Form Msc 0415F PDF Details

Accessing support through Self-Sufficiency Programs is a critical step for many individuals and families navