Form Dhr Fsd 2198 PDF Details

Understanding the intricacies of the Dhr Fsd 2198 form is paramount for residents of Alabama who are of elder age or live in households where all members are 60 years or older and do not receive earnings from work. The form represents a straightforward avenue for applying for Food Assistance, offering an essential lifeline in ensuring nutritional needs are met. The completion process has been simplified, requiring only basic personal information and a signature to initiate, yet it encompasses wide-ranging aspects from expedited service eligibility to detailed financial, household, and personal information disclosure. Applicants are encouraged to disclose all sources of income, resources, shelter, and utility expenses to accurately assess their eligibility. Additionally, the form attends to special considerations like the appointment of an authorized representative, acknowledgment of legal obligations, and recording of out-of-pocket medical or child support expenses, ensuring a comprehensive evaluation can be made. Through its design, the state of Alabama, in compliance with federal law, commits to a discrimination-free assistance process, emphasizing its commitment to equality and access. This form not only facilitates food assistance but also underscores a societal promise to uphold dignity and support for its elderly populations.

QuestionAnswer
Form NameForm Dhr Fsd 2198
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesaesap, elderly simplified application project, ALABAMA, Washington

Form Preview Example

STATE OF ALABAMA

Case Number____________________

FOOD ASSISTANCE

Application Date_________________

SIMPLIFIED APPLICATION FOR THE ELDERLY

 

 

County_________________________

 

 

This application is for persons applying for Food Assistance when:

Everyone in the Food Assistance household is age 60 or older; or

All household members are age 60 or older and purchase and prepare food separately from the other people in the home; and

No Food Assistance household member receives earnings from work.

You may file this application by completing at least your name, address, and signing the form. If you need help completing this

 

application, call toll free 1-800-438-2958.

.

In accordance with Federal law and U.S. Department 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 (866) 377-8642 (TDY). USDA is an equal opportunity provider and employer.

Tell us who you are and where you live.

Your Name ______________________________________ Date of Birth _________Social Security Number_________________

(First, Middle, Last)

Mailing Address___________________________________ Street Address (if different) __________________________________

City____________________________County____________________________ State _________Zip Code ___________

Telephone or Message Number_________________________(We must be able to reach you at this number 8-5, M-F)

Expedited Services

If you are not already certified to get food assistance this month, you may be able to get food assistance within 7 days if your household has little or no money. If you want to see if you qualify for Expedited Services answer these questions.

1.

How much 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.

How much is your monthly rent/mortgage payment? $__________ Utilities other than phone

$__________________

 

AUTHORIZED REPRESENTATIVE

 

 

Do you want to give someone else permission to apply or get food assistance benefits for you?

Yes ________ No ________

Responsible person to make application for you.

Responsible person to get an EBT card to buy groceries for you.

Name________________________________________________

 

Name__________________________________________

Telephone Number___________________________________________

Telephone Number____________________________________

Tell us who lives in your Food Assistance Household. (List yourself on Line 1)

 

 

 

 

 

 

 

 

 

 

US

Relationship

SSN

First Name

M. I.

Last Name

DOB

Age Sex

Race

Hispanic Citizen

to You

 

 

 

 

 

 

 

 

Yes 

 

 

Self

 

1.

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes 

 

 

 

 

2.

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

Yes 

 

 

 

 

3.

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

Yes 

 

 

 

 

4.

 

 

 

 

 

 

 

No

 

 

 

 

List other people living in your house that are not included in your Food Assistance Household.

Name

Relationship to you

Birth date

1.

2.

3.

4.

Is anyone in your Food Assistance household a fleeing felon or probation/parole violator? Yes ____ No______

Was anyone in your Food Assistance household convicted of a felony involving drugs that occurred after August 22, 1996? Yes_________ No_________

DHR-FSD-2198

Tell us about ALL the income your Food Assistance household receives. Types of income may include Social Security benefits, SSI, pensions or retirement, Veteran’s benefits, Child Support, cash contributions, Unemployment, Railroad Retirement, dividends, interest, and any other income. *Amount before deductions.

