Dhs 1240 Form – Fill Out and Use This PDF

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.

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

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

El Financial

El SNAP

YES

NO

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:

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

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

NAME

Job or Training Program

Participation Dates

13. Is anyone on strike?

LI Yes

LI No

f yes, name?____________________________________________________________

PERSON’S NAME

Insurance Name, Type and Policy Number

PERSON’S NAME

Date of Accident / Incident

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

$

$

$

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

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

B oat SI ‘p

Propane, Kerosene, Coal,

Wood

—

Mortgage/2 nd Mortgage

Telephone

31. Are you billed separately for utility cost?

EYes

El No

If Yes, (/) check the utilities:

El Electric/Gas

El Water

El Sewer/Trash

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

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

$

$

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

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

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

•

Unit

Service Area

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

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