By signing this application, I am stating that:
1. I have told the truth on this form and I did not lie or hide information to get benefits that my household should not get.
2. I understand the Food and Nutrition Services rules and what I must do to get Food and Nutrition Services.
3. I agree to provide information about what I have said so that my application can be processed. I am aware the information I give
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.
4. I give permission to the local agency to get proof of what I have said from any person, business or other outside agencies, but not
limited to: employers, banks, savings and loans, landlords, etc.
5. Under penalty of perjury, I have told the truth about information on the application, including the information concerning
citizenship and alien status for all the members applying for benefits/assistance.
6. I understand my expenses may be used to figure my Food and Nutrition Services amount. If I do not tell you about some of my
expenses and/or verify them, they may not be used in the budget to calculate the amount of my benefits.
7. I have read, understand, and received the Program Information and Rights and Responsibilities form.
8. I have the right to ask for a hearing if I think my case is wrong. I have 90 calendar days to ask for a hearing. Unless you ask for a
hearing by then, you cannot have one. A household member or someone else such as a lawyer, friend, or relative can represent
me at a fair hearing.
9. I will report lottery and/or gambling winnings in the amount of $3,500 or more. I am aware all household members will lose
eligibility to receive Food and Nutrition Services.
10. I am aware of the Intentional Program Violation Penalties.
Individuals found to have committed an Intentional Program Violation either through an administrative disqualification hearing or
by a Federal, State or local court, shall be ineligible to participate in the Food and Nutrition Services:
For A Period of Twelve months for the first Intentional Program Violation, Twenty-four months for the
second violation and Permanently for the third violation of any Intentional Program Violation.
Additional Program Violations:
• If you use your food assistance benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit
accounts you will lose your benefits.
• Giving wrong information knowingly may also mean we may reduce your benefits, you may have to repay benefits, may
be subject to criminal prosecution or not able to get benefits for twenty-four months.
• If a court finds you guilty of trading Food and Nutrition Services for controlled substances, you will lose Food and
Nutrition Services for two years for the first violation and permanently for the second violation.
• If a court finds you guilty of buying, selling, or trading benefits $500 more, trading benefits for firearms, drug trafficking,
ammunition, or explosives after August 22, 1996 you may lose Food and Nutrition Services forever.
• You will not get Food and Nutrition Services for 10 years if you are found guilty of getting or trying to get Food and
Nutrition Services in more than one household at a time. This penalty happens if you give wrong information about who
you are or where you live.
• If you intentionally break any of the rules above, you may not be able to get Food and Nutrition Services permanently and
may be fined up to $250,000 and/or jailed up to 20 years. You may also be ineligible for Food and Nutrition Services for an
additional 18 months, if court ordered.
• I understand the information I provided 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 and Nutrition Services may be denied,
and I may be subject to criminal prosecution for knowingly providing incorrect information.
“If you are not registered to vote where you live now, would you like to apply to register to vote here today? ❑ Yes ❑ No
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS
If you want to register to vote or to update your registration, you can complete a voter registration form at www.ncsbe.gov/nvra/01, ask your
caseworker or contact your local DSS for a voter registration form. Applying to register or declining to register to vote will not affect
the amount of assistance that you will be provided by this agency. If you would like help in filling out the voter registration application
form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. If you believe
that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or
in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the
North Carolina State Board of Elections, PO Box 27255, Raleigh NC 27611-7255 or you may call the toll free number, 1-866-522-4723.”
Turn in the application to your local agency as soon as possible: You can mail, fax or bring the application to your local agency.
Your Signature or Authorized Representative Date Signed
Witness Signature (if signature is an X) Date Signed