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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

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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.

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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		$

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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

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21.OTHER INCOME AND BENEFITS — Check if you are receiving, have applied for or have been denied any of the following. Include any income that may not be listed here.:

TYPE OF BENEFIT	RECEIVING		AMOUNT	APPLICATION STATUS		APPLICATION
	BENEFITS					OR DENIAL
						DATE
Alimony	YES	NO	$	Applied for	Denied
Child Support	YES	NO	$	Applied for	Denied
Social Security Claim #:	YES	NO	$	Applied for	Denied
SSI Claim #:	YES	NO	$	Applied for	Denied
Railroad Retirement Benefits Claim#:	YES	NO	$	Applied for	Denied
Veteran’s Pension/Benefits	YES	NO	$	Applied for	Denied
Unemployement Benefits	YES	NO	$	Applied for	Denied
Worker’s Compensation	YES	NO	$	Applied for	Denied
Pension or Retirement	YES	NO	$	Applied for	Denied
Disablility/Sick/Maternity Benefits	YES	NO	$	Applied for	Denied
Union Benefits	YES	NO	$	Applied for	Denied
Military Allotment	YES	NO	$	Applied for	Denied
Money from Friends or Relatives (loans & other)	YES	NO	$	Applied for	Denied
Money from Rental income	YES	NO	$	Applied for	Denied
Black Lung Benefits	YES	NO	$	Applied for	Denied
Lump Sum Amounts	YES	NO	$	Applied for	Denied
Civil Service Annuity	YES	NO	$	Applied for	Denied
Public Assistance/State Disability Benefits from	YES	NO	$	Applied for	Denied
Another State
Interest or Dividends from Stocks, Bonds,	YES	NO	$	Applied for	Denied
Savings, or Other Investments
Other Income (not listed above)	YES	NO	$	Applied for	Denied
Specify ______________________________

22.SHELTER COSTS — Are you paying for any of the following? Complete only if you are applying for Food Supplement benefits

Expenses

Check One

Amount

How

Who

Expenses

Check One

Amount

How

Who Pays?

Often

Pays?

Often

Paid?

Rent

YES

Sewer

YES

Mortgage

YES

Garbage

YES

Electric

YES

Coop/

YES

Condo Fee

Oil

YES

Homeowner

YES

Insurance (if

Gas

YES

not included

in mortgage)

Property Taxes

YES

Other Utility

YES

Cost, list

Telephone

YES

Other Utility

YES

Cost, list

Water

YES

Other Utility

YES

Cost, list

23. TYPE OF EXPENSES

WITH WHOM

TOTAL AMOUNT

AMOUNT OF YOUR

SHARED

OF SHARED EXPENSES

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24. ADDITIONAL INFORMATION

25.HOUSEHOLD’S DECLARATION INQUIRY – Complete if you are applying for Temporary Cash Assistance or Food Supplement benefits

1.Has anyone in your household ever been convicted of a felony committed on or after August 22,1996 that involved drugs?

□ YES	□ NO	If yes, who?	___________________________________________________________________
2. Is anyone in your household currently violating parole or probation or fleeing from the police or the courts?
□ YES	□ NO	If yes, who?	___________________________________________________________________

3.Has anyone in your household been convicted since August 22, 1996 in a Federal or State Court for not telling the truth about where they lived or their identity in order to receive food supplement benefits or cash assistance from more than one

place in the same month?

□ YES □ NO If yes, who? ___________________________________________________________________

4. Has a court convicted any member of your household for trading or trafficking food supplement benefits of $500 or more? □ YES □ NO If yes, who? ____________________________________________________________________

5. Is anyone in your household receiving benefits under another identity or as a member of another household or in another State?

□ YES □ NO If yes, who?___________________________________________________________________

RIGHTS AND RESPONSIBILITIES

Requesting a reasonable accommodation:

If you are an individual with a disability, you may be entitled to reasonable accommodation to help you access DHR's activities, programs and services. This applies even if you are working with a local department of social services or a vendor who provides services for DHR's customers.

