Apply For Food Stamps In Missouri Form – Fill Out and Use This PDF

Missouri Department of Social Services

FAMILY SUPPORT DIVISION

Application for Supplemental Nutrition Assistance Program (SNAP)

To apply: You have the right to apply for SNAP benefits at any time.

•Benefits are provided from the date Family Support Division (FSD) receives your application which must contain your name, address and signature. Please complete sections 2 through 6 to help FSD process your application faster.

•You can email, mail, or fax your application. If an interview is required, it can be completed by phone. Family Support Division will attempt to call you, if you provided a phone number on the application, the next business day after your application is registered to complete an interview. If you did not provide a phone number, or if you are unable to complete your interview at the time we call, please call 855 823 4908 to complete your interview or visit an FSD office to complete this as soon as possible. We may ask you for proof of some of the information you give to FSD.

Date of application: : If approved, your SNAP benefits are provided from the date FSD receives your application. This is your filing date. If you are in an institution and apply for SNAP benefits and Supplemental Security Income (SSI) at the same time, your filing date is the date of release from the institution.

Authorized Representative: You can choose more than one person or facility to complete your application and/or manage your benefits on your behalf. They will act as your authorized representative. If you want an authorized representative, complete the Authorized Representative Form (IM-6AR) at https://dss.mo.gov/fsd/formsmanual/pdf/im-6ar.pdf or call FSD.

Section 1 – Tell us about yourself

Your full name (first, middle, last):__________________________________________________________

I am homeless

Home address (street, city, state, zip): ______________________________________________________________________________

_____________________________________________________________________________ County:________________________

Mailing address, if different: ______________________________________________________________________________________

_____________________________________________________________________________				County:________________________
Phone 1: __________________________	Cell	Home	Work	Other
Phone 2: __________________________	Cell	Home	Work	Other

E-mail address: _______________________________________________________________________________________________

The best way to contact you:   Call      Email      Mail      Text (not available everywhere)

UNDER THE LAWS OF THE STATE OF MISSOURI, AND THE REGULATIONS OF THE UNITED STATES DEPARTMENT OF AGRICULTURE, I HEREBY APPLY FOR SNAP BENEFITS.

Your signature: ____________________________________________________ Date: _________________________

Section 2 – Key questions for faster service

If eligible, you will receive your benefits within 7 days of filing your application if you answer “yes” to any of the questions below. Otherwise, you will receive your benefits within 30 days of filing your application.

1.	Does your household expect to receive less than $150 in income this month and have
	$100 or less available in cash and/or in a bank account?	Yes	No
2.	Does your household have rent/mortgage and/or utility costs that are more than your
	total income, available cash, and bank accounts for this month?	Yes	No
3.	Does your household include a migrant or seasonal farm worker whose income
	has stopped and whose available cash and bank accounts do not exceed $100?	Yes	No

Help FSD verify your identity for faster service. FSD will try to verify your identity electronically. Please (1) include a copy of your identification with your application, or (2) bring someone such as a friend, family member, landlord, or employer to any FSD office, or (3) list a contact below in order to help us verify your identity. FSD will call this person if needed.

Name of person to		Phone
verify your identity:		Number:
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Section 3 - Household members

Write your information on line 1. Enter the information of all the people who live in your household, including your spouse, any children under age 22 who are in your household at least half (50%) of the time, and anyone who eats the majority of their meals in your household. Include all household members regardless of their citizenship or immigration status.

Citizenship or immigration status does not automatically disqualify an applicant from receiving SNAP benefits. Racial and ethnic information is collected to assure that program benefits are distributed without regard to race, color, or national origin. Providing this information is optional and does not affect your eligibility or the amount of SNAP

benefits you receive.

Providing the Social Security Number (SSN) and immigration status of each household member is voluntary. However, you will not receive SNAP benefits for individuals who do not provide a SSN and/or immigration status. Immigration status of applicant household members may be subject to verification by U.S. Citizenship and Immigration Services (USCIS). Information provided by USCIS may affect your eligibility and benefit level.

