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AGENCY USE ONLY: |
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DATE RECEIVED |
State of Alabama |
FS Case Number ___________________________ |
BY COUNTY |
Name ______________________ |
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Department of Human Resources |
Race/Sex _______ |
IEVS Function ______ |
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Food Stamp Application |
Check Digit _____ |
Process Std. ________ |
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FA Case No. ____________________ |
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Appointment Date _____________ Time _________
You have the right to file an application the same day you contact the Food Stamp Office. To file an application, you need only complete your name, address, and signature, and turn this form into the county Food Stamp Office where you live. We will interview you to decide if you are eligible. You will receive benefits from the date we received your signed application if you are determined eligible.
YOUR NAME (First, Middle, Last) |
Birth date (Mo., Day, Yr.) |
Social Security Number |
Mailing Address |
Street Address, if different |
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City |
State |
Zip Code |
Telephone/Message Number during |
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the day |
Expedited Services
You may get food stamps benefits within 7 calendar days if: your food stamp household has less than $150 in monthly gross income and liquid resources such as cash, checking or savings accounts are less than or equal to $100 or; your rent/mortgage and utilities are more than your household’s combined monthly income and liquid resources or;
a member of your household is a migrant or seasonal farm worker.
1.How much money do the members of your household have in cash or a bank account? $__________________
2.What is the total amount of income you expect your household to receive this month? ___________________
3.What is your current monthly rent/mortgage payment? $________Utilities other than phone? $______________
4. Is anyone in your household a migrant or seasonal farm worker? Yes No |
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If yes, answer these questions: Did all of your household income stop recently? Yes |
No |
Does anyone in your household expect to receive income from a new source this month? |
Yes No How |
much?____________ |
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In accordance with Federal law and U. S. Dept. of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write: USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 401-720-6382 (TTY) USDA is an equal opportunity provider and employer.
Penalty Warnings, Perjury Statement and Signature
When your household receives food stamp benefits, you must follow all the rules. You must provide true and complete information about everyone in your household and you must provide documents to prove what you say if you are asked to by the worker. The Social Security numbers for all household members will be used in computer matches with other agencies in determining eligibility for food stamps. Any member who breaks any of the rules on purpose can be barred from the Food Stamp Program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. S/he may also be
subject to prosecution under other applicable federal and state laws. There are also penalties if any household member is found guilty of using food stamp benefits to purchase illegal drugs or firearms.
♦Do not trade or sell food stamp benefits or EBT cards.
♦Do not use someone else’s food stamp benefits, identification card or EBT card for your household. ♦ Do not give false information or hide information to get or continue to get food stamps.
I certify under penalty of perjury that my answers to all questions about each household member, including those about citizenship or alien status, are correct and complete.
Household Member Signature or mark (X) |
Date |
Witness if Signed with X |
DHR-FSP-2116 |
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Household Members
INSTRUCTIONS: Please print clearly. List everyone in your household that you are asking to get food stamps benefits for. Your spouse and any children under age 22 must be included with you in your household. Answer all questions for each household member.
Verification of information about all household members may be required. Some of the things you should bring to your interview include: proof of identity( driver’s license, birth certificate), check stubs, proof of unearned income ( child support, social security, or SSI), rent receipts, medical bills , bank statements, and day care receipts. We will tell you what we need to finish your application during your interview.
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Relation |
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Social |
U.S. |
In |
Working |
Name (First, Middle, Last) |
of |
Sex |
Race Security |
Citizen |
School |
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to you |
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Birth |
M/F |
Number |
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Yes No |
Yes No |
Yes No |
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List any other people who live in the same house with you but you do not want included in your food stamp household because they do not purchase and prepare food with you. (Use another sheet of paper to add other people if there is not enough room for everyone here.)
Name |
Age Relation |
Does this Person give you |
Does this person pay any part of |
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to you |
or anyone listed above any |
the household bill? |
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money? |
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No Yes |
Reason |
No Yes What bill(s)? |
Authorized Representative
You may appoint someone outside your household to act for your household to make an application and to be interviewed. This person should know your household’s situation well enough to give any information needed to determine your eligibility for food stamps. You are still responsible for the information that anyone acting as your authorized representative gives, including any information that may be incorrect. If you want to appoint someone for this, write his/her name here:_______________________________________________________________________
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IMPORTANT INFORMATION ABOUT FOOD STAMPS
The information provided by the applicant in connection with the application for food stamp benefits will be subject to verification by Federal, State, and local officials to determine if such information is true. If any information is found to be untrue or incorrect, food stamps may be denied to the applicant and the applicant may be subject to criminal prosecution for knowingly providing incorrect information.
SOCIAL SECURITY NUMBERS
The submission of the Social Security Number (SSN) for each household member is mandatory under the Food Stamp Act of 1977 as amended by P. L. 96-58 (7 U. S. C. 2025F). The Social Security Number will be used in the administration of the Food Stamp Program to check the identity of household members to prevent duplicate participation and to facilitate making changes. Your SSN will also be used in computer matching and program reviews or audits to make sure your household is eligible for food stamps. This may result in criminal or civil administrative claims against persons fraudulently participating in the Food Stamp Program.
If you or anyone you are applying for does not provide a Social Security Number, the persons who do not provide a Social Security Number will not be eligible for benefits. If you or anyone you are applying for does not have a Social Security Number we will refer you to the Social Security Office to apply for one.
VERIFICATION
The information given on this application will be checked by using the State Income and Eligibility Verification System, other computer matching systems, program reviews and audits. This includes such information as receipt of Social Security benefits, Unemployment benefits, unearned income such as interest and dividends, and wages from employment. When
discrepancies are found, verification of this information may be obtained through contact with a third party such as employers, claims representatives or financial institutions. This information may affect your eligibility and level of benefits.
CITIZENSHIP AND IMMIGRATION STATUS
Only U.S. citizens and eligible immigrants may participate in the Food Stamp Program. Any household member who is not a citizen or permanent resident alien, may be left out of your food stamp household. The Food Assistance Division will check with the U.S. Citizenship and Immigration Service (USCIS) on all non-citizens you include on your application. We will not check on the non-citizens you do not include in your food stamp household but their income and resources may count in determining the eligibility and allotment for the other people included in the food stamp household.
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