Dhs 1240 Form PDF Details

Individuals and families facing financial challenges and in need of nutritional support can find a beacon of hope through the Department of Human Services, particularly with the introduction of the DHS 1240 form in Hawaii. This document serves as the gateway to applying for Financial Assistance and the Supplementary Nutrition Assistance Program (SNAP), previously known as the Food Stamp Program. Completing this form marks the first step toward receiving the assistance many need to navigate through tough times. Eligibility criteria hinge on the details provided in this application, with signatures required on multiple pages to ensure compliance and integrity of the information given. The form outlines the necessity for an interview, either in person or over the phone, as a prerequisite for receiving benefits, ensuring that applicants meet the requirements. It also touches on the provision that children in households receiving SNAP or Temporary Assistance for Needy Families (TANF) benefits automatically qualify for free meals at school, highlighting the interconnected benefits aimed at lifting families out of financial hardship. For non-English speakers or those with limited English proficiency, the form offers guidance on accessing interpretation services, ensuring that language barriers do not impede the application process. Additionally, the DHS 1240 form makes provisions for emergency assistance, signifying swift actions for those in immediate need, underlining the commitment of the DHS to serve as a lifeline for the community.

QuestionAnswer
Form NameDhs 1240 Form
Form Length18 pages
Fillable?No
Fillable fields0
Avg. time to fill out4 min 30 sec
Other nameshawaii snap form, hawaii application assistance, hawaii application snap, hawaii ebt application

Form Preview Example

STATE Department

OF HAWAII

of Human Services

BENEFIT, EMPLOYMENT, AND SUPPORT SERVICES DIVISION

Application for Financial and SNAP Assistance

IMPORTANT INFORMATION WHEN APPLYING

FOR PUBLIC ASSISTANCE PROGRAMS

IF YOU ARE APPLYING FOR:

Financial Assistance only

Supplemental Nutrition Assistance Program (SNAP) only (formerly the Food Stamp Program)

Financial Assistance and SNAP

SIGNATURES REQUIRED ON PAGES:

1, 3 and 11

1, 3 and 11

1, 3 and 11

If any member of your household receives SNAP or TANF benefits, then all children in your household are eligible for free school meals if their school participates in the USDA meal program. Please call the child’s school if you have questions about the School Lunch Program including:

You think your child should get free meals but does not receive them;

You do not want your child to receive free school meals; or

You have questions about the USDA meal programs.

Information about TANF and other public assistance programs can be found on the Department of Human Services website: http ://hurnanserviceslhawaii . gov/bessd/

DHS 1240 (7/12)

This is an important letter from the Department of Human Services (DHS). Please call the phone number indicated on

English

the letter. When you call, you will be asked what language you speak and your call will be put on hold for an

 

interpreter. You can also call 1-888-764-7586 for all DHS services.

 

, r-i-

1-888-764-7586.

El taropwe ml auchea seni ewe putain tumwunun aramas Department of Human Services (DHS). Kose mwochen kokkori na nampan foon won na taropwe. Nupwen omw kokko, repwe elsinuk menni kapas ke sine pwe repwe kutta ngonuk emon choon chiaku. Ka pwan tongeni kokkori 1-888-764-7586 ren meinisin aninnis seni DHS.

Ceci est une lettre importante du Department of Human Services (DHS). Merci d’appeler le numéro indiqué dans Ia lettre. Lorsque vous téléphonez, vous serez demandé(e) queUe langue vous parlez, et votre appel sera mis en attente afin de vous mettre en relation avec un interprète. Vous pouvez aussi appeler le 1-888-764-7586 pour tous les services de DHS.

Dies 1st em wichtiges Schreiben des Departements for Human Services (DHS). Bitte wählen Sie die unten stehende Telefonnummer. 51€ werden gefragt, welche Sprache Sie sprechen. Daraufhin werden Sie mit elnem Dolmetscher verbunden. Es können auch alle weiteren DHS-Dienste unter der Telefonnummer 1-888-764-7586 erreicht werden.

He leka ko’iko’i keia mal ka Oihana Lawelawe Kanaka (Department of Human Services). E kelepona mal I ka helu kelepona ma luna o ka leka Ke kelepona oe e ninau a ana oe he aha kau olelo oiwi a laila e kali oe a ba a ke kanaka mahele ‘olelo. Hiki Pu Ia oe ke kelepona i 1-888-764-7586 no na lawelawe a pau a ka Oihana Lawelawe Kanaka (DHS).

Daytoy ket importante a surat nga aggapu iti Department of Human Services (DHS). Pangngaasiyo koma ta awaganyo ti numero a nailanad iti surat. No umawagkayo, madamag kadakayo no ania ti lengguaheyo ket malyallatiw ti awagyo ti maysa a paraitarus. Mabalinyo pay ti umawag iti 1-888-764-7586 para kadagiti amin a servislo ti DHS.

Cantonese

Chuukese

French

German

Hawaiian

Ilokano

 

 

-r--

 

i:

0)

 

ItL

DH S co co--—

0)J% 1-888-764-7586

-ii MolIM

2F XI L-IIf. oIjxIo1l

7IXJ

AFtf 9jO

1°jO-12.j 2jOfj71I

 

7J

IHM 1-888-764-7586 .

 

izU < 3E

 

‘ioI

iifl

‘joI

 

 

 

2

J?J AlJI AIO1IOIIO1I)o1I

 

 

4-j-

 

Japanese

Korean

Mandarin

4t

1-888-764-7586

 

Juon in kojela im elap an aurok im ej itok jen ra eo an department of human services. Jouij im call e nomba in im ej bed ilo pepa in ak letta in. Ne koj call, renej kajitok ibbem kin kain kajin eo am im elikin am ba renej ba kwon kottar bwe ren lewoj juon am ri okok. Komaron call 1-888-764-7586 non aolepen ra ko kajojo lb DHS services.

0 se fa’asilasilaga ta’ua Jenei mal le Ofisa o le Human Services. Fa’amolemole, valaau mai I le numera lea o lo’o i luga a lenel tusi. A e vala’au mai, o le a fesili atu p00 le a le gagana e te moomia,T ona tu’u sa’o lea o lau

telefoni I se tagata e mafal ona fesoasoani Ia oe. E mafal fo’i ona e vala’au I le number 1-888-764-7586 mo nisi ‘au’aunaga mal lenei Ofisa.

Esta es una car-ta importante del Departamento de Servicios Humanos (DHS). Por favor Ilame a! nümero de teléfono indicado en Ia carta. Cuando usted haga Ia Ilamada, se le preguntara el idioma que habla y su liamada se pondrá en

espera de un intérprete. Usted también puede Ilamar al 1-888 -764-7586 para acceder a los servicios de DHS.

Ito ay mahalagang sulat mula sa Department of Human Services (DHS). Mangyaring tawagan ang numero ng teleponong nakalista sa sulat. Sa inyong pagtawag, itatanong sa inyo ang wikang nais ninyong gamitin. 1-lintaying sumagot ang tagasalin. Maaari din kayong tumawag sa 1-888-764-7586 para sa lahat nang serbisyo ng DHS.

Ko e tohi mahuinga eni mel he Potungaue Ngaue Maae Kakai. Kataki o telefoni ki he fika oku ha ‘I he tohi ni. E fehui atu pe ko e ha e faahinga lea ‘oku ke Ieaaki i he taimi te ke ta mai ai pea tnitokoe ke tall kae ‘oua kuo mau ha toko taha fakatonu lea. Te ke lava o ta ki he ki he ngaahi tokoni kotoa a e DHS.

