Fillable De0415f Application for Services 415F

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De0415f Application for Services 415F

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DHS 0415F (01/19), Recycle prior versions
• •
SM
Application for Services
What do I need to do to get benets?
1. Pick up an application (DHS 0415F).
You can get an application by:
• Printing one from https://apps.state.or.us/Forms/Served/de0415F.pdf;
• Calling your local self-sufficiency office to have one mailed to you;
• Picking one up at your local self-sufficiency office; or
• For SNAP food benefits only, you may apply online by going to: https://apps.state.or.us/connect
Tondtheclosestoce,dial211orgoonlineto:www.oregon.gov/DHS/Oces/Pages/index.aspx.
2. Fill out the application.
• Child care, Employment Related Day Care (ERDC): For low income working families.
More information can be found at the following website:
http://www.oregon.gov/dhs/assistance/CHILD-CARE
To apply, fill out pages 1–5. Read pages 13–15 and sign page 15.
• Food benefits, Supplemental Nutrition Assistance Program (SNAP): Help to buy food. To apply, fill
outpages1–7.Readpages12–15andsignpage15.You can submit page 1 with only your name,
address and signature to file a request for food benefits and start the application process. If you
are eligible for food benefits, benefits will begin from this filing date.
• Medical assistance: To apply for health coverage, go online to: OregonHealthCare.gov or
call 1-800-699-9075 or 711 (TTY) Monday through Friday, 7 a.m. to 6 p.m. to request an application.
• Cash assistance, Temporary Assistance for Needy Families (TANF): For very low
income families with dependent children, those who are in the late stages of pregnancy, or
Refugee Cash Assistance: For refugees who are within their eight months in the United States.
To apply for cash assistance, fill out the entire application.
3. Turn in the application. Youcanmail,faxordroptheapplicationoatyourlocal
self-suciencyoce (you can make a date-stamped copy for your records). If you are a newly arrived
refugee within 8 months of U.S. arrival and reside in Multnomah, Washington or Clackamas counties,
turninyourapplicationatthelocalrefugeeresettlementoce.YouwillbeservedintheRefugeeCase
Service Project (RCSP).
4. Make an appointment for an interview with a caseworker. We may go over the application with you
in an interview. It is important to make it to your interview. If you need to reschedule, please let us know.
What if I need food benets right away?
Wemaybeabletogiveyoufoodbenetswithinsevendaysifyouqualify.
To qualify, one of the following must be true:
• Your income is less than $150 per month and your cash and bank accounts total less than $100;
• The total of your monthly income, cash and money in the bank is less than your total housing and
utility costs for a month; or
• You are a migrant or seasonal farm worker and have very little money.
You must be able to show proof of your identity.
Continued on next page
Clear form
Print form
• •
DHS 0415F (01/19), Recycle prior versions
What do I need to bring to the interview?
You may need to bring:
 1.Youridentication;
 2. Proofofyourincome;
 3. SocialSecuritynumbersforeveryoneinyourhouseholdwhowantsbenets;and
 4. Proofofyourlegalimmigrationstatusforthosepersonswhowantbenets.
Please let us know if you need help getting the information and we may be able to help you.
When will my benets start if I qualify?
• Cash benefits usually start based on the date we get the application. The amount of your benefits is
also based upon this date.
• Food benefits usually start based on the date we get the application. The amount of your benefits is
also based upon this date.
• Child care benefits start on the first day of the month in which the request is made if you qualify.
However, the effective date for payment cannot be earlier than the date your provider of choice is in
approved listing status with the Department of Human Services (DHS).
Social Security numbers (SSN) and citizenship.
If you are applying for someone else and not for yourself, we do not need your SSN or citizenship status.
PeoplewhoarenotU.S.citizensmaystillqualifyforcertainbenets.IfyoudonothaveanSSNyourself,
other family members who do have SSNs may still qualify. Page 13 tells why DHS collects each SSN and
what each SSN is used for.
Social Security numbers are not required for Refugee Cash Assistance.
You can get this document in other languages, large print, braille or a format you prefer. To request this
forminanotherformatorlanguage,contactyourlocaloceor711forTTY.Foralistoflocalocesplease
seewww.oregon.gov/DHS/Oces/Pages/index.aspx.