A reasonable accommodation is a modification or adjustment to an activity, program or service which helps a qualified individual with a disability have meaningful access to DHR's activities, programs and services.

Examples of reasonable accommodations:

Hearing Impairment: sign language interpreter; providing an assistive listening device

Visual Impairment: having a qualified reader read to a customer

Mobility Impairments: mailing forms to a customer; meeting a customer at a more accessible location

Developmental Disabilities: Having things written down; taking breaks; scheduling appointments around a customer's medical needs

You may request a reasonable accommodation from the local department of social services or a vendor at any time. Your request may be oral or written. A request for a reasonable accommodation may be made in person, in writing or over the telephone. There are no particular words that you need to use to request an accommodation. A request may be made by you or someone helping you. If you need to request a reasonable accommodation because of your disability, you should speak with the case manager or the supervisor or the ADA Field Coordinator at your local department of social services. You may ask the case manager for the name of the ADA Coordinator at your local department of social services. You may use the form on the reverse side of this notice. You may also ask for more information at the front desk.

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YOUR RIGHTS AND RESPONSIBILITIES

Name of Person needing an Accommodation

Name of Person requesting an Accommodation

Address:

City/State/Zip Code:

Telephone number:

Nature of Disability or Impairment (specify):

Local Department of Social Services Location:

Accommodation Request (Type of accommodation requested.) Please print or type. Be as

specific as possible. If required, attach additional comments.

Note: If requesting sign language services, specify type: American Sign Language Interpreter (ASL), Certified Deaf Interpreter (CDI) or Communication Access Real Time Translation (CART).

Please provide any additional information that may assist us in providing a reasonable

accommodation (specify):

Customer/Applicant's Signature :________________________________ Date:_______________

Return this form to the case manager or the Customer Access Coordinator in your local department

of social services.

For Office Use Only

Date Request Received:

Action Taken:

CAC Signature:

___________________________ Date: _________________

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RIGHTS AND RESPONSIBILITIES

EQUAL RIGHTS – This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

(1)mail: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410

(2)fax: (202) 690-7442; or

(3)email: program.intake@usda.gov.

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

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FACTS YOU SHOULD KNOW ABOUT APPLYING FOR TEMPORARY CASH ASSISTANCE, FOOD SUPPLEMENT PROGRAM (FORMERLY FOOD STAMPS) AND MEDICAL ASSISTANCE

Social Security Numbers

You must give us a social security number for each family member who wants benefits.

If a person who wants benefits does not have a social security number, that person must apply for a number. We can help applicants get their numbers.

If a family member has applied for a social security number, we will not delay your application while you wait for the number.

We use social security numbers to prove income. We do not give numbers to other agencies like Immigration and Customs Enforcement.

Citizenship and Immigration Status

You must tell us about the citizenship and immigration status for each family member who wants benefits.

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.

Information

If a family member will not tell us about citizenship, immigration status or social security number, that person will not get benefits.

They must still give us proof of income, expenses and other things.

The other family members who give us their information will get benefits if they meet the rules.

Emergency Medical Assistance

Immigrants who are not eligible for other kinds of medical assistance and apply only for emergency medical assistance do not have to tell us their social security number, immigration or citizenship status.

Time Limits

Temporary Cash Assistance has time limits.

The Food Supplement Program (formerly Food Stamps) and Medical Assistance do not have a time limit.

When Temporary Cash Assistance ends because of time limits, earnings or other reasons, you may still get Food Supplement benefits and Medical Assistance.

Interviews

You, a responsible family member or someone you choose to represent you must be interviewed.

In most cases, we can interview you by telephone.

You must give or send us the proof we ask for at your interview.

If you need help applying for benefits, or have questions about information you must give us, want to know what will happen to your benefits, do not speak English and need free translation services. Call your case manager or call 1-800-332-6347. Si necesita ayuda para llenar el formulario favor de llamar al 1-800-332-6347.