Day là Ia tho’ quang trQng tir cáo Bô Phuc Vu Nhân Dan (DHS). Lam an gi x6 din thoal nm trên Ia tho’. Khi b?n gçi,

b?n sé &rçc hói ngon ngcr nào b?n nói và cii din thoi cüa bn sé ch ngi.rô’i thông djch.

£ng thô b?n cüng cô th gçi

s6 1-888-764-7586 cho các phuc vu DHS.

 

Importante kini nga sulat gikan sa Department of Human Services (DHS). Palihug tawagi ang numero nga anaa sa sulat. Sa imong pagtawag, pangutan-on ka kung unsa ang imong pinulongan ug pahulaton ka samtang nangita sila ug maghuhubad. Mahimo usab nga tawagan nimo ang 1-888-764-7586 alang sa tanang serbisyo sa DHS.

Marshallese

Samoan

Spanish

Tagalog

Tongan

r+i L.J

Vietnamese

Vit Nam

Visayan (Cebuano)

Rev. fl/flh1

C,

STATE OF HAWAII Department of Human Services

BENEFIT, EMPLOYMENT, AND SUPPORT SERVICES DIVISION

FOR OFFICIAL USE ONLY

CASE NAME

 

CATEGORY/CASE NUMBER

 

 

APPLICATION FOR FINANCIAL

WORKER CODE

WORKER’S NAME

AND SNAP ASSISTANCE

FORM MAILED

 

El GIVEN

APPLICATION FILING: The day your application is received is the date from which your eligibility for

 

benefits will be determined Benefits will be paid from that filing date if you are eligible If you are unable

 

to fill out the application now Just complete your name address and signature below and turn it in You

 

must still answer the rest of the questions on the application form before benefits are issued. If you cannot

.;. ... ‘.

complete the application the eligibility worker will help you. If you are currently residing in a public insti

 

tution and will be released within 30 days, you may file your application today but the date of application will be the day of release from the institution.

PLEASE PRINT CLEARLY

BRANCHUNIT

PHONE

DATE

DATE SIGNED FORM RETURNED

-

I would like to apply for the following types of benefits: LI Money El Supplemental Nutrition Assistance Program (SNAP)

YOUR NAME (Lust, First, MI.)

 

 

 

 

YOUR SOCIAL SECURITY NO.

BIRTHOATE

 

PHONE NO.

SPOUSE’S NAME (Last, First, Mi.)

 

 

 

 

SPOUSE’S SOCIAL SECURITY NO.

SPOUSE’S BIRTHDATE

 

MESSAGE PHONE NO.

ADDRESS WHERE YOU LIVE (NUMBER AND STREET OR DIRECTIONS TO YOUR HOME)

APT/SPACE NO.

CITY & STATE

 

ZIP CODE

 

MILITARY BASE (IF RESIDING IN BASE HOUSING)

YOUR WAILING ADDRESS /F DIFFERENT FROM ABOVE NUMBER AND STREET)

APT/SPACE NO.

CITY & STATE

 

ZIP CODE

 

 

HOW MANY PERSONS PURCHASE FOOD AND PREPARE

HOW MANY PERSONS DO NOT PURCHASE FOOD AND

ARE THEY RELATED TO ANYONE

 

HOW MANY CHILDREN

MEALS WITH YOU) (INCLUDE YOURSEL9

 

PREPARE MEALS WITH YOU?

 

IN YOUR HOUSEHOLD?

YES

NO

LIVE WITH YOU)

(S ANYONE IN YOUR

 

 

IF YES, INDICATE WHO

 

 

 

 

 

WHEN IS THE BABY DUE?

HOME PREGNANT?

EYES

NO

NAME:

 

 

 

 

 

 

DATE:

SIGNATURE OR MARK OF ADULT APPLICANT

 

 

DATE

SIGNATURE OR MARK OF SPOUSE OR OTHER ADULT APPLICANT

DATE

 

 

 

 

 

 

(This signature is required fur Money Assistance un)y)

 

 

WITNESS IF SIGNATURES ARE “X”

 

 

 

DATE

 

 

 

 

 

APPOINTMENT NOTICE: When your application is received, an Appointment Notice for your interview will be sent or given to you. You must be interviewed before you can receive benefits. A telephone interview may be conducted in lieu of an office interview for aged, disabled or working individuals or for others

in hardship situations. To shorten the processing time, you should bring to the interview written proof of information and verification as noted on your appointment letter. You may be asked at the interview to bring more information. If you miss your appointment, or need to change it, you must call the local office to reschedule. The following action will be taken if you miss your appointment:

For SNAP, if you do not reschedule by the 30th day from the day you filed your application or the last day of your certification, your application will be denied. If your application is denied, you may be required to reapply to receive benefits. You may lose benefits for failing to appear at your interview.

For cash benefits, if you do not reschedule your appointment date, your application will be denied within the time limits specified by our policies. If you are currently receiving benefits, they may be stopped if you do not reschedule the missed appointment. If benefits are denied or stopped, you may reapply if you still want benefits.

AFTER YOUR INITIAL INTERVIEW WE ENCOURAGE YOU TO REPORT CHANGES AS SOON AS THEY HAPPEN, THIS MAY PREVENT ANY DELAYS IN BENEFITS TO YOU.

INTERVIEW INFORMATION: An interview must be completed before you can receive help. A single interview is sufficient when applying for SNAP and financial benefits. Appointments are scheduled according to the date you apply, with the earliest application given the first available appointment. You will be notified of the date and time of your appointment, EXCEPTION: If you meet the EMERGENCY ASSISTANCE requirements, you will be interviewed and provided financial benefits within two (2) working days and/or SNAP within seven (7) calendar days from the date of application. Answer the EMERGENCY ASSISTANCE questions below only if you need help right away.

YOU MAY GET SNAP WITHIN SEVEN (7) CALENDAR DAYS IF YOUR HOUSEHOLD:

Monthly rent/mortgage and utilities are more than your household’s gross monthly income and liquid resources; or

Gross monthly income is less than $150 and your household’s liquid resources, such as cash or checking/savings accounts, are $100 or less; or

Is a seasonal farmworker household whose income terminated prior to applying, is not expecting income of $25 within the next 10 days and has liquid assets of less than $100.

CHECK THE BOX FOR EACH TYPE OF EMERGENCY ASSISTANCE YOU ARE APPLYING FOR:

El Financial

El SNAP

YES

NO

 

 

El El

El El

El El

El El

El LI

Is anyone in your home a seasonal farm worker whose only source of income for the month terminated before applying and income of less than $25 is expected within the next 10 days?

Does anyone in your home have cash or savings or bank accounts? If yes, how much? Has anyone in your home received money this month? If yes, how much?

Does anyone in your home expect to receive any money this month? If yes, how much?

When? (Date)

Are you currently paying any of the following shelter expenses? If yes, list the amounts: Rent/Mortgage

Electric

Gas

Water

Phone

 

El El

El El

Have you been served court papers to get out of your present living arrangements? (Attach papers) Are you living in an agency temporary facility and have to get out in five days? If yes, name of facility?