DHS 0415F (01/19), Recycle prior versions
• •
1. I am applying for:
Child care
Domestic violence help
Food
Cash for families
Refugee Cash Assistance (RCA)
2. Do you plan to stay in Oregon? Yes No
3. Has anyone you are applying for received services from another state within the last 30 days?
Yes No If yes, where?__________________________ Date last received: ______________
4. Doyouwanttogivepermissiontosomeoneelsetoapplyorgetbenetsforyou? Yes No
5. Do you usually buy food and eat with everyone you live with? Yes No
If no, who buys their food separately?___________________________________________________
Please ask if you need help lling out this form.
Tell us about you
(last, rst, middle initial) (or other names used)
Social Security number Phone or message number (check one) Email
Home address City State ZIP code
Mailing address (if dierent) City State ZIP code
Signature of applicant (ling date for food only). All programs, sign page 15 to complete request. Date
Full name Maiden
Language I speak: ___________________________________________________________________
Let us know if you need: An interpreter A sign language interpreter
Written materials translated (what language): ____________________________________________
Materials in: Braille Large print Audio tape Computer disk Oral presentation
Do you have an immediate need?
1. Please answer the following for you and anyone you are applying for:
a) Does anyone have income of $150 or more a month? Yes No
b) Does anyone have $100 or more in cash, checking or savings accounts? Yes No
c) Are your monthly rent and utility payments more than your monthly income,
cash and money in your bank accounts? Yes No
d) Is anyone a migrant or seasonal farm worker? Yes No
If yes, does anyone have $100 or more in cash, checking or savings? Yes No
Willyougetincomeof$25ormoreinthenext10days? Yes No
2. Do you need a place to live? Yes No
3. Do you have an eviction or foreclosure notice? Yes No
4. Doyouhaveorexpecttogetautilityshut-onotice? Yes No
5. Do you need to get away from an abusive or unsafe situation? Yes No
6. Does your partner make you afraid by threatening, yelling or physically hurting you?
Yes
No
1
Agency
use
only:
Branch: Case number: Worker ID: Case name: Date of request: Filing date:
Expedited service?
Yes No
Appointment date/time: Receptionist ID:
MA notice
To complete your application for food benets, ll in pages 1–7 and sign page 15.
• •
DHS 0415F (01/19), Recycle prior versions
2
5. Listanyonewhowantsbenetsandisahighschool,college,tradeorvocationalstudent.
Student 1 Student 2
Name of student:
Name of school/training program:
Type of student:
High school
GED
Graduate
Vocational
Undergraduate
High school
GED
Graduate
Vocational
Undergraduate
Credits:
Student last term, this term or both?
Last term
This term
Both
Last term
This term
Both
Applyfororgetnancialaid?
Apply
Getting
Apply
Getting
1. Tell us about the people in your household
Pleaseanswerbelowforthosewhowantbenets.
Please complete below for everyone in your household. You
can choose not to give your ethnic group and racial heritage
information.Itwillnotaectyoureligibility.Thisinformation
helps us follow Title VI of the Civil Rights Act of 1964.
2. Is anyone in your household pregnant? Yes No
If yes, who? _________________________________________ Due date: __________________
3.
Is anyone in the military, a veteran or a spouse/dependent of someone who is? Yes No
4.
Forcashbenets,wouldyouliketotalkwithsomeoneaboutconcernsyouhavewithyour
children? (Such as acting out, school problems, medical needs or nding child care.) Yes No
Self
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
DHS 0415F (01/19), Recycle prior versions
• •
* If you need additional space, see the back of this sheet.
Additional space for other people living with you
Pleaseanswerbelowforthosewhowantbenets.Please complete below for everyone in your household. You
can choose not to give your ethnic group and racial heritage
information.Itwillnotaectyoureligibility.Thisinformation
helps us follow Title VI of the Civil Rights Act of 1964.
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
• •
DHS 0415F (01/19), Recycle prior versions
* If you need additional space, please make copies or ask for the DHS 0415X.
Additional space for other people living with you
Pleaseanswerbelowforthosewhowantbenets.
Please complete below for everyone in your household. You
can choose not to give your ethnic group and racial heritage
information.Itwillnotaectyoureligibility.Thisinformation
helps us follow Title VI of the Civil Rights Act of 1964.