	Full Legal Name	Sex	Relationship	Date of birth		SSN			Hispanic or	Race
		**	to applicant						Latino?	*
1.			Self
2.
3.
4.
5.
6.
7.
8.
*List ALL that apply:								**Not required for SNAP
1 - White	2 - Black/African American		3 - American Indian/Alaska Native
								eligibility determination
4 - Asian	5 - Native Hawaiian/Pacific Islander

If you do not have enough space for all household members, attach an additional list with their information.

1.Do you and all the people in your household buy and eat (cook) meals together?    Yes    No

If no, who does not buy and eat (cook) with your household? ___________________________________________

2.List anyone who is a boarder in your household: _______________________________________________________

3.List anyone who is a foster child or foster adult in your household: ________________________________________

4.List anyone who is not a U.S. citizen in your household: _________________________________________________

5.Is English your preferred language?    Yes    No

If no, what is the language spoken most often in your home? ____________________________________________

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Section 4 - Household declarations

Answer “yes” or “no” to each of the questions in this section. For each question you answered “yes,” explain in the space provided. A “yes” response to any of the questions in this section may result in a disqualification for SNAP

benefits for the person in which the “yes” answer applies.

1.	Have you or any member of your household been convicted of buying or selling SNAP
	benefits of $500 or more after 9-22-96?	Yes	No
	If yes, who? _________________________________________________________________
2.	Are you or any member of your household hiding or running from the law to avoid prosecution,
	custody, or jail for a crime (or attempted crime) that is a felony?	Yes	No
	If yes, who? _________________________________________________________________
3.	Are you or any member of your household violating a condition of probation or parole?	Yes	No
	If yes, who? _________________________________________________________________
4.	Have you or anyone in your household made false statements about your identity or address
	to receive SNAP benefits in 2 or more households at the same time?	Yes	No

If yes, who? _________________________________________________________________

5.Have you or any member of your household been convicted in a federal or state court of a felony committed after 8-22-96 related to illegal possession, use, or distribution of a controlled

	substance?	Yes	No
	If yes, who? _________________________________________________________________
6.	Have you or any member of your household ever been convicted of fraudulently receiving
	duplicate SNAP benefits in any state after 9-22-96?	Yes	No
	If yes, who? _________________________________________________________________
7.	Have you or any member of your household been convicted of trading SNAP benefits for
	guns, ammunitions, or explosives after 9-22-96?	Yes	No
	If yes, who? _________________________________________________________________
8.	Have you or any member of your household ever been convicted of trading SNAP benefits
	for drugs after 9-22-96?	Yes	No

If yes, who? _________________________________________________________________

Section 5 - Household information

Answer these questions for yourself and all of the people who live with you (as listed in Section 3).
1. Has anyone received SNAP benefits in a state other than Missouri within the past 30 days?	Yes    No
If yes, who? _________________________________ State: ____________________________

2.Is anyone disabled?    Yes    No

If yes, who? _____________________________________________________________________

3.Is anyone age 18 to 49 and enrolled in school?    Yes    No

If yes, who?	_________________________________		School: ___________________________
If yes, who?	_________________________________		School: ___________________________
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Resources

Resources are bank accounts and other types of money you own by yourself or with other people.

1.	Does anyone have a bank account or is anyone’s name on a bank account?			Yes	No
	If yes, who? _________________________	Balance: $ ____________	Bank name: ______________________
	If yes, who? _________________________	Balance: $ ____________	Bank name: ______________________
2.	Does anyone have any other cash?    Yes    No
	If yes, who? _________________________	Balance: $ ____________
	If yes, who? _________________________	Balance: $ ____________
3.	Does anyone have stocks, bonds, and/or retirement accounts such as an IRA?			Yes	No
	If yes, who? _________________________	Cash Value: $ ______________
	If yes, who? _________________________	Cash Value: $ ______________

Income

Income is money that’s paid to you, such as earnings from a job or payments from Social Security or child support.