U

:—

.—

(C

Refer to codes below for responses to questions marked with the corresponding asterisk symbols (*)

1.HOUSEHOLD MEMBERS

On line #1 enter the name of the primaly person who will receive the money and/or SNAP benefits for your household, If spouse is in the household, list spouse on line #2.Then list the other household members who are applying for assistance. For money assistance applicants, if anyone in the home it pregnant, list unborn child as a household member. All other household members not applying for assistance shall be listed under section #2.

Last Name, First, M.I.

1.

OTHER NAMES USED

(*)

RSOCIALSECURITh’

T BIRTHDATENUMBER

t.

A

TP SEX I E 0 P

N

S

 

(42 USC 1320b-7 requires

5

0

 

that SSN’s be provided for

H

N

 

each household

I

 

 

member applying

WE P

I

MO/DAY/YR

for assistance.)

SAGE’______

(**)(***) () YES

or H NO I C

G 0

BM S D H M

T R A T I E P

HA R A S S L

N C I T A T E

iB T U B G T

CA S L R E

L E A D

D D

E

Was child’s mother married to child’s father

NAME OF CHILD’S at time of PARENT(S) IF NOT IN birth?

THE HOME

(Check

 

 

one)

 

Yes No

2.

OTHER NAMES USED

AGE:

 

3.

 

OTHER NAMES USED

AGE:

 

4.

 

OTHER NAMES USED

AGE:

 

5.

 

OTHER NAMES USED

AGE:

 

6.

 

OTHER NAMES USED

AGE:

 

7.

 

OTHER NAMES USED

AGE:

 

8.

 

OTHER NAMES USED

AGE:

 

2.HOUSEHOLD MEMBERS WHO DO NOT WANT HELP

Write in the names of others in your home who do not want assistance (include yourself if you do not need help.) These people do not need to give us information about their citizenship, immigration status or social security number. These people will not be considered applicants and will not be eligible, however, they may need to tell us about their income and answer the other questions on this form,

.AGE

2.

 

 

 

3.

 

AGE

 

 

 

 

 

 

——

 

4.

 

 

 

 

AGE:

 

3. Is anyone temporarily out of the home?

El Yes

El No

Name

I

Date Left

 

..

Date to Return

Where Person Went

(9 Relationship Codes to Person #1:

SP - Spouse

GR - Grandparent

EX - Ex-Spouse

PA - Parent

GC - Grandchild

SS - Step Sibling

CH - Child

NR - Not Related

ST - Step Parents

SI - Sibling

OR - Other Related

CL - Common Law

 

.

 

ALl - Aunt/Uncle

UB - Unbom

CO - Cousin

NN - Niece/Nephew

FC - Foster Child

SC - Step Child

(*9 Ethnic Codes - Select only one code

HI . Hispanic

NH- Not Hispanic

(***)Race Codes - Select one or more codes below

WH -

White

JA

-

Japanese

BL

-

Black

KO -

Korean

Al

-

American Indian

CH

-

Chinese

 

 

or Alaskan Native

El

-

FihpinO

HA -

Hawaiian

OA

-

Other Asian

SA

 

- Samoan

OP

-

Other Pacitc

 

 

 

 

 

Islanders

1mm question is optional to aoswer. Failure to answer will not affect eligibility)

ocap lssa

(***)Marital Status Codes:

NM

- Never Married

 

 

 

ML

- Married, Living With Spouse

 

 

DI

- Divorced

 

 

 

LS

- Legally Separated

 

 

 

 

 

 

-

, -

MS

- Separated

 

 

 

MI

- Married, Involuntary Separation

 

 

WI

- Widowed

 

 

 

CL

- Common Law

 

 

 

crrpa

ccri,m

cTc’,-

coor,

,isc’r

ETRC

MNDA SSDO SEPA

 

 

j

-

 

 

)

 

 

 

 

 

 

 

 

 

Address

1

 

Name

 

.8

.sponsor(s) the of number phone and address, name, give refugee, or citizen .S.U-non sponsored If

 

 

.history work of verification provide to required be will you alien, permanent a are you If

NOTE:

y,’rp

(V/N)

wo,krtYINl

Number

 

 

Status

 

 

Status

 

Entry

Birthplace

.cit

 

Nat’l

US

 

Name

 

 

 

 

 

 

 

 

of Date

 

 

 

 

 

 

 

 

MiIita?

 

 

Registration

 

 

Of Date

 

 

Immigration

 

US

 

US

-

 

 

 

 

of Child )ejs

Active or

or

 

 

Alien

 

 

Effective

 

 

 

 

 

 

-Non

 

 

 

 

 

 

Veteran

 

or Form INS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

500 Spo

50

yu Do

 

 

 

 

 

 

 

 

 

 

 

ONE) (CHECK

 

 

 

 

 

 

 

CITIZEN .US-NON A ARE YOU IF COMPLETE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.aid for applying persons of status immigration

 

 

 

the verify to INS the with shared be may information However, .(INS) Service Naturalization and Immigration the with information

 

 

and name your share not will we benefits, for applying not are you If

.member household applicant each of status citizenship the perjury

 

 

 

of penalty under certify must member household applicant one 7,-1320b USC 42 to Pursuant

.DECLARATION STATUS CITIZEN

.7

 

 

 

 

 

 

 

 

name(s): yes, If

No LI

Yes LI

drugs? illegal of distribution or use possession, for

 

 

felony State or Federal a of convicted been or violator; parole/probation a

arrest; for warrant felony a fleeing household the in anyone Is

.6

 

 

 

 

 

benefits Blindness or Disability SSA or (SSI) Income Security Supplemental for eligible be could They

-‘

 

 

 

 

 

 

person(s) disabled of name yes If

No LI

Yes LI

disabled children) (including anyone Is

 

5

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

name: yes, If

 

 

 

 

No LI

Yes LI

 

veteran9

S U deceased a of child a or spouse disabled a or veteran

S U disabled a anyone Is

 

4

 

 

 

 

ASSISTANCE FOR APPLYING ARE WHO THOSE ONLY FOR

 

 

 

 

 

 

 

 

 

ANSWERED BE TO ARE 35 THROUGH 4 QUESTIONS

 

 

 

 

 

 

.No Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

code) Zip State, city,

,.Apt Street, (Namber, Address Representatives

 

 

Number Security Social

 

 

 

 

 

Birth of Date

 

 

 

 

 

ML) First, (Last, Name Representative’s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

).only purposes security

for used be will number security social and birth of date The .representative arrangement living group or facility treatment drug or alcohol

licensed the or name individuals the (Include

.number) identification (personal PIN and card EBT an issued be will representative This

 

No

]

[

Yes ]

[

.food my purchase to and BENEFITS SNAP MY TO ACCESS HAVE to individual following the permit

 

 

 

 

 

 

 

No ]

[

Yes ]

[

.ASSISTANCE CASH MY TO ACCESS HAVE to individual following the permit

I

 

 

 

 

REPRESENTATIVE AUTHORIZED TRANSFER BENEFIT IC ELECTRON

 

 

 

 

 

 

.No Phone

 

 

 

 

 

 

code) Zip State, City, ,.Apt Street, (Number, Address Representative’s

 

 

 

).Ml First, (Last, Name Representative’s

 

 

 

 

).representative arrangement living group or facility treatment drug or alcohol licensed the or name individual’s (Include

 

 

 

 

 

 

.behalf my on assistance SNAP FOR APPLY TO representative my be to individual following the permit

I

 

 

 

 

 

 

 

 

REPRESENTATIVES AUTHORIZED SNAP

 

 

 

 

 

 

 

 

 

.No Phone

 

 

 

 

 

 

code) Zip State,

city, ,.Apt Street, (Number, Address Representatives

 

 

 

).Ml First,

(Last,

Name Representative’s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.below representative applicant’s of address and name the Enter .).etc child, foster handicapped, (elderly, myself so do

to unable am

I as behalf, my on ASSISTANCE (CASH) FINANCIAL FOR APPLY TO representative my be to individual following the permit

I

REPRESENTATIVE APPLICANT’S FINANCIAL

C

9.What is the primary language spoken in your home?