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
Full name (last, rst, middle initial)
Sex: Male Female
Marital status: Married Single Widowed
Divorced Married, but separated
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Racial heritage: Asian White
NativeHawaiian/PacicIslander
American Indian/Alaska Native
Black or African American
U.S. citizen:
Yes No
If no complete the information below:
Alien Resident number:
Social Security number:
Check below the benets for this person:
None Food Child care
Cash Domestic violence help
Does this person have a disability? Yes No
For food and cash benets, does this person have an
outstanding arrest warrant? Yes No
Last grade completed: _____________________
Place of birth: _____________________________________
(City/state or country)
Date of U.S. entry: ______ Date of Oregon entry: _______
Date of birth (mm/dd/yyyy)
Relationship (mother, son)
DHS 0415F (01/19), Recycle prior versions
• •
Tell us about your household’s work and income.
3
Please answer the following for you and anyone you are applying for.
1. Does anyone have or expect to get any money?
Yes
No
If yes,pleaseanswerquestions2and3. We will need proof of income for the last 30 days.
2. Money from work. Please tell us about wages, salaries and commissions for this month from
jobs and self employment.
a. Self-employment means you are being paid for doing work, but you don’t have a regular employer
otherthanyourselfwhogivesyouapaycheckandtakesouttaxes.Perhapsyouhaveyourown
company with a separate bank account, or perhaps you do odd jobs for people who pay you in cash.
We need to know about money that has already been paid or that will be paid this month to
anyone in your home who is related to you or your children. Use gross income (totals before
taxes and deductions).
Does anyone in your home get money for working?
Yes
No
If yes,pleaselloutthispage.
b. Has anyone lost a job or quit a job within the last 30 days?
Yes
No
If yes, who? _____________________________________ Date of last day worked: ____________
Reason for job loss? _______________________________________________________________
Date of last pay: ___________________________________________________________________
3. Does anyone in your household work as a volunteer?
Yes
No
If yes, name of volunteer: _________________________________ Hours per week? ____________
Earned income Job 1 Job 2 Job 3
Person working:
Employer’s name:
Employer’s phone:
Position title:
Hourly pay: $ $ $
Hours (per week):
How often paid
(weekly, monthly):
Other pay:
Tips
Overtime
Bonus
Commission
ShiftDi.
Other
Tips
Overtime
Bonus
Commission
ShiftDi.
Other
Tips
Overtime
Bonus
Commission
ShiftDi.
Other
Is income from
self-employment?
Yes
No
Yes
No
Yes
No
Do you have any
costs associated with
this business?
Yes
No
Yes
No
Yes
No
Income this month: $ $ $
Income last month: $ $ $
*If any income has recently changed or will be changing, please let us know why:
New amount: $ $ $
Date of the change:
Agency
use only
Branch: Case number: Worker ID: Case name:
• •
DHS 0415F (01/19), Recycle prior versions
Unearned income 1 2 3
Person receiving
the money:
Source/type:
Expectedtocontinue: Yes No Yes No Yes No
Amount received: $ $ $
How often received
(weekly, monthly):
Unearned income
this month: $ $ $
Unearned income
last month: $ $ $
4. Please list any unearned income.
Does anyone in your home get money from places other than work?
Yes
No
If yes, tell us about this month’s income for anyone in your home who is related to you or your
children (including expected children).
► You must send proof. Tell us about money, including:
• Loans repaid to you
• Cash assistance
• Retirement pension
• Supplemental Security
Income (SSI)
• Educational income (such
as nancial aid)
• Disabilitybenets
• Child or spousal support
• Guardian or foster
care payments
• SocialSecuritybenets
• Veteransbenets
• Other:
• Dividends or interest
on investments
• Worker’s compensation
• Tribal payments
• Unemployment compensation
• Rent paid to you
Dependent care expenses
1. Does anyone pay for child care or care for an adult with a disability?
Yes
No
If yes, who pays? ____________________________ $ ______________ a month.
2. Ifyougetchildcarebenets,doyoupayforchildcarecostsinadditiontoyourcopay?
Yes
No
If yes, enter monthly amount. $ ______________ a month.
Tell us about your household’s expenses
4
Ifyouneedhelpchoosingaprovider,contact:211Infobydialing211,textthekeyword“children”to
898211,emailchildren@211.orgorvisit211Info.org.
1. Please list information about your work schedule.
Parent 1:
Usual work hours: From ________________ a.m. / p.m. To ________________a.m. / p.m.