RIGHT TO WRITTEN NOTICE – We must always give you a written notice explaining your benefits when we approve your case. We must always give you written notice when we change your benefits, deny or close your case. You have 90 days from the notice date to ask for a hearing. If you ask for a hearing within 10 days, you may be able to keep getting benefits while you wait for the hearing.

RIGHT TO APPEAL – Ask for a hearing if you disagree with the Department’s decision. Your case manager can help you write your appeal. At the hearing, you can speak for yourself or bring a lawyer, friend or relative to speak for you.

RIGHT TO PRIVACY – You are giving personal information in the application. We use the information to see if you are eligible for benefits. If you do not give the information, we may deny your application.

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You have a right to review, change, or correct any information. We will not show your information or give it to others unless you give us permission or federal and state law allows us to do so.

RIGHT TO CLAIM GOOD CAUSE – If you want Temporary Cash Assistance (TCA), you must help the Department get child support. You may not have to help if it puts you or your family in danger.

RIGHT TO REFUSE HELP – You do not have to accept help from a religious organization if it is against your religious beliefs.

RIGHT TO TIMELY APPLICATION PROCESSING – If you are eligible for expedited Food Supplement Program benefits we must give you your benefits within 7 days. For the regular Food Supplement Program and other programs, except for certain Medical Assistance programs, we must process your application within 30 days. There are times when there is a delay in processing. If there is a delay, we will send you a letter to tell you why there is delay in processing your application. If you are incarcerated or in another such institution and file an application for Food Supplement benefits or cash assistance, you may not receive FSP or cash benefits until you are released. The filing date of your application for assistance will be the date of your release from the institution, if it is less than 30 days from the date your signed application was received in the Local Department of Social Services (LDSS). FSP benefits are issued from the date of your release based upon your application date.

Authorization to Receive Family Planning Information

If you want information, you can ask your case manager for a Family Planning Guide. You may also contact:

1-800-546-8900 if you need help in finding a provider for birth control or arranging prenatal care, or The Center for Maternal and Child Health at 410-767-6713 www.fha.state.md.us/mch

YOU HAVE THE FOLLOWING RESPONSIBILITIES

PROVIDE INFORMATION – You must give true and complete information. You may need to give us proof of this information. We will keep this information private. Any delay in providing proof may result in your case being delayed or denied.

Collecting application information, including the social security number of each household member, is authorized under the Food and Nutrition Act of 2008, U.S.C.2011-2036, Social Security Act §1137(f) and 42 U.S.C. §1320b- 7(d). We use the information to find out if your household is eligible. We check this information by matching computer programs.

We also use the information to see if you meet program rules. We may contact your employer, bank or other party. We may also contact local, state or federal agencies to make sure the information is correct. We can give your information to other federal or State agencies for official use and to law enforcement officers who need it to find persons fleeing to avoid the law.

If you get too much in benefits:

You may have to repay the money for the benefits, and

We may give the application information, including social security numbers, to federal or state agencies, as well as private claims collections agencies, for action.

Giving information is voluntary. If you do not give us information such as social security numbers for everyone who wants help, we may deny benefits for each person who does not give a social security number. If you do not have a social security number, we will help you get one.

REPORT CHANGES - You must report all changes within ten days unless you are part of the Food Supplement Program simplified reporting group and are not receiving Cash Assistance or Medical Assistance. If you want to know if you are part of this group, ask your case manager. You may tell us about any changes in person, by telephone, or by mail to the Department.

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Warning – We may deny, lower or stop your benefits if you give us wrong information or do not report changes. A judge may fine and/or imprison you if you deliberately give wrong information or do not report changes.

WORK REQUIREMENTS FOR THE FOOD SUPPLEMENT PROGRAM

Individuals applying for or receiving Food Supplement benefits must know and understand the following information about the Food Supplement Program work registration and work requirements. Food Supplement work requirements are covered in federal law at 7 CFR 273.24.