How well is English spoken in the home? (Check only box) LI Does not speak or understand English

LI Limited understanding

LI Speaks well, does not read or write English

LI Speaks well, limited reading and writing skills LI Speaks well, adequate reading and writing skills

Do you need an interpreter? If needed, an interpreter will be provided free of charge. Li Yes. What language:

LI No. I will provide my own interpreter or have a family member or friend who can interpret for me.

10. Has anyone ever received financial or SNAP assistance? LI Yes LI No

NAMEType of AssistanceDate Last ReceivedCounty/State Last Received

11. Has any household member been disqualified from the SNAP or financial assistance programs?

 

LI Yes LI No

If yes, list name, program, disqualification period, county and state.

 

NAME

PROGRAM

DISQUALIFICATION PERIOD

COUNTY/STATE

12. For SNAP applicants/recipients only: if you are age 18 through 49, and are an able-bodied adult without dependents (ABAWD), you will only be eligible for three months of assistance in a 36-month period unless you meet additional work/training requirements. You must be employed or participating in an eligible work/training program for 20 hours weekly. Have you participated in a job training program under the Employment and Training (E&T) program, Workforce Investment Act or Trade Adjustment Assistance Act? LI Yes LI No

NAME

Job or Training Program

Participation Dates

13. Is anyone on strike?

LI Yes

LI No

f yes, name?____________________________________________________________

14.List the person(s) who is needed in the home to care for a disabled person.

15.Does any household member have private health, dental insurance, vision insurance, long-term care insurance, Medicare, TRICARE, VA benefits or prescription drug coverage?

PERSON’S NAME

Insurance Name, Type and Policy Number

16. Does any household member have medical problems or need medical treatment due to an accident or incident?

PERSON’S NAME

Date of Accident / Incident

MAST PRAW VOQS SAWR WORA WORF FIAC LIAS OTAS

5

EDWO

UNIE

VEHI OTAS

Name:

No LI

LIYes

school? vocational or training, college,

a to admission for applied anyone

Has .20

.MOJDAYIYR

.MOJDAY/YR

liME’ TiME?

SCHOOL OF NAME

STUDENT OF NAME

 

 

 

 

 

 

 

below: complete yes, If

No LI

Yes LI

student? a older and years 16 aged anyone Is

.19

 

 

INFORMATION STUDENT

 

$

$

$

 

 

 

 

$

$

$

 

 

 

 

$

$

$

 

 

 

 

$

$

$

 

 

 

 

$

$

$

 

 

 

 

RECEIVED AMOUNT

OWED AMOUNT

ACTAMLUE

.ETC TRANSFERRING, SELLING, FOR REASON

DATE

.ETC TRADED, SOLD, ITEM

 

 

 

 

 

 

 

 

 

 

below:

complete

yes,

If

 

No LI

Yes

LI

 

 

 

 

 

 

 

 

assistance)?

financial for applying

(if

months

24

last

the

in or

only),

SNAP

for applying (if

 

months

3

last

the

in

resources/assets other or

property, vehicles, money, away given or transferred

traded, sold,

anyone Has

.18

 

 

 

 

 

 

 

 

 

 

 

 

 

PROPERTY OF TRANSFER

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

——

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

).Etc Items, Hobby Instruments,

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

Musical Stereo, Radio, TV,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Jewelry, .e.i (Specify, Other

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

Policies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

all List-Insurance Life

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

$

 

 

 

 

 

 

 

 

 

Plot Plans/Cemetary Burial

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Property

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Real of Sale of Agreement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Buildings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Houses/Land! Other

 

 

 

 

$

 

 

 

$

$

 

 

 

 

 

 

 

 

 

Home Home/Mobile Your

 

 

EQUITY

 

 

OWED AMOUNT

VALUE MARKET

 

ITEM OF LOCATION/ADDRESS

OWNERS AS LISTED PERSON(S)

 

 

ASSETS

 

 

NO YES

 

 

 

 

 

 

 

 

ASSETS OTHER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.Comp Deferred

IRA/KEOGH

Certificate lime

Market! Money

bonds) (savings

Stocks/Bonds

$

 

 

 

 

Credit Refundftax Tax

 

$

 

 

 

 

Hand on Cash

 

AMOUNT

.NO ACCOUNT

BRANCH & INSTITUTION FINANCIAL OF NAME

ACCOUNT ON PERSON(S) OF NAME

ASSETS

NO

YES

 

 

 

 

ASSETS LIQUID

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

$

 

 

 

 

Savings Christmas

 

 

 

 

 

 

 

 

$

 

 

 

 

Accounts Union Credit

 

$

 

 

 

 

Accounts Savings

 

 

 

 

 

 

 

 

 

 

 

 

 

Personal/Business

 

 

 

 

 

 

 

 

Accounts: checking

 

 

 

AMOUNT

.NO ACCOUNT

BRANCH & INSTITUTION FINANCIAL OF NAME

ACCOUNT ON PERSON(S) OF NAME

ASSETS

NO

YES

 

 

ACCOUNTS EINANCIAL

 

 

 

 

 

 

 

 

 

 

.below provided spaces

 

 

blank in listed not

assets other Include .item each for No” or “Yes Check

.you with live not does who anyone with owned

 

 

co are which assets and month the ot first the ot as owned assets Include

below? listed items the of any have anyone Does

.7

1

C

UNEARNED INCOME

21.Is anyone receiving, expect to receive, or have an application pending for any type of income listed below? Check “Yes or No” for each source of income. If “Yes” is checked, complete the information about the item.

YES NO PEND- G

SOURCE OF INCOME

PERSON WHO RECEIVES INCOME

MONTHLY AMOUNT

Social Security

 

$

Supplemental Security Income (SSI)

 

$

Assistance Payments from Another State

 

$

Unemployment Benefits

 

$

Housing Authority (HUD, Section 8), Energy

 

$

Assistance

 

 

 

Child Support, Alimony

 

$

Money from friends, relatives, charities,

 

$

contributions, gifts, etc.

 

 

 

Blood/Plasma income

 

$

Interest/Dividends/Royalties

 

$

Veteran’s Benefits, Railroad Retirement, other

 

$

Governmental Benefits

 

 

 

Retirement/Pension, Profit Sharing, Annuity Pmts.

 

$

Temporary Disability Insurance/Worker’s

 

$

Compensation

 

 

 

Training Allowance, Vocational Rehabilitation, JTPA

 

$

Foster Care Payments

 

$

Strike Pay

 

$

Military Enlistment Bonus

 

$

Military Allotment

 

$

Money from land/building sales, rentals or leases

 

$

(to include agreement of sales)

 

 

 

Prizes, Cash, Gifts, Awards

 

$

Insurance Settlements

 

$

Reapplication or Appeal of a Denied Benefit (such as SSI

 

$

or Unemployment benefits, etc.)