1.Does anyone earn income or money from working?    Yes    No

If yes, list who gets it, their employer, and monthly gross income before taxes or deductions:

Who earns income from working?	Employer	Monthly amount
		$
		$
		$
		$

2.Does anyone receive income or money from the following sources?    Yes    No If yes, check the source and list who gets it and the monthly amount:

Source	Who gets it?	Monthly amount
Social Security Income (Retirement,		$
Disability or Survivor’s)
Supplemental Security Income (SSI)		$
Veteran’s Administration (VA)		$
benefits
Child support		$
Unemployment benefits		$
Gifts or donations		$
Student loans, grants, scholarships		$
Other sources—list here:
1.	1.	$
2.	2.	$

3.Has anyone’s income stopped or been reduced in the last 30 days?    Yes    No

If yes, whose? _______________________________ Date and amount of last check _______________________
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FSD FAIR HEARING RIGHTS: You have the right to a hearing if you have applied for or are receiving SNAP benefits, and the following happens:

•FSD decides that you are not eligible and you think you are.

•FSD provides you with SNAP benefits and then reduces or stops the benefits and you think the reasons are wrong.

•You disagree with the information used to determine the benefit amount or disagree with the benefit amount.

•FSD refuses to take your application.

•FSD does not act promptly on your request for help and you think that they have had enough time to do so.

If your application has been refused or rejected or any action on your case has already been taken, you may request a hearing within 90 days of the refusal or action. If the proposed action will change or stop your benefits and you request a hearing within ten days from the date of the notice, you may continue to receive the same benefits until the hearing decision. You or your representative may request a hearing by phone, in-person, or in writing. Your case can be presented by a household member, or a representative such as legal counsel, relative, friend or other spokesperson.

YOU MAY BE DISQUALIFIED FROM RECEIVING SNAP BENEFITS IF YOU:

•Sell your SNAP benefits for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone.

•Lie or hide information to get SNAP benefits that your household should not get.

•Use SNAP benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit accounts.

•Purchase a product with SNAP benefits that has a container requiring a return deposit with the intent of obtaining cash by discarding the product and returning the container for the deposit amount.

•Intentionally purchase products with SNAP benefits in exchange for cash. For example, do not purchase food to make products for resale.

•Pay for food purchased on credit with SNAP benefits.

•Use or have in your possession EBT cards that are not yours.

•Trade or sell EBT cards or provide food purchased with SNAP benefits to non-household members.

NOTIFICATION AND ACKNOWLEDGEMENT OF FRAUD PROVISIONS

It is against the law to lie to receive SNAPs or to sell or trade your SNAP benefits. Excessive Electronic Benefit Transfer (EBT) card replacement requests may result in a referral for fraud investigation. 7 USC 2015(b)(1) any person who has been found by any state or federal court or administrative agency to have intentionally made a false or misleading statement, or misrepresented, concealed or withheld facts or committed any act that constitutes a violation of this act, the regulations issued thereunder, or any state statute, for the purpose of using, presenting, transferring, acquiring, receiving, or possessing SNAP benefits shall, immediately upon the rendering of such determination, become ineligible for further participation in the program for a period of 1 year upon the first occasion of any such determination, 2 years for the second occasion and permanently upon the third occasion.

Applicants cannot violate the Food and Nutrition Act of 2008 which includes the following:

•Any member who breaks any of the rules on purpose can be ineligible from the SNAP Program for one year, up to permanently, fined up to $250,000, imprisoned up to 20 years or both. S/he may also be subject to prosecution under other applicable Federal and State laws. S/he may also be barred from SNAPs for an additional 18 months if ordered by a court.

•Any member of your household who intentionally breaks the rules may be ineligible to receive SNAPs for one year for the first offense, two years for the second offense, and permanently for the third offense.

•If a court of law finds any household member guilty of using or receiving benefits in a transaction involving the sale of a controlled substance, you will not be eligible for benefits for two years for the first offense, and permanently for the second time.

•If a court of law finds you guilty of having used or received benefits in a transaction involving the sale of fire-arms, ammunition or explosives, you will be permanently ineligible to participate in the Program upon the first occasion of such violation.

•If you are found to have made a fraudulent statement or representation with respect to the identity or place of residence in order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the Program for a period of 10 years.

•If a court of law finds you guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently ineligible to participate in the Program upon the first occasion of such violation.

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