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MARYLAND DEPARTMENT OF HUMAN RESOURCES

FAMILY INVESTMENT ADMINISTRATION

APPLICATION FOR ASSISTANCE FOR ONE PERSON

PLEASE PRINT ALL ANSWERS

Date Signed Application

Received in

Local Department

MUST BE DATE STAMPED

I wish to apply for:

Cash Assistance Medical Assistance Food Supplement Program (formerly food

stamps)

Other, list: _______

I am currently receiving:

Cash Assistance	Medical Assistance:
ID#_________ Food Supplement Program
(formerly food stamps)	Other,
list:____________

Do you have unpaid medical bills in the last 3 months?

YES NO

1. IDENTIFYING INFORMATION

Last Name

First Name

Middle Name

Jr. III, etc.

Maiden/Other Name

What language do you speak?				Do you need an interpreter?			YES	NO
Are you visually impaired		YES NO		Are you hearing impaired?			YES	NO
2. ADDRESS — Where do you live?
Number	Street		Apt No.		Floor No.	Telephone Number

City			State		Zip Code + 4	Number where you can be reached
						during the day

3. MAILING ADDRESS (IF DIFFERENT)

Number Street

Apt No.

Floor No.

Telephone Number

P.O. Box

City

State

Zip Code + 4

If you are applying for the Food Supplement Program (FSP) you can complete all of the form and give it to us now. You may also fill in your name, address, sign this page and give it to us. You can then finish the rest of the application at home and bring or mail it back to the office. Your Food Supplement benefit is based on the date you sign this application and give it to the department of social services.

You may get Food Supplement benefits right away if you meet one of the following conditions:

Your household’s monthly rent or mortgage and utilities are more than your household’s income and resources.

Your household’s gross monthly income is less than $150, and your resources, such as bank accounts, are $100 or less.

Your household is a migrant or seasonal farm worker household.

If you qualify to get Food Supplement benefits right away, you will receive them within 7 days from the date you sign the form. You may not get expedited Food Supplement benefits, if eligible, until we get a completed application form and interview you.

YOUR SIGNATURE

DATE

4. EXPEDITED SERVICES (CUSTOMERS SHOULD NOT WRITE IN THIS AREA – FOR AGENCY USE ONLY)

Applicants who meet the standards below are eligible to receive FSP benefits within 7 days. Customers must be interviewed, either in person or by telephone, in order to determine eligibility for expedited service. The application must be complete, signed, and identity

verified before expedited benefits can be issued.
1. Is the total household income this month, before deductions, less than $150 AND household cash/savings $100 or less? □Yes □ No
Estimated self-reported income for this month = $__________	Household’s monthly rent or mortgage amount	= $___________

Household cash and savings for all members = $__________	Appropriate utility standard (SUA, LUA or actual) = $___________
A. Total income and liquid resources = $__________	B. Total shelter costs	= $___________

2.	Is the total amount for B. (Total shelter costs) greater than the total for A. (Total income and liquid resources)?	□ Yes	□ No
3.	Are the household members destitute migrant or seasonal farm workers whose cash and savings are $100 or less?	□Yes	□ No
	If the answer to any of the above questions is yes, this household is potentially eligible for expedited FSP benefits
4.	If there is another reason why this household should NOT be expedited, list it here: _______________________________________

I certify that I screened this applicant for expedited Food Supplement Program benefits and determined that the household □ was □ was not eligible for expedited issuance at this time.

Signature of Case Manager			Date


FOR	LDSS Office	Programs Applied For / Receiving	Assistance Unit
WORKER			ID’s
WORKER	Case Manager’s Name		ID’s
USE

			Client ID
ONLY			Client ID
	Application/Redetermination Date
	Application/Redetermination Date

		1

DHR/FIA 9702-Application for one person revised 12-2016 other versions obsolete

5. AUTHORIZED REPRESENTATIVE (IF DESIRED)

First Name		Middle Name			Last Name		Jr., III, etc.

Number	Street			City		State	Zip Code
							+ 4

Telephone Number			Relationship to you

Check what you want the representative to do:
	Complete interview for you	Cash your check			Receive your notices
	Sign your application	Cash your Food benefits			Receive your Medical Assistance Card

6. INDIVIDUAL INFORMATION Complete the section below.

Last Name		First Name		Middle Name			Jr.,III etc.

Maiden/Other Name		Social Security Number	List Additional Social Security Number				Date of Birth

Sex		Ethnicity* (see below)	Race* (see below)		Marital Status
Male	Female
Resident of Maryland		Due date if pregnant	Number of babies		Receiving Prenatal Care?
YES	NO		expected?		YES	NO

Receiving benefits in another state:

Public Assistance?

YES

Food benefits?

YES

Medical Assistance?

YES

U.S. Citizen?

Student?

On Strike?

Disabled or

Medical

Medicare

Medicare#

YES NO

YES

Incapacitated?

Insurance?

Part A

YES

YES NO

YES

7. MIGRANT WORKER

8. BOARDER If you are a boarder, fill in this sections:

Are you a migrant worker?

Number of Meals per Day

Cost of Meals per Month

YES

8 IMMIGRATION STATUS — If you are not a United States citizen, fill in this section

INS Status

Newly Legalized Status Date

Sponsored Alien

Country of Origin

YES NO

US Entry Date

INS Number

Maryland uses the Systematic Alien Verification and Eligibility or SAVE

system through the United States Citizenship and Immigration Service

(USCIS) formerly known as Immigration and Naturalization Service (INS)

to verify the alien status of all applicant and recipient non-citizen

households. Information received from USCIS may affect your

household’s eligibility and benefit amount.