 

 

 

Other (Specify)

 

$

HOW OFTEN

RECEIVED?

(MONTHLY/WEEKLY)

UNIN EAIN

C

0

0

C

Lii C

C) CC

C-)

C) 0

0 11)

C.) C S

z -2c 0

w

z C

C)

Lii -d

C)

C

C,

0

S

0

S

z

C,

0

-C

C,

S

z

C,

C

C.

0F

I—

0

C)

>

C)

4-,

C

C)

C

0

4-,

(C C-)

C)

>

C

-o

-C

C

CC

C)

C

2

C

U

C

z

LI

LI

CO

C

-

C

C)

C

>-

C 0

CC0

Cl)

z

0

I

H

z

0

LU

Cl)

H

(3

LU

I

U

z

0LU

I

0

D

0

I

LU

LU

C

 

 

z

 

 

LU

 

 

H

 

 

LU

 

 

0

CC

 

 

>-

 

C

0

 

C

0

I

 

0

 

F—

0

0

C

z

0

 

I

I

 

H

H

 

z

z

 

0

0

 

LU

LU

 

cC

 

 

CJC

U)

 

0

 

 

H

H

 

C.)

C.)

 

LU

LU

 

I

I

 

U

U

z

F

z

F

0

0 LU

 

I

0

I

 

 

C

D

D

0

0

I

I

LU

141

LU

LU

LU

LU

 

0

C

C

LU

LU

0

0

U)

11)

D

D

0

C

I

I

CC

z

0

 

z

LU

 

 

LU

H

 

 

H

LU

 

 

LU

C

C

 

0

 

 

CC

 

0)

z

 

 

 

>-

0

 

0

0

0

C 0

I

CCC

0

0

 

 

 

UI

v-i C) z

LU

CC

CO LU

U)

4-,

I

I

2 z

0

(CC)

(C

v-i

(I

 

0

CO ci

CC

C

(C

0.. U I

F—

z

C)> 0

(C CO

C)

o -o C

C C(C LU

o CO LU

4.4C

D

o

CC

C)

CCC

4-,

>-_

-

—C

U)C-ti

Cl)v-i

C)C LU

C C.) z

(F)

0>- D

CC

LU

20

CLU

>-,z >-

LI

CO>

C

C

(C

C)

-C

z

C)

0

>-

(I-)

o

 

 

LU

C)Ll) C

-5

U)L)

Ct

C

>-

(CC)

U)

2

LU

>

LU

U

LU

CO Hz

C

D

0 0

C)

I

H

C) z

C)

E0

C

C.)

C

z

LI

LI

C’-.

UF

C)

-C

(C

C

LU

C CCX:

Cl) z

C)Cl-i

2

CLU

C0

2

C

‘4-

>—

C)

C

C

2

C)

>

C)

C.)

C)

1

C)

C

C

(C

U-i

C)

0

0

L

(N

C

z

LI

LI

C.)

Ci)

C)

CO (C

C

C)

CO

C

CC

C-)

CC

..0

C

C)

C

CC

Ci)

CC

C.)

U)

C)

2

C

C.)

C

C

C)..

C._

(C

U9

‘4-

4-

C)—

C0.

(CL)

U)U

(N

UI

(.3

z

I

U

LU

0

z

-J

><

UI

z

0

Cl)

LU

0

LU

C

LU

z

I

z

LU

LU

UI

U-)

C.

C

COMPLETE FOR SNAP ONLY

DEDUCTIBLE EXPENSES

EXPENSES ARE USED AS A DEDUCTION IN THE DETERMINATION OF THE AMOUNT OF SNAP YOUR HOUSEHOLD MAY BE ENTITLED TO RECEIVE. FAILURE TO REPORT OR VERIFY EXPENSES WILL BE SEEN AS A STATEMENT BY YOUR HOUSEHOLD THAT YOU DO NOT WANT TO RECEIVE A DEDUCTION FOR THE UNREPORTED OR UNVERIFIED EXPENSE. TO CLAIM EXPENSES IN THE FUTURE YOUR HOUSEHOLD WILL NEED TO REPORT AND VERIFY EXPENSES.

SHELTER EXPENSES

27. Does any person or agency outside your household help pay for or provide, at no cost to you, any of the expenses listed below?

El Yes

LI

No

If Yes,

( / ) the expense(s):

 

 

 

El Rent

El Utilities

El Taxes

LI Mortgages

LI Personal Supplies

El Food

LI Household Supplies

El Medical Care

LI Clothing

LI Other

 

 

 

If Yes, what person or agency helps pay or provide the expense(s)?

 

 

 

Do you need to pay them back?

El Yes

LI No

 

 

 

28. Is anyone in your household working off any part of the rent?

29. Do you live in Public Housing? EYes LI No

30. Check Yes or No and complete information for each item:

ITEM

How OFTEN BILLED

CURRENT BILLED

YES NO

(Monthly, Weekly)

AMOUNT

 

 

 

Rent

 

 

LI Yes

LI No

 

If Yes, indicate amount $

 

 

ITEM

HOW OFTEN BILLED

CURRENT BILLED

YES

NO

 

(Monthly, weekly)

AMOUNT

 

 

 

 

Gas

B oat SI ‘p

Propane, Kerosene, Coal,

Wood

Mortgage/2 nd Mortgage

Telephone

Sales/Local Property Tax/

Homeowner’s Insurance

Water

Garbage, Sewer,

Trash Collection Electricity

USTYOUR LANDLORD’S NAME, ADDRESSAND PHONE NUMBER

Utility Installation Fees

Unoccupied Home Expenses

Car Payment

(If car is used as a home)

Car Insurance

— — (If car is used as a home) Other (Specify)

— —

31. Are you billed separately for utility cost?

EYes

El No

If Yes, (/) check the utilities:

El Electric/Gas

El Water

El Sewer/Trash

 

 

If yes, choose one of the following options “A” or “B” for each utility billed separately:

Electricity/Gas_____________ Water

Sewer/Trash

 

A. Standard Utility Allowance (SUA)

 

B. Actual Utility Costs

The SUA is an amount which reflects the average

If you Choose to use ACTUAL COSTS, you will need to

statewide amount spent for specific utilities and

verify these costs.

other mandatory fees. You may choose to have

 

either the actual cost or the SUA for each utility cost used in determining the SNAP shelter cost deduction amount.

ANY QUESTIONS REGARDING THESE OPTIONS CAN BE DISCUSSED WITH YOUR WORKER. ONCE YOU SELECT AN OPTION, YOU CAN CHANGE IT ONLY ONETIME IN 12 MONTHS.

32. Does your room or rent payment include meals?

ElYes

LI No

If Yes, complete the following:

PAYMENT ROOM’MEALS

NO. OF MEALS PROVIDED PER DAY

MONTHLY AMOUNT

$

 

 

 

$

EXPE 8

9

DEID

EXPE

/

$

$

/

$

$

 

$

$

 

$

$

 

$

$

 

$

$

 

$

$

 

.