Everyone over age 18 is required to be registered for work unless otherwise exempt, because they are: over age 60, caring for a child under age 6 living in their home, receiving unemployment benefits, self-employed- working a minimum of 30 hours or more per week at the equivalent of federal minimum wage, attending a recognized school or institution of higher education at least half time, or the individual is mentally or physically unfit for work. Work registration is not the same as participation.

Beginning January 1, 2016 able bodied individuals with no dependent children (ABAWDS), ages 18-47, who are not exempt under one of the above reasons or who have an individual exemption or they reside in an area that is designated as exempt, are required to be work registered and participate in a work program/activity or be employed. These individuals known as ABAWDS may only receive Food Supplement benefits for three months in a fixed 36-month period unless the individual is employed or participating in an approved work or educational activity a minimum of 80 hours per month. The individual may not receive Food Supplement benefits again until he or she meets the work requirements. You will receive additional information from the case manager and information is available on the DHR website at http://www.dhr.state.md.us/blog/

AUTHORIZED REPRESENTATIVES – In most instances, if your authorized representative gives us wrong information, you will have to pay back any amount you are overpaid.

If your authorized representative knowingly gives us the wrong information or does not use your benefits properly, we may disqualify the person from being an authorized representative.

If a drug and alcohol treatment center or a group living arrangement acts as your authorized representative for your food benefits and they willfully give us wrong information about your situation, we may prosecute the person under applicable State or federal law.

TCA and FOOD SUPPLEMENT PROGRAM PENALTIES

Do not:

Give false information or withhold information to get or continue to get TCA and/or FSP benefits. Trade or sell TCA or FSP benefits, or electronic benefit cards.

Use TCA and FSP or electronic benefit cards to buy items not allowed, such as alcohol and tobacco or to pay on credit accounts.

Use someone else’s TCA or FSP benefits.

Use someone else’s Electronic Benefits Card without authorization.

Use your EBT card containing TCA benefits in a liquor store, adult entertainment venue such as a strip club or in a gambling establishment such as a casino.

Your FSP benefits will not increase if your cash assistance is reduced or closed because you did not follow the rules.

If a household member deliberately breaks the rules, we may bar the person from the TCA or FSP.

We may bar this person for one year after the first violation.

We may bar this person for two years:

*After the second violation, or

*After the first time a court finds this person guilty of buying illegal drugs with TCA or Food Supplement Program benefits.

We may bar this person permanently: * After the third violation, or

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*After the second time a court finds a person guilty of buying illegal drugs with TCA or FSP benefits, or

*After the first time a court finds this person guilty of buying guns, bullets, or explosives, with TCA or FSP benefits.

*After a court finds this person guilty of trafficking TCA or FSP benefits of $500 or more.

We may bar this person for ten years if found guilty of making a false statement about the person’s identity in order to receive multiple benefits at the same time.

A judge can also fine this person up to $250,000, imprison the person for up to 20 years, or both. A judge can also bar this person for an additional 18 months. The person may also have to face further prosecution under other federal laws.

ASSIGNMENT OF SUPPORT RIGHTS FOR TEMPORARY CASH ASSISTANCE

I assign to the State of Maryland all rights, titles, and interest in support that I may have for myself or for any person receiving TCA.

This includes any overdue support that has not been collected for the time that I or any person received TCA assistance.

I agree to have the child support agency collect any support owed to me and to keep up to the amount of TCA paid to me.

I agree to send to the State of Maryland any support l receive. If l do not turn over this support, I will have to repay this amount to the State of Maryland. I may also be prosecuted for fraud.

When I am eligible for Medical Assistance:

I assign all rights, title, and interest in medical support and health insurance payments I may have for myself or any person receiving Medical Assistance. This includes overdue medical support or health insurance payments that have not been collected.

I agree to have the child support agency collect medical support payments owed to me and to keep up to the amount of Medical Assistance payments that were made for me.

I agree to give the State of Maryland any medical support or health insurance payments I receive.