Usual work days: Mon. Tue. Wed. Thu. Fri. Sat. Sun.
Other schedule (describe): ______________________________________________________
Note: If your work schedule varies, give information on the days and times you have worked.
Parent 2 or spouse if in household or additional employment:
Usual work hours: From ________________ a.m. / p.m. To ________________a.m. / p.m.
Usual work days: Mon. Tue. Wed. Thu. Fri. Sat. Sun.
Other schedule (describe): ______________________________________________________
2.
Please list information about your child care provider.
Care provider: __________________________ Phone number:
Second provider: _______________________ Phone number:
Tell us about your child care needs
DHS 0415F (01/19), Recycle prior versions
• •
Paid to Amount paid Who pays
$
$
If you are applying for child care only, please skip to page 13,
read pages 13─15 and sign page 15.
To apply for food and cash please continue.
5
Housing expenses
1. Do you or anyone in your household pay for housing?
Yes
No
If yes, please complete below.
Rent
Mortgage What is the total rent/mortgage? ___________________
2. Doyouexpecttopaythesameamountforhousingnextmonth?
Yes
No
3. Do you get help to pay for housing?
Yes
No
If yes, please complete below.
4. Ifyouhavereportedthatyouhavenoincome,howareyoupayingyourhousingexpenses?
_________________________________________________________________________________
_________________________________________________________________________________
How much do you pay of the
total amount?
Fire/hazard insurance,
if separate:
Propertytax,ifseparate:
$________________ per
Week Month Year
$________________ per
Week Month Year
$________________ per
Week Month Year
Person or company you pay rent/mortgage to:
May we contact this person/company?
Yes
No
If yes, their phone:
3. Are you homeless?
Yes
No
Homeless could mean living in an emergency shelter, shared housing with another family
because of job loss or loss of your housing, in a motel, car, park, public place, campsite or
other similar place.
4. Do you need child care for a foster child?
Yes
No
5. Do you have shared custody for any of the children needing care?
Yes
No
6. Do you need child care while you are working and attending classes?
Yes
No
Class hours can only be approved if you are working and attending a school that is eligible for
federalnancialaid.Youmustgiveacopyofyourschoolregistrationandcurrentclassschedule.
7. For child care needs, are your children’s immunization (shot) records up-to-date?
Yes
No
If no, contact your doctor or local health department for more information. You must
agreetomeetstateimmunizationguidelinesorexemptionstogetchildcarebenets.
8. Is anyone in the household an active military member?
Yes
No
If yes, who: _________________
Full time active military
National Guard or Reserve Unit
9. Doyourfamily’sassetsexceedonemilliondollars($1,000,000)?
Yes
No
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2. Is anyone buying, or an owner of, real estate, land or buildings you are not living on?
Yes
No
3. Does anyone have any items of value? (Examples: car, truck, boat, etc.)
Yes
No
Tell us about your household’s resources
1. Do you, or anyone you are applying for own or have their name on any of the following?
a) Checking, savings, credit union accounts, IRA, 401K.
Yes
No
b) Stocks, bonds, money market accounts, CDs, trust funds.
Yes
No
c) Cash on hand or other: __________________________________________
Yes
No
If yes to any of the above, please complete below.
Type Name/location of bank Current balance/value Belongs to
Court-ordered child support expenses
For which child Amount paid Person who pays support
$
1.
Does anyone in your home pay court-ordered child support to someone outside your home?
If yes, please complete below.
Yes
No
1.
Is anyone you are applying for 60 or older or a person with a SSI/SSD disability?
Yes
No
If yes,listanyout-of-pocketmedicalexpenses,includingmedicalinsuranceexpenses.
Person with the out-of-pocket expenses Amount paid
$ __________________ a month
Medical expenses
4. Have you or a member of your family been injured in an accident that you are
making a claim for money?
Yes
No
If yes, what is the date of the injury? ____________________
If yes, please complete form MSC 0451, Vehicle Related Personal Injury or
MSC 0451NV, Non-Vehicle Related Personal Injury.
Utility expenses
1. Do you pay to heat/cool your home?
Yes
No
a) Is theheat/coolexpense
included in the rent/mortgage?
Yes
No
2.
What other kind of utilities do you pay?
