agency use: BILS, FMED
l Confirmed response
Verification: l requested l attached
Yes No
20. For General Assistance only: Does anyone in the household have expenses related to work,
training or job search, such as transportation, meals or uniforms? Ask your worker if these
expenses apply to the programs you are requesting.
Agency use: WKEX
l Confirmed response
Verification: l requested l attached
What do you own? (Answer all questions below.)
Check yes or no
for each item.
Bring or
send proof.
21. Does anyone in the household own, or is anyone buying, any of the following?
Yes No Cash Yes No Life or burial insurance
Yes No Bank accounts (savings, checking, etc.) Yes No Stocks bonds, annuities, etc.
Yes No Vehicles (cars, trucks, motorcycles, etc.) Yes No Real estate property (house, land, etc.)
Yes No Other assets (tools, boats, livestock, etc.)
Agency use: CASH, CARS, ACCT,
REST, SECU, SPON, OTHER
l Confirmed response
EFT offered? l Yes l No
Verification: l requested l attached
Yes No
22. Has anyone in the household given away, sold or traded anything of value in the past 12
months? (For example: real estate property, bank accounts, annuities, vehicles, etc.)
Agency use: TRAN
l Confirmed response
Verification: l requested l attached
Other information: (Answer all questions below.)
Yes No
23.
For recertifications: Did anyone move in or out of your home in the past 12 months?
Agency use: ADME, REMO
l Confirmed response
Verification: l requested l attached
Yes No
24. Are both parents of each child under age 19 living in the home?
Agency use: INFC/CSIA, ABPS
l Confirmed response. Referral made to
Child Support and Collections? l Yes l No
Yes No
25. For Minnessota Supplemental Aid recipients only: Is anyone in the household on a diet
prescribed by a doctor?
Agency use: DIET
l Confirmed response
Verification: l requested l attached
-7-
You may authorize another person(s) to act on your behalf to help you:
Fill out forms and apply for help from the agency (for example, go to an interview for you, talk to
or work with Employment services provider(s))
Get notices and information related to your case
Get your SNAP benefits and buy food for you through your Electronic Benefit Transfer (EBT) account.
You can ask more than one person(s) to help you with the items listed above. The authorized person(s) may be a friend,
relative, conservator acting on your behalf, a person authorized by the courts, or a person with your power of attorney.
This person(s) can act for you until you notify your worker that you want this to end. Ask your worker for more
information about authorized representatives.
I want the person named to:
Fill out forms
Get notices
Get and use my
SNAP benefits
NAME RELATIONSHIP PHONE NUMBER
ADDRESS
CITY STATE ZIP CODE
Fill out forms
Get notices
Get and use my
SNAP benefits
NAME RELATIONSHIP PHONE NUMBER
ADDRESS
CITY STATE ZIP CODE
Fill out forms
Get notices
Get and use my
SNAP benefits
NAME RELATIONSHIP PHONE NUMBER
ADDRESS
CITY STATE ZIP CODE
Legal guardian. Do you have a legal guardian or conservator, or is there a power of attorney?
If yes, what is this persons full name? (attach copies of legal documents)
Yes No
NAME DO YOU PAY A FEE?
Yes No If yes, amount? ________
HOW OFTEN?
Yes No
Are you currently getting help from a social worker or social services agency?
Yes No
Do you need help with referrals for other areas (for example, food shelves, housing, transportation)?
Comments:
-8-
Yes No
1. Has a court or any other civil or administrative process in Minnesota or any other state
found anyone in the household guilty or has anyone been disqualified from receiving public
assistance for breaking any of the rules above?
Yes No
2. Has anyone in the household been convicted of making fraudulent statements
about their place of residence to get cash or SNAP benefits from more than one state?
Yes No
3. Is anyone in your household hiding or running from the law to avoid prosecution,
being taken into custody, or to avoid going to jail for a felony?
Yes No
4. Has anyone in your household been convicted of a drug felony in the past 10 years?
Yes No
5. Is anyone in your household currently violating a condition of parole, probation
or supervised release?
If you checked yes to any of the above questions, list the household member(s) and question number below:
QUESTION NO. HOUSEHOLD MEMBER QUESTION NO. HOUSEHOLD MEMBER
Employment services registration. I understand that signing this application registers me for employment services.