I will cooperate to the best of my ability and knowledge with the child support agency while I am receiving TCA and Medical Assistance

If I do not cooperate with the child support agency, I may lose all my benefits and my case may be closed

I HAVE READ THESE STATEMENTS OR SOMEONE READ THEM TO ME. I UNDERSTAND WHAT THEY MEAN. BY SIGNING MY NAME BELOW, I AGREE TO FOLLOW WHAT THEY SAY.

Signature

Date

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

MEDICAID WARNING AND PENALTY - Only use Medical Assistance cards if you are eligible.

Every person convicted of “Medicaid Fraud” with a value of $500 or more in money, services, or goods is guilty of a felony, and shall:

Pay back money, services or goods; or the value of those services or goods unlawfully received; Be subject to a fine of no more than $10,000, imprisoned for no longer than five years, or both.

Every person convicted of “Medicaid Fraud” with a value of less than $500 in money, services or goods is guilty of a misdemeanor, and shall:

1. Pay back money, services or goods; or the value of those services or goods unlawfully received; 2. Be fined no more than $1,000 and imprisoned for no longer than three years or both.

READ BEFORE SIGNING:

I understand that it is important to give true information and if I do not, I am breaking the law.

I understand that I can be fined, imprisoned or have my benefits reduced for making false statements or for pretending to be another person.

I know I can be punished for not reporting changes that may affect my eligibility or benefit amount.

I understand that if I get more Food Supplement benefits than I should, all adult members of my household are liable for repaying the debt.

I know the Department can use the application against me in a court of law for fraud prosecution.

I know that failing to report or verify shelter, medical or dependent care expenses or child support payments is the same as saying I do not want a deduction for the expenses I did not verify or report.

I understand that the Department may check the information on this form to see if it is correct and may select my case for a spot check, such as for a Quality Control Review.

I agree to allow someone from the Department to visit me at home. I will help them get all needed proofs from any source.

I understand by signing this application:

•I accept cash assistance and/or medical assistance.

•I agree that Medicare Part B will make payments directly to doctors and medical suppliers.

•I give the Department the right to seek payment from private or public health insurance and any liable third party. I understand that I must cooperate with the department in securing such payments. The Department may seek payment without legal action, as long as it does not keep more than the amount Medical Assistance paid.

•I give the Department the right to inspect, review and copy all medical records for services received through the Medical Assistance Program.

I understand that when a person is deceased who was at least 55 years old when receiving Medical Assistance the state may take money from the estate to repay payments made on behalf of that person. The program may take the money only if there is no surviving spouse, unmarried child younger than 21, or blind or disabled child (married or unmarried) of any age.

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

SIGNATURE SECTION

I understand that, as required by Maryland law, certain law enforcement agencies that investigate fraud can obtain information about my application, income, benefits and other documentation as part of their investigation. While access to my application and benefit information is normally limited (under Md. Code Ann. Human Resources Article § 1-201), these limits do not apply to these investigative agencies. Such agencies include the Department of Human Resources’ Office of the Inspector General. I understand that I do not need to provide consent to these agencies in order for them to investigate any allegations of fraud against me. Any information found as a result of the investigation may be used against me if an allegation of fraud is prosecuted.

I have read or someone has read and explained the entire application to me. I swear or affirm under penalty of perjury, that all the information I gave is true, correct, and complete to the best of my ability, belief and knowledge. I received a copy of my rights and responsibilities. I authorize any person, partnership, corporation, association, or governmental agency that knows the facts about my eligibility to give that information to the Department. I also authorize the Department to contact any person, partnership, corporation, association, or governmental agency that has given proof of my eligibility for benefits. I certify, under penalty of perjury, that by signing my name below, all persons for whom I am applying are U.S. citizens, lawfully admitted immigrants or individuals in satisfactory immigration status.

Signature of Applicant/ Recipient

Signature of Witness (If you Signed an X)

Signature of Spouse (If Applicable)

Signature of Authorized

Representative (If

Applicable)

Signature of Case Manager

Date

I withdraw my application for: □ Cash Assistance □Food Supplement Program □ Medical Assistance

Signature of Applicant,Date

Recipient, Authorized

Representative

Printed Name of Applicant

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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