Water/sewer
Garbage
Electric
Gas
Phone
Other: __________________
6
Agency use only
FUA LUA IUA TUA COS
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• •
Tell us about your time on TANF
1. Oregon has a 60 month time limit for Temporary Assistance for Needy Families (TANF).
Months you received TANF in another state or from a tribal TANF program may be counted
towards the Oregon Time Limit.
Did you or anyone you are applying for get TANF in another state or from a
tribal TANF program since 1996?
Yes
No
If yes, please complete below.
Person State or tribe Months on TANF
If you are applying for food and child care benets only,
skip to page 12. Read pages 12–15 and sign page 15.
To apply for cash please continue.
Tell us about your out of state food benets
1. Oregon has a 3 month time limit for SNAP benets. This time limit is for most adults age 18
but not yet 50, who are able to work. There are no children in the home. They can get SNAP for
only 3 months in a 3-year period. The months you received SNAP in another state may be
counted towards the Oregon Time Limit.
Did you or anyone you are applying for get SNAP in another state since January1, 2019?
If yes, please complete below.
Yes
No
Person State
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• •
Tell us about your household’s disabilities
1. Does anyone you are applying for have a disability that will last more than 12 months?
Yes
No If yes, who? _____________________________________________________
2. Has anyone in your home applied or considered applying for disability benets through the
Social Security Administration?
Yes
No
If yes, was the application: Approved Denied Pending
Tell us about the community in which you live
1. Do you live on one of the following?
Indian Reservation
Yes
No
If yes, which? ________________________________________________________________
Dependent Indian community
Yes
No
If yes, which? ________________________________________________________________
Indian allotment
Yes
No
If yes, which? ________________________________________________________________
Tell us about your tribal membership
1. Is anyone you are applying for a member of one of Oregon’s nine federally recognized tribes?
If yes, which tribe(s):
Yes
No
2. Is anyone you are applying for a member of any other federally recognized tribe?
Person Tribe
Burns Paiute Tribe
Confederated Tribes of the Coos, Lower
Umpqua and Siuslaw Indians
Coquille Indian Tribe
Cow Creek Band of Umpqua Indians
Confederated Tribes of Grand Ronde
Klamath Tribes
Confederated Tribes of Siletz
Confederated Tribes of the Umatilla
Indian Reservation
Confederated Tribes of Warm Springs
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9
Important – By applying for services, you are letting us establish paternity (legally name the child’s father)
and pursue child support from parents not living in your household unless you think this parent might harm
you or the child.
1. If anyone in your household is pregnant, is the father living in the house?
Yes
No
2. Do any of the children’s parents live outside the child’s home?
Yes
No
If yes, please list parent(s) even if the child has not been born yet. Also, list your parents if you are
under 18 and not living with them. Please give as much information as possible.
Tell us about any parents not living in your household
*Please make copies of this page for additional parents.
a) Absent parent 1
Name (rst, middle initial, last):
This is my:
spouseorex-spouse child
partnerorex-partner step child
other: _________________________________
Sex: Female
Male
Date of birth: (month, day, year):
Social Security number (if you know it):
Address: City: State: ZIP code:
Phone:
Date this parent stopped living with child (month, day, year):
Number of hours each week this parent spends with the child(ren):
How many of these hours are spent in the child(ren)’s home?
List this parent’s child(ren)
whom you have written about
on this application.
If this is an absent father, has paternity been legally established?
Yes No I don’t know
Doyouthinkthisparentmighthurtyouorthechildifwetrytondout
about paternity or health insurance? Yes No
b) Absent parent 2
Name (rst, middle initial, last):
This is my:
spouseorex-spouse child
partnerorex-partner step child
other: _________________________________
Sex: Female
Male
Date of birth: (month, day, year):
Social Security number (if you know it):
Address: City: State: ZIP code:
Phone:
Date this parent stopped living with child (month, day, year):
Number of hours each week this parent spends with the child(ren):
How many of these hours are spent in the child(ren)’s home?
List this parent’s child(ren)
whom you have written about
on this application.
If this is an absent father, has paternity been legally established?
Yes No I don’t know
Doyouthinkthisparentmighthurtyouorthechildifwetrytondout
about paternity or health insurance? Yes No
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• •
CashbenetsisalsoknownasTemporaryAssistanceforNeedyFamilies(TANF)orRefugee
CashAssistance(RCA).Cashbenetsareformeetingafamily’sbasicneedslikefood,clothing,
shelter and utilities.