COMPANY INSURANCE PHARMACY,

WEEKLY) (MONTHLY,

EXPENSE

BILLED

FOR IS EXPENSE THE PERSON OF NAME

HOSPITAL DOCTOR, OF NAME

BILLED OFTEN HOW

ESTIMATED

.AMT ACTUAL

 

 

 

.etc attendant, or nurse, a of service aids, hearing

dentures, glasses, costs, transportation medical bills, dental and doctor drugs, prescription premiums, insurance hospitalization and health

premiums, Medicare include bills/expenses Medical

.deceasedVeteran a of child a or spouse disabled a (5) or veteran, disabled a (4) Benefits,

Blindness or Disability Security Social or SSI receiving not but to, entitled (3) payments, disability government other or Retirement Railroad

payments, Blindness or Disability Security Social (SSI), Income Security Supplemental receiving (2) older, or 60 age (1)

are: who household

your of members for months 12 next the for expenses medical anticipated for estimate and bills medical current List

.EXPENSES MEDICAL .35

 

EXPENSES MEDICAL

 

 

CARE PROVIDING PERSON

DUE TOTAL

SHARE YOUR

CARE PAYING

CARE RECEIVING

OF ADDRESS AND NAME

PERSON OF NAME

PERSON OF NAME

 

BILLING

 

 

 

 

 

following: the complete Yes, If

No El

ElYes

work?

 

for look or training, or school attend work, can someone so adult disabled or child a of care the for billed anyone is or pay anyone Does

.34

 

EXPENSES CARE DEPENDENT

 

 

 

 

 

 

 

$

 

 

 

 

 

$

 

 

PAID PERSON OF NAME

PAID OFTEN HOW

AMOUNT

PAYMENT OF TYPE

 

 

following: the complete Yes, If

No LI

Yes LI

 

home? your in live not do and dependents tax as claim you whom those for payments make or support, child alimony, pay anyone Does

.33

EXPENSES SUPPORT ALIMONYICHILD

C...

(1)SOCIAL SECURITY NUMBER(SSN):

Pursuant to 42 Usc 1320b-7, the SSN5 of persons applying for and receiving help in the Financial and SNAP will be used to check identities of household members prevent duplicate participation, verify income/asset amounts and to do mass changes. SSNs will also be used in program reviews or audits and in computer matching with the Internal Revenue Service, State Department of Labor, and Social Security Administration to make sure your household is eligible. This may result in criminal or civil action of administrative claims against persons fraudulently participating in the Financial Program and SNAP.

(2)YOU HAVE THE RIGHT:

To discuss any action regarding your case with your worker or the supervisor if you are dissatisfied.

To be notified in advance before your benefits are reduced or discontinued.

To ask for a hearing in writing, or orally for SNAP, if you are dissatisfied with any action by the DHS, and to ask the Legal Aid Society of Hawaii, or anyone you want, to help get a hearing. Your case may be presented at the hearing by any person you choose.

To have your record kept confidential.

To have a bilingual or sign-language interpreter. All our oral and written communication to you will be in English. If you do not understand what

you hear or read, please contact your worker right away.

In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food and Nutrition Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs. To file a complaint of discrimination with the Department, contact the civil Rights compliance office at 1390 Miller Street Room 214, or call (808) 586-4955, or contact USDA or HHS Write USDA, Director, Office of civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). Write HHS, Director, Office for civil Rights, Room 506-F, 200 Independence Avenue, SW., Washington, D.C. 20201 or call (202) 614-0403 (voice) or (202) 619-3257 (TDD). USDA and HHS are equal opportunity providers and employers.

(3)YOUR RESPONSIBILITIES:

All households (Simplified and Change Reporting) must apply for and accept all potential sources of income and assets. Failure to do so may result in benefits stopping and ineligibility.

SIMPLIFIED REPORTING HOUSEHOLDS

If your household is determined to be a Simplified Reporting household you are required to complete a Six Month Report form. You are only required to report the following items on your Six Month Report: any change in residence; new employment; earned income verification and self-employment expenses all other sources of income; changes in household composition; and any changes in resources. For the SNAP, you must also report a change in shelter cost if you have moved and any changes in legal obligation to pay child support. For the medical program, you must also report changes in private health insurance, the offer of health insurance by an employer, and the occurrence of any accident.

In addition to the Six Month Report, you will have to report the following within 10 days of the change for the financial assistance programs: any change in household composition and when the household’s total gross income exceeds 100% of the Federal Poverty Limit (FPL). For the SNAP, you are required to report when the household’s total gross income exceeds 130% of the FPL. For SNAP households that include a member who is considered an able-bodied aduft without dependents (ABAWD), you must report when work or training hours decrease below 20 hours a week or termination of employment or training. Households receiving assistance from more than one program shall report the changes as required for each program. changes may be reported in writing, in person or by telephone.

REPORTING CHANGES FOR ALL OTHER HOUSEHOLDS

Households who are not simplified reporting households shall be required to report the following changes within ten days of the date the change becomes known; or if the change involves income, the change must be reported within ten days of the date that the first payment is received.

Unearned Income: A change in the source of unearned income and a change of more than $50 in the amount of unearned income, except changes

related to the financial assistance grant. Examples of unearned income: Supplemental Security Income (SSI); Unemployment Compensation (UIB); Veteran’s Benefits (VA); Tax Refunds; Insurance Settlements; Inheritance, gifts or contributions from relatives; dividends pensions, retirement or Social Security benefits, child support and alimony, etc.

Earned Income: All changes in earned income, including starting, stopping or changing a job. Receipt of irregular earned income, for example, commissions, lumpsum payments, etc.

Household Composition: All changes in household composition, such as the addition or loss of a household member.

Assets: When cash on hand, stocks, bonds, and money in a bank account or savings institution reaches or exceeds the program’s asset limit.

Chances in Residence and Shelter Costs: A change in residence, and for the SNAP the resulting change in shelter costs.

Child Support Obligations: For the SNAP, any change in legal obligation to pay child support.

ELECTRONIC BENEFITS TRANSFER (EBT) You are responsible to report lost, stolen, or misused EBT CARDS immediately by calling the EBT toll-free customer service number, or by accessing the EBT website at www.ebtaccount.JPMorcian.com. There will be no replacement of any benefits accessed with an EBT card prior to the card being reported lost, stolen or misused. You are responsible to report immediately any changes in the status of your alternate payee. There will be no replacement of any benefits accessed by alternate payees or any other individuals using an EBT card and a valid PIN. Benefits not withdrawn for 90 days for cash assistance accounts and for 365 days for SNAP accounts will be returned to the state.

(4)PENALTY WARNING:

Do not make any false statements or hide any information.

Sanctions and court prosecution may be pursued under applicable state and federal laws.

Do not do anything dishonest to get money and SNAP benefits which you are not supposed to get.

Do not give, trade or sell your SNAP benefits or EBT card to anyone else.

Do not alter or use someone else’s SNAP or EBT card for your household.

Do not use your SNAP benefits or EBT card to buy ineligible items such as alcoholic drinks and tobacco.

For the financial assistance program, an intentional program violation disqualification penalty is twelve months for the first violation, twenty-four months for the second violation and permanently for the third or more violations.

For the SNAP, any household or family member who intentionally breaks SNAP rules, can be fined up to $250,000, imprisoned up to 20 years or both. A member of your household can be barred from SNAP for one year for the first violation; two years fc a second violation and permanently for the third or any subsequent violation and an additional 18 months if court ordered. The individual may also be subject to further prosecution under other applicable Federal laws. A member convicted of using or receiving SNAP benefits in a transaction involving the sale of firearms, ammunition or explosives is permanently ineligible to participate in SNAR Individuals convicted of trafficking SNAP benefits of $500 or more are permanently ineligible.