I also understand that doing so automatically registers everyone in my home whom the agency approves to receive assistance
with me for employment services. I understand that I or others in my home might have to take part in employment services to
receive cash assistance or SNAP benefits.
Penalty warnings and qualification questions
If you get cash or SNAP benefits, you must follow the rules
listed below.
• Do not give false information or hide information to
get or continue to get benefits. If you get cash or SNAP
benefits and give false information or hide information
about your identity and residency to get multiple
benefits for the same period of time, you may be
barred for 10 years.
• Do not trade or sell SNAP benefits or Electronic
Benefit Transfer (EBT) access cards. The trade or sale
of benefits valued at over $500 may result in
permanent ineligibility.
• Do not use cash or SNAP benefits to buy ineligible
items, such as alcohol and tobacco.
• Do not use someone else’s EBT access card(s) to get cash
or SNAP benefits for your household.
The state may bar household members who break any of
these rules. The bar lasts one year for the first fraud, two years
for the second fraud and is permanent for the third fraud.
The months you are barred from MFIP for breaking the rules
may count toward your 60-month lifetime limit.
You can also be prosecuted for fraud if you break the rules
and additional fines and penalties may apply. The maximum
penalty is a fine of $250,000 or a jail term of 20 years,
or both.
Special SNAP penalty warning: If a federal, state or local
court finds you or any household member guilty of giving
or receiving SNAP benefits in exchange for:
• Controlled substances, that household member will be
barred from getting SNAP for 24 months for the first
offense and permanently for the second offense.
• Firearms, ammunition or explosives, that household
member will be barred from getting SNAP permanently.
If you admit committing a drug felony in the
past 10 years, the agency may ask you to take random
drug tests. The first time you fail a drug test, the agency
will reduce your households MFIP or SNAP benefits by
30 percent. If you fail the test a second time, you will be
permanently disqualified.
-9-
By signing:
• I understand cash assistance is provided to help eligible families meet their basic needs.
• I understand if I give incorrect information or misuse an electronic benefit transfer (EBT) card, I may be prosecuted for
fraud. [Minnesota Statute, sections 256.98 and 609.821]
• I acknowledge that since my last application or recertification, I have received my cash and/or SNAP benefits directly or
used my EBT card to get my cash and/or SNAP benefits.
• I acknowledge that I have read and understand the “Penalty warnings and qualification questions” section on page 8.
• I acknowledge that my worker gave me a copy of the “Notice of Privacy Practices” (DHS-3979) and explained the “Your
responsibilities” and “Your rights” sections on page iii.
• I agree to assign my child support as stated above.
• I agree to the sharing of information as stated on the fraud release information section above.
• I agree to the sharing of information as stated in the Social Security numbers section on page ii.
SIGNATURE OF APPLICANT OR AUTHORIZED REPRESENTATIVE DATE SIGNATURE OF SPOUSE OR OTHER ADULT DATE
Assignments
I understand that when I get MFIP I must assign my rights
to child support and maintenance to the state of Minnesota.
Perjury and general declarations
I declare under the penalties of perjury that I have examined
this application and to the best of my knowledge, it is a true
and correct statement of every material point. I understand
that a person convicted of perjury may be sentenced to
imprisonment of not more than five years or payment of a fine
of not more than $10,000, or both.
[Minnesota Statutes, section 256.984, subd. 1]
Authorization to share information
for fraud investigation and audits
I agree that third parties may share information about me
with persons investigating fraud and conducting Federal or
state audits. This may include, but is not limited to:
Employers and schools,
Landlords and utility companies,
Financial and insurance agencies, and
Other government offices.
I understand this consent is good for six months after my
benefits stop.
Agency Use:
Provided applicant with the following documents:
Family Violence Referral (DHS-3323)
Domestic Violence Information brochure (DHS-3477)
Notice of Privacy Practices (DHS-3979)
Responsibilities and Rights (pages iii - iv)
ADA brochure (DHS-4133)
Change Report Form (DHS-2402)
Reviewed all pages of application with client
AGENCY SIGNATURE INTERVIEW DATE CASE NUMBER
Mary M. Today
x
X
X
X
X
x
x
Eligibility Worker Today
-10-
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