Type of Income

Who Receives It?

*Gross Monthly Amount

Tell us about ALL your Food Assistance household resources. Types of resources include cash, checking or savings accounts, Certificates of Deposit, stocks, bonds, annuities, IRA or Keogh accounts.

Type of Resource

Resource Belongs To?

Value of the Resource

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tell us about your shelter expenses.

 

 

 

Type of Expense

Who pays this expense?

Amount Paid

How Often?

Mortgage or rent payment

 

 

 

Lot rent for mobile home

 

 

 

Property taxes on your home

 

 

 

Homeowner’s insurance

 

 

 

Tell us about your utility expenses.

 

 

 

Type of Expense

Who pays this expense?

Amount Paid

How Often?

Electricity

 

 

 

Gas

 

 

 

Water

 

 

 

Garbage/ trash

 

 

 

Telephone

 

 

 

How do you heat your home? Gas___ Electricity___ Wood___ Other__________________________________

Do you have an Air Conditioner? Yes No

Have you received Low Income Home Energy Assistance Program or do you expect to get LIHEAP?

Yes

No If yes, when? ________

Does anyone in your Food Assistance household pay out-of-pocket medical expenses?

Example: (prescriptions, doctor visits, hospital bills, health insurance, Medicare premiums,

transportation, etc.)

Yes

No If yes, list their name(s) here: __________________________

If yes, to receive credit for these expenses, list each type of medical expense, the monthly amount paid and provide proof.

Medical Expense

Monthly Amount

 

Medical Expense

Monthly Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does anyone in your Food Assistance household pay legally obligated Child Support to or for someone not

living in your home?

Yes

No If yes, list their name(s) here: __________________________

Amount Paid per month ___________, Paid to _____________________, Paid for _______________________.

Please read and sign this statement/application.

I certify that under penalty of perjury the information I or my authorized representative have provided above is true to the best of my knowledge. I give permission for the Department of Human Resources to make any necessary contacts to check my statements. I know that I could be penalized if I knowingly give false information or hide information. I certify that I received the Rights and Responsibilities Handout.

Signature of Applicant: __________________________________________ Date: _____________________________

Signature of Witness if signed with an “X”: _________________________________

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This PDF doc needs specific details; to guarantee consistency, please make sure to take note of the subsequent guidelines:

1. To begin with, when filling out the aesap alabama, beging with the page with the following blank fields:

Writing segment 1 of aesap

2. The subsequent stage is to submit these fields: If you are not already certified, AUTHORIZED REPRESENTATIVE, Do you want to give someone else, US Relationship, Yes No Yes No Yes No Yes No, and List other people living in your.

Filling in segment 2 in aesap

3. This 3rd step is usually fairly easy, Is anyone in your Food Assistance, Was anyone in your Food Assistance, and DHRFSD - these fields has to be filled out here.

Was anyone in your Food Assistance, Is anyone in your Food Assistance, and DHRFSD inside aesap

4. This part arrives with the next few empty form fields to type in your information in: Type of Income, Who Receives It, Gross Monthly Amount, Tell us about ALL your Food, Type of Resource, Resource Belongs To, Value of the Resource, Tell us about your shelter expenses, Type of Expense, Mortgage or rent payment Lot rent, Tell us about your utility expenses, Who pays this expense, Amount Paid How Often, Type of Expense, and Who pays this expense.

Completing part 4 of aesap

5. This form must be wrapped up by dealing with this part. Below there can be found a full set of fields that have to be filled out with correct information to allow your document usage to be accomplished: Electricity Gas Water Garbage, Amount Paid How Often, Do you have an Air Conditioner Yes, Have you received Low Income Home, Yes No If yes when, Does anyone in your Food, Example prescriptions doctor, Medical Expense, Monthly Amount, Medical Expense, Monthly Amount, Does anyone in your Food, living in your home Yes No If yes, and Please read and sign this.

Writing segment 5 of aesap

Be very mindful when filling out Have you received Low Income Home and Please read and sign this, since this is where a lot of people make mistakes.

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