MostcashbenetsinOregonareissuedviaanElectronicBenetTransfer(EBT)card.Thisisknown
asanOregonTrailCard.Cashassistancebenetsmaynotbewithdrawnorspentusingan
Oregon Trail Card in any:
• Liquor store. This includes retail businesses that only or mostly sell beer or wine.
• Casino, gambling casino or gaming establishment.
• Retail business that provides adult entertainment in which performers disrobe or perform in an
unclothed state. This includes adult video stores that only or mostly sell or feature adult-oriented
videos or movies.
• Marijuana dispensary.
These restrictions apply:
• In Oregon.
• Outside Oregon.
• On tribal lands.
Theserestrictionsalsoapplytocashbenetsinaprivatebankaccount.
If you are applying for cash for families:
“Assigning” payments and the state’s right to place a lien on any injury claims
To qualify for assistance, you must let DHS have money you or other members of your family,
including any child born in the future, receive or have the right to receive from:
• Other people, businesses or other sources who are or may be liable to cover costs related
to an injury, such as a car accident.
There is a limit on how much DHS can take. It cannot take more than the amount it has paid in cash
benefits for you and your family.
Bysigningthisform,youagreetohelpDHSndandobtainthesepayments.Ifyouor
afamilymemberreceivingbenetsisinanaccidentorinjuredbyanotherpersonorbusiness
you must tell DHS within 10 days. The state may place a lien on money from such claims.
If you are applying for cash for families:
What you need to know about “assigning support”
“Support”meansmoneyyougetforyouoryourchildren,likealimonyorchildsupport.
Whenyougetcashbenets,youare“assigning”thestatetherighttokeepthesupportyouoranyone
in your family get from another person. The money goes to repay the state for the cash you get.
NOTE: This does not apply during any periodoftimeyoureceivecashbenetsfromJOBS
Plus, the State Family Pre-SSI/SSDI Program (SFPSS) or the Post-TANF Program; when you
are a two-parent family; or when you are receiving Employment Payments.
This means that while you are getting cash benets:
The state will keep part of the support payments (for both current and past-due payments) received for
you and members of your family. The state will not keep all your child support. The state will send you
$50ofcurrentchildsupportreceivedperchildpermonthupto$200perfamilypermonth.Thestatewill
notcountthismoneyasincomewhenguringyoureligibilityandbenets.
Information about cash benets
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If you knowingly do the following to get Temporary Assistance for Needy Families (TANF) and/or
Refugee Cash Assistance (RCA) you will get a penalty:
• Give false information about yourself or someone you are applying for;
• Hide information about yourself or someone you are applying for;
• Give false information about where you live.
ThersttimeyoudoanyofthesethingsyouwillnotgetTANFfor12months.Thesecondtimeyouwill
notgetTANFfor24months.ThethirdtimeyouwillnotbeabletogetTANFatall.Youwillalsohaveto
paybackalltheTANFyouwerenotsupposedtoget.Yourfoodbenetswillnotgoupeventhoughyou
get less in TANF if you told us something that was not true or did not tell us something that was true.
Information about TANF program penalties
NOTE: If you are an applicant for cash assistance and you are in SFPSS or JOBS Plus, or you are a
two-parent family, the state will generally not keep any of your child support. When determining your
eligibilityandbenets,$50(per child per month up to $200 per family per month) of current child support
received will not be counted towards your monthly income.
When you leave the cash program:
• Current support payments will go to you;
• Any past-due payments for months you were on cash assistance will be kept by the state;
• Any past-due payments for months you were not on cash assistance may go to you.
Working with Child Support
Whileyouaregettingcashbenets,youwillneedtoworkwiththestate’sChildSupportProgram.
Important: You do not have to work with child support if you think it would mean danger for you or
your children.
Working with child support can mean:
• Helping to locate your child’s other parent (unless you think it would mean danger for
you or your children);
• Legally naming the child’s father (establishing paternity);
• Getting a support order.
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Information about Supplemental Nutrition Assistance Program (SNAP) penalties
If you do the following... You will lose food benets...
• Hide information or make false statements;
•UseElectronicBenetsTransfer(EBT)cardsthat
belong to someone else;
•Usefoodbenetstobuyalcoholortobacco;
•TradeorsellbenetsorEBTcards;
• Dump containers only for the cash redemption value;
•Resellfoodboughtwithfoodbenetsforcash.