Individuals found guilty to have used or received SNAP benefits in a transaction involving the sale of controlled substance are ineligible to participate for two years for first violation and permanently for the second violation, Individuals who have committed and been convicted of Federal or State felonies after 8122/96 for possession, use or distribution of illegal drugs and who refused to comply with treatment or with a treatment program are ineligible for the program. An individual is ineligible to participate in the financial and SNAP for 10 years if found to have filed more than one application at the same time and have given false identification or residence information. Fleeing felons and probation/parole violators are ineligible for the financial and SNAR

10

 

 

 

DATE

 

 

 

 

 

WORKER ELIGIBILITY OF SIGNATURE

 

 

NAME WORKER’S ELiGIBILITY PRINT

 

 

 

 

 

 

 

 

 

 

 

.eligibility determine which facts concealing

 

 

 

 

or misrepresenting for charges criminal of possibility the and responsibilities and rights his/her of informed been has applicant/recipient the that certify

I

 

 

 

 

 

 

 

 

 

 

 

 

 

WORKER: ELIGIBILITY BY CERTIFICATION (11)

 

 

 

ADDRESS

 

.ND PHONE

 

RELATIONSHIP

 

 

 

 

 

NAME

 

 

 

 

 

 

 

Print) (Please IS: CONTACT TO PERSON THE DEATH, OR EMERGENCY OF CASE IN (10)

 

 

 

.ND PHONE

 

 

 

 

 

 

 

 

 

 

 

ADDRESS HOME

 

 

 

DATE

 

 

 

 

 

RELATIONSHIP

 

 

 

 

 

 

SIGNATURE

 

 

 

.applicant/recipient the by provided was U or him/her; about personally know I what is U form this on me by given answers the that certify

I

 

 

 

 

.penalties criminal to subject is benefits getting dishonestly in person another helping anyone that understand I .form this

Out

fill applicant the helped

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

).box one off check

 

(Please

LI: APPLICATION OUT FILLING IN ASSISTING PERSON OTHER OR LI REPRESENTATIVE AUTHORIZED BY CERTIFICATION

(9)

 

 

 

 

 

 

 

 

only) anmintanc, money for (Required APPLICANT

 

 

 

APPLICANT OF MARK) (OR SIGNATURE

 

 

 

“X” IS SIGNATURE IF WITNESS

DATE

 

ADULT OTHER OR SPOUSE OF MARK) (OR SIGNATURE

DATE

 

 

 

 

correct is member household applicant each on Declaration Status Citizen the on provided information the that perjury of penalty under certify

I

 

 

 

 

 

 

 

 

eligibility of condition a as them fulfill to agree and agreements and assignments the understand

I

 

 

 

 

responsibilities these heed to agree I and worker the by responsibilities and rights my of informed been have I that certify

I

 

 

 

 

 

 

 

 

information false giving or hiding for penalty the and application this on questions the understand

I

 

 

 

 

 

 

.knowledge my of best the to complete and correct are answers my that perjury, of penalty under certify

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.agreements and assignments your consent, your authorization, your warning,

 

penalty the responsibilities, and rights your understand you sure Make

.question each answered have you that check and back go application, this signing Before

 

 

 

 

 

APPLICATION): VALID A CONSIDERED BE TO SIGNED BE (MUST CERTIFICATION YOUR

(8)

 

 

 

 

 

 

 

 

 

 

 

.household your to benefits SNAP of denial the

 

 

in result will information this provide to failure However,

.voluntary is member, household each of SSN the including information, requested the of providing The

 

 

 

 

 

 

 

 

 

 

 

.action collection claims for agencies collections claims private

 

 

to as well as agencies, State and Federal to referred be may

SSNs, all including application, the on information the household, your against arises claim SNAP a If

 

 

 

 

 

 

 

 

 

 

 

 

 

.law the avoid to fleeing persons

 

 

 

apprehending of purpose the for officials enforcement law to and examination, official for agencies State and Federal other to disclosed be may Information

 

 

 

 

SNAR the in participate to eligible be to continues or eligible is household your whether determine to used be will information The

 

 

 

 

 

 

 

 

 

 

 

 

.2036-2011 .C.S.U 7 amended, as 2008, of

 

Act Nutrition and Food the under authorized is member household each of (SSN) number security social the including application, this for information of Collection

 

 

 

 

 

 

 

 

 

 

 

 

STATEMENT: ACT PRIVACY SNAP

(7)

 

 

 

 

 

 

 

 

 

 

 

.pregnant am I unless benefits medical for eligible

 

 

be not may

I however benefits, medical children’s my affect not will it cause, good Without .this support to information provide must I

household, my of interest

 

 

best the in be not may it believe I because cooperate not do

I If .assistance receives household my in anyone time the for care medical for received money other or

 

 

payments insurance health any Hawaii of State the give will

I

.payments party third obtaining in cooperate will

I .care medical for payments party third any to rights

 

 

my Hawaii of State the to assigning am I applying, by that understand I assistance medical and financial for eligibility of condition a As

LIABILITY: PARTY THIRD

 

 

 

 

 

 

 

 

 

 

 

.assistance further for ineligible become will I and dependents my

 

 

market, open the in get I what than money less for property any transfer or assign

I If .property such of transfer or exchange lease,

sale, the from received money any

 

days five within Department the to report to agree also

I

.property my on information verify to permission Department the give

I AGREEMENT: PROPERTY REAL

 

.application my in

children minor the for paternity establishing in State the with cooperate to agree I .agreement support spousal or child my of status existing the

 

 

change otherwise or order court new a seek or negotiate to permission State’s the have must

I State the to support spousal and child assign I when that understand

 

 

also I

.payments party third obtaining in cooperate will

I

.care medical for payments party

third any to rights my Hawaii of State the to assigning am I applying,

 

 

by that

understand

I assistance financial for eligibility of

condition a As

.children your or yourself to harm

mental or physical fear

you if requirement this from

 

 

exempt be may You

.granted assistance of amount the to up State the reimburse to used be will payments Such

.support future and present as well as previous from

 

 

support to rights includes assignment This .assistance receiving or applying am I

whom for person any or myself for person, another from have may I that support

 

 

spousal and child to rights any Hawaii of State the to assigning am I assistance, financial for eligibility of condition a as that understand I

RIGHTS: OF ASSIGNMENT

 

 

 

 

 

 

 

 

 

 

 

 

AGREEMENT: AND ASSIGNMENTS

(6)

 

 

 

 

 

 

 

 

 

 

.writing in withdrawn is consent the or reached been has

 

 

SSfor eligibility of determination final a until good is consent This .benefits assistance public my affect may information this of release that understand I .information for requests and appointments with comply to failure any and SS for claim my of status the regarding Department the to information release to advocate the authorize also I .history work and information asset and income medical, include shall released be may which information of type The .me for benefits Ss get help

to used be will information This .Department the by contracted advocate (SS) security social the to case my from information release to Department the authorize I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.Department the owes household my that overpayments outstanding

 

any

offset

to

used

be

may

account

EBT

my in

balance

the

benefits,

my

access

to failed

I because inactive becomes account EBT my if

that

understand

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.violator parole

a or felon fugitive a as recipient a identify to or purpose, enforcement law criminal

 

or

civil,

administrative,

official

an

for

needed

if

officers

enforcement

law

to released be may address business and residence

my

that

understand

I

 

 

 

 

 

 

 

 

 

 

 

 

 

.benefits SNAP approving notice the on possibility this of notified am I as long as notice further without reduced