9. SCHOOL — If you are in school, fill in this section:

Student Status

Educational Level

Highest Grade Completed

Full-time

Elementary

College

Half-time

Secondary

Other, List:_______________

Expected Graduation Date (If in high

Less than half-time

school)

School Name

School Number

School Address

City

State

Zip Code + 4

10. DISABILITY — If you are disabled or incapacitated, what is the disability?

*Use the codes below to complete the Race and Ethnicity blocks. Enter each code that applies, using at least one code for each person. Ethnicity Codes: 1= Hispanic or Latino, 2=Not Hispanic/Latino. Race Codes: You can choose one or more race code - 1=American Indian/Alaskan Native, 2=Asian, 3=Black/African American, 4=Native Hawaiian/Pacific Islander, 5=White

Note: You do not have to give information about your race or ethnicity. If you do, it will help show how we obey the Federal Civil Rights Law. We will not use this information to decide if you are eligible. If you do not give us your race, it will not affect your application. The case manager will enter a race code for statistical purposes only. Title VI of the Civil Rights Act of 1964 allows us to ask for this information.

DHR/FIA 9702-Application for one person revised 12-2016 other versions obsolete

11. MEDICAL INSURANCE — If you have medical insurance, fill in this section:

Policy Number	Group Number	Policy Holder Name

Relationship to Policy Holder

POLICY HOLDER ADDRESS

Number Street

City

State

Zip Code + 4

Telephone Number

INSURANCE COMPANY

Insurance Company Name

Number Street

City

Union Name

State	Zip Code + 4	Telephone Number

UNION

Union Local Number

Number Street

City

State

Zip Code + 4

Telephone Number

12.VETERAN INFORMATION — If you are a veteran or a disabled widow or widower, or a disabled child of a deceased veteran, fill in this section:

Veteran’s Name	Relationship to Veteran	Veteran’s Status	Military Service Number

13. MEDICAL EXPENSE

If you are 60 or older, blind or disabled and applying for or receiving Food Supplement Program benefits, do you have

medical bills that you must pay?	YES	NO	If Yes, bring in your bills.
14. LIQUID ASSETS — Complete for assets as of the 1st day of the month. Check Yes or No for each ASSET TYPE
				AMOUNT	ACCOUNT	FDIC	INSTITUTION
ASSET TYPE	CHECK ONE		OWNER	Balance/value	NUMBER	NUMBER
Cash on Hand	YES	NO		$	N/A	N/A	N/A

Checking Accounts	YES	NO		$

Savings Accounts	YES	NO		$

Credit Union Accounts	YES	NO		$

Trust Funds	YES	NO		$

IRA or Keogh Accounts	YES	NO		$

Stocks, bonds, Certificates,	YES	NO		$
Money Market Funds,
mutual funds, treasury or
Other Notes
Annuities:	YES	NO		$

Other, List:	YES	NO		$

Other, List	YES	NO		$

Other, List	YES	NO		$

DHR/FIA 9702-Application for one person revised 12-2016 other versions obsolete

Lawyer Name

Lawyer Telephone

15.LIFE INSURANCE AND FUNERAL PLANS — If you have any life insurance or pre-paid burial plans or funds, fill in this section. List all policies and plans no matter who pays for them.

NAME OF PERSON	ORIGINAL FACE	CURRENT	POLICY NUMBER	LIFE	COMPANY,
WHO PAYS	VALUE OR	CASH	OR ACCOUNT	INSURANCE	FUNERAL HOME
	VALUE OF PLAN	VALUE	NUMBER	OR BURIAL	OR BANK NAME
				PLAN

16. REAL PROPERTY — If you own property other than where you live, fill in this section. Include burial plots.

Number	Street	City	State		Zip Code + 4

How Used?		Current Fair Market	Amount Owed Now	Trying to Sell
				YES	NO
Number	Street	City	State		Zip Code + 4

How Used?		Current Fair Market	Amount Owed Now	Trying to Sell
				YES	NO

17.OTHER ASSETS — If you own other assets not listed, such as antiques, boat, recreational vehicle, coin collections, furs, jewelry, livestock, or stamp collections, fill in this sections:

ASSET TYPE		CURRENT FAIR MARKET VALUE	AMOUNT OWED
	$		$
	$		$

18.POTENTIAL ASSET OR INCOME — If you are expecting to receive an accident settlement, trust fund, inheritance or other money or property, fill in this section.

Type

Explanation

19.TRANSFER OF ASSETS — if you sold, traded or gave any property, motor vehicles, stocks, bonds, cash or other assets in the past 3 years (5 years for a trust), fill in this sections:

Transfer Date	Who Received the Asset?			Type of Assets

Fair Market Value When Transferred		Amount Received	Reason for Transfer

20.INCOME FROM WORKING — If you are working now, fill in this section. If not, list the last job held. Include full-time, part-time or temporary work or self-employment, such as owning a business, roomer or boarder income, babysitting, home demonstrations, cleaning houses, odd jobs, etc.

NAME OF EMPLOYER

(INCLUDE ADDRESS AND PHONE NUMBER)

Rate of Pay

Number of

Hours

Worked

Amount Per Pay Period

How often Received?

if Job Ended,

Date and amount of Last Pay

DHR/FIA 9702-Application for one person revised 12-2016 other versions obsolete

Question	Answer
Form Name	Dhr 9702 Form
Form Length	14 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 30 sec
Other names	md dhr application assistance one, dhr fia 9702 one, md dhr fia, dhs fia 9702

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