•12monthsfortherstoense;
•24monthsforthesecondoense;
•Permanentlyforthethirdoense.
•Tradefoodbenetsforcontrolledsubstances
such as drugs.
•24monthsfortherstoense;
•Permanentlyforthesecondoense.
• Tradefoodbenetsforrearms,ammunition
orexplosives.
• Permanently.
•Trade,buyorsellfoodbenetsof$500ormore. • Permanently.
• Give false information about who you are or where
youlivesoyoucangetextrafoodbenets.
•10yearsforeachoense.
Youcanalsobenedupto$250,000orputinprisonforupto20yearsorboth,
for doing these things. You may also be charged under other federal laws.
If you knowingly do the following... You may be...
• Use EBT cards that are not yours;
• Transfer your EBT cards to other people;
• Acquire or possess EBT cards that are not yours.
• Guilty of a felony or misdemeanor;
• Fined;
• Put in prison;
•
Ineligibleforfoodbenetsfora
period of time.
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• •
Information about all programs
The Department of Human Services (DHS) does not discriminate against anyone. This means that
DHSwillhelpallwhoqualifyandwillnottreatanyonedierentlybecauseofage,race,color,national
origin, gender, religion, political beliefs
1
,disabilityorsexualorientation
2
.
YoumayleacomplaintifyoubelieveDHStreatedyoudierentlyforanyofthesereasons.
Toleacomplaintwiththestate,youcancalltheGovernor’sAdvocacyOceat1-800-442-5238
(TTY711)orwritetotheiroceat:
Governor’sAdvocacyOce
500 Summer Street NE, E17
Salem, OR 97301
Email:DHS.info@state.or.us
“Equal opportunity is the law!”
The United States Department of Agriculture (USDA) and the United States Health and Human
Services(HHS)areequalopportunityprovidersandemployers.Auxiliaryaidsandservicesare
available upon request to individuals with disabilities.
ToleacomplaintwithUSDAandHHS,pleasereadthe“Client Discrimination Complaint Information”
form(DHS9001).Youcanndthisforminthe“Information and Referral Packet” (DHS 6609).
Our non discrimination policy
1
SNAP clients are protected against political belief discrimination.
2
SexualorientationisprotectedbytheStateofOregon,butnotfederallaws.
Why we need your Social Security number
Social Security numbers (SSN) –Federallaws(42USC1320b-7(a)and(b),7USC2011-2036,42
CFR435.910,42CFR435.920and42CFR457.340(b))andDHSrule(OAR461-120-0210)require
anyoneapplyingforcashorfoodbenetstogiveDHStheirSSN.Ifyouprovidean
SSN, it can speed up the application process. If someone doesn’t have an SSN, visit www.ssa.gov.
a.DHSwilluseyourSSNtohelpdecideifyouareeligibleforbenets.YourSSNwillbeused
to verify your income, other assets and to match with other state and federal records such
asIRS,Medicaid,childsupport,SocialSecurity,Unemploymentbenetsandotherpublic
assistance programs.
b. DHS may use your SSN to prepare aggregate information or reports requested by
fundingsourcesfortheprogramyouapplyfororreceivebenetsfrom.
c. DHS may use or disclose your SSN:
• Ifitisneededtooperatetheprogramyouapplyfororreceivebenetsfrom;
• To conduct quality assessment and improvement activities;
• Toverifythecorrectamountofpaymentsandrecoveroverpaidbenets;
• Tomakesurenobodygetsbenetsinmorethanonehousehold.
Social Security numbers not required for Refugee Cash Assistance.
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By signing below I agree that:
• IunderstandthatifIamintheRefugeeCaseServicesProject(RCSP),theterm“DHS”includes
DHS contractors.
• I have given DHS true, correct and complete information;
• I understand that making false statements or hiding information may mean state and federal penalties,
as well as having to repay any overpayment (this includes authorized representatives for cash
benets);
• DHS can review my case. This could include coming to my home;
• I declare I am a resident of Oregon;
• I will report changes in information I give DHS when DHS requires me to;
• I have given true citizenship information about myself and the others I am applying for;
• IknowthatDHSwillchecktheimmigrationstatusofpeoplewhoapplyfororgetbenets.