 

be

may

benefits

SNAP

of

amount

the

 

that

made,

is

eligibility

financial

of

determination

a

before issued are benefits SNAP

if

that

understand

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.System Verification Eligibility Income the administering states all in agencies

 

and

Compensation, Unemployment

and

 

wages

for

Labor

of Department Administration, Security Social

 

the with me about information exchange and

 

Service

Revenue Internal

the from eligibility and

income

my verify to me about information exchange and obtain will Department

the

that

understand

I

 

 

 

 

 

 

 

 

 

 

 

 

.need of basis the on assistance provides which programs assisted federally of administration the or program, assistance

 

Department’s

the

of

administration

the

 

with

connected

purposes for me about information release

to need may Department

the

that

understand

I

 

 

 

 

 

 

 

 

 

.review

a for selected is case my if auditors and/or reviewers Control Quality Federal Department, the with cooperate to agree I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.help for eligible am I that show

 

to needed be may which me about

information for contact may Department the whom

agency)

Federal or State employer, doctor,

as

(such

organization

 

or person

of

name

the give

to

agree I available, not

are documents

If

.made

have I statements

the verify to documents necessary

the

provide to agree

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.institution financial the with have may

account any in amount and of nature and existence the on

 

information including information, Department the provide

to institution financial any authorize

I

.help for eligible am I that verify

to

unions, credit and

 

companies

thrift associations, loan and

savings

banks, to,

limited not but

including,

institution,

financial

any with check

to Department the authorize

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

.information incorrect providing

 

knowingly

for prosecution

criminal

to subject

be

may

I

and denied; be may benefits SNAP incorrect,

 

is

information any

if and

factual; is information

 

such if

determine

to

officials

local

and

State

Federal,

by

verification

to

subject

be

will Department

the to provide I

information

the

that agree

I

AUTHORIZATION: YOUR (5)

OAHU BRANCH APPLICATION UNIT

Unit

Service Area

Pohulani Processing Center

677 Queen Street

Suite 400B

Honolulu HI 96817

Telephone: 587-5283

Fax: 587-5297

OR&L Processing Center

333 North King Street

Room 200

Honolulu HI 96817

Telephone: 586-8047

Fax: 586-8138

KPT Processing Center

1485 Linapuni Street

Suite 122

Honolulu HI 96819

Telephone: 832-3800

Fax: 832-3392

Waipahu Processing Center

94-275 Mokuola Street

Room 303

Waipahu HI 96797

Telephone: 675-0052

Fax: 675-0038

Kapolei Processing Center

601Kamokila Boulevard Room 117

Kapolei HI 96707 Telephone: 692-8384 Fax: 692-7783

Waianae Processing Center

86-120 Farrington Highway

Suite A103

Waianae HI 96792

Telephone: 697-7881

Fax: 697-7184

Honolulu District

Hawaii Kai thru Makiki

Pauoa and Waikiki

Honolulu District

Sand Island thru Chinatown

Honolulu District Kalihi to Moanalua

IHS and Kam IV Housing

Salt Lake thru Aiea

Pearl City, Waipio Gentry, Milllani and parts of Waipahu

Kunia, Ewa, Kapolei, and parts of Nanakuli and Waipahu

Waianae to Makaha Valley and parts of Nanakuti

Wahiawa Processing Center

Mililani, Wahiawa, Waialua and

929 Center Street

Haleiwa

Wahiawa HI 96786

 

Telephone: 622-6315

 

Fax: 622-6484

 

Koolau Processing Center

Windward District

45-260 Waikalua Road

Includes: Waimea to Kahaluu,

Kaneohe HI 96744

Kaneohe, KaiIua and

Telephone: 233-3621

Waimanalo

Fax: 233-3620

 

07/20/2012

BESSD/NIB

APPLICATION

As of 05/07/12

UNITS

East Hawaii

Section:

 

North Hilo Unit, #526

 

Kulana

Naauao Bldg.

 

13 Kekaulike St.

 

Hilo, HI

96720

 

Phone:

808-933-0331

 

Fax:

 

808-933-8856

 

South Hilo Unit, #575

 

Kinoole

Plaza

 

1990 Kinoole St., Ste. 108

Hilo, HI

96720

 

Phone:

808-981-2754

 

Fax:

 

808-981-2819

 

West Hawaii

Section:

 

North

Kona I Unit, #664

 

75-5722

Hanama P1., Ste

1105

Kailua-Kona, HI 96740-4127

Phone:

808-327-4980

 

Fax:

 

808-327-4684

 

South Kona Unit, #633

 

Captain Cook Civic Center

82-6130 Mamalahoa Hwy., Bldg. 2

Captain Cook, HI 96704

 

Phone:

808-323-7573

 

Fax:

808-323-4549

 

Ka’u Sub-Unit, #635

 

Naalehu

Civic Center

 

95-5669

Mamalahoa Hwy.

 

Naalehu, HI 96772

 

Phone:

808-939-2421

 

Fax:

808-939-9500

 

Kamuela-Hamakua Unit,

#632

State Office Building #1 Rm#1 10

45-3380

Mamane St.

 

Honokaa, HI 96727

 

Phone: 808-775-8854

 

Fax:

808-775-8858

 

Kohala Sub-Unit, #634

 

State Office Building

 

54-3900 Akoni Pule Hwy.

 

Kapaau, HI 96755

 

Phone: 808-889-7141

 

Fax:

808-889-7132

 

Mailing Address:

P.

0.

Box 1562, Hilo, HI 96721-1562

Mailing Address:

P.

0.

Box 1562, Hilo, HI 96721-1562

Service Area: Kaiminani Drive to Waikoloa (on Queen

Kaahumanu Hwy) and

Puuanahulu South to Alii Drive (to

White Sands Beach)

 

Service Area: Kahuku

Ranch to Holualoa and

Kamehameha Ill Rd to Alii Drive (to White Sands Beach)

Mailing Address:

PC Box 225, Captain Cook, HI 96704

Service Area: Kapapala Ranch to Kahuku Ranch

Mailing Address:

P0 Box 6, Naalehu, HI 96772

Service Area:

Waimea (1st Traffic Light) to Papaaloa)

Service Area: Waikoloa to Kohala, and

 

Puuanahulu North to Waimea

1st Traffic Light

Mailing Address: PC Box 249,

Kapaau,

HI 96755

Page

1 of 2

BESSD/NIB APPLICATION UNITS

As of 05/07/12

Kauai Section:

 

 

East Kauai Processing Center-445

Service Area: Islands of Kauai & Niihau

3060 Eiwa Street, Room 103

 

Lihue, HI 96766

 

Phone:

808-274-3371

 

Fax:

808-241-3187

 

Maui Section:

 

 

Maui Public Assistance

 

54 High St. #125

 

Wailuku, HI 96793

 

Phone: 808-984-8300

 

Fax:

808-984-8333

 

Molokai Unit

Mailing Address: PC Box 70, Kaunakakai, HI 96748

55 Makaena P1. Rm. 1

 

Kaunakakai, HI 96748

 

Phone: 808-553-1715

 

Fax:

808-553-1720

 

Lanai Sub-Unit

Mailing Address: PC Box 631374,

730 Lanai Avenue

Lanai City, HI 96763

Lanai City, HI 96763

 

Phone: 808-565-7102

 

Fax:

808-565-6460

 

Page 2 of 2

C,

f -