I know the information DHS gets from the United States Citizenship and Immigration
Service(USCIS)couldaectwhogetsbenets.DHS will not contact USCIS for anyone
not seeking benets;
• I authorize release of my child support records from the Department of Justice (DOJ), Division of Child
Support (DCS) to DHS;
• Theadultsunderage60onthisformwhoapplyforfoodbenets(SNAP)willregisterforthestate’s
employment program. If I add people to the program in the future, they will also register;
• IfIdonotgiveDHStheSocialSecuritynumberforsomeonewhowantsbenets,thatpersonmay
not be able to get them;
• DHSwillnotusecostsforshelter,medical,childcareandcourtorderedchildsupporttoguremy
benetsifIdonotreportthem;
• DHSwillrequestandusetheIncomeandEligibilityVericationSystem(IEVS)dataandthisinformation
mayaecteligibilityandbenetlevels.Thisincludesvericationthroughthirdpartycontactswhen
discrepancies in information are found. Third party contacts may include matching with bank, income
andunemployment-benetrecords
• I understand that DHS may use or disclose my SSN and the SSN of each person I apply for,
for the purposes listed on page 13;
• DHS may give the information on this application to:
• Federal and state agencies who are doing reviews;
• Law-enforcementocials,tohelpthemarrestsomeonewhoiseeingfromthelaw;
• Federal and state agencies and private collection agencies, if I have to repay
benetstoDHS.
• DHS may use this information to administer other public assistance programs that I receive from DHS.
• IunderstandDHSmaymonitorwhereIuseTANFcashbenetsthroughmyOregonTrailCardor
withdrawTANFcashbenetsusingmyOregonTrailCard.IalsounderstandthatImaynotusemy
OregonTrailCardtospendTANFcashbenetsorwithdrawTANFcashbenetsatany:
• Liquor store. This includes retail businesses that only or mostly sell beer or wine.
• Casino, gambling casino or gaming establishment.
• Retail business that provides adult entertainment in which performers disrobe or perform in an
unclothed state. This includes adult video stores that only or mostly sell or feature adult-oriented
videos or movies.
• Marijuana dispensary.
Information about your rights and responsibilities
Please continue to page 15, read and sign.
14
DHS 0415F (01/19), Recycle prior versions
• •
These restrictions apply:
• In Oregon.
• Outside Oregon.
• On tribal lands.
Theserestrictionsalsoapplytocashbenetsinaprivatebankaccount.
• IunderstandthepersonwhosignsthisformmustrepaybenetstoDHSwhenthereisan
overpayment in my case. Other individuals that are required to apply with me and an authorized
representative could also be liable for overpayments.
• I understand I can request a copy of my application in paper or electronic form.
• People applying for cash benets — I am giving the state the right to keep support payments,
asexplainedonpages10–11.IunderstandIdonothavetoworkwiththechildsupportprogramifit
would mean danger for me or my children.
• People applying for cash and food benets—IunderstandIcannotgetfoodbenetsfromthe
Tribal Food Distribution program and the SNAP program at the same time. I also cannot get Tribal
TANFfromatribeandTANFcashbenetsfromDHSatthesametime.
• I state under penalty for making a false statement that the statements made about persons
in my home, including statements about citizenship, income, resources, property and all other
information I have given DHS and their contractors are true and correct.
• I will give proof of the information I have given DHS. I will also let DHS contact other people
and agencies to get proof.
• People applying for Employment Related Day Care—IunderstandthatanychildcarebenetsI
receivewillbereportedtotheOregonDepartmentofRevenue,whichmayaectmytaxdebtand/or
potential return.
15
Stawitnesssignature
Date
Full legal signature of other parent, spouse or other adult
Date
Full legal signature of applicant/authorized representative
Date
Declaration and signature
I have read and understand my rights and responsibilities as explained above and in the
DHS 0415R form, and I have a copy of the form.
What is the best way for us to contact you?
Phone: _________________________________________________________________________
Email: _________________________________________________________________________
Other: _________________________________________________________________________
What days and times are best for us to contact you? ________________________________________
Voter registration
If you are not registered to vote where you live now, would you like to apply to vote today?
Yes No
Applyingtoregistertovoteordecliningtoregisterwillnotaecttheamountofassistance
you will be provided by this agency.
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De0415f Application for Services 415F

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Completed 13 March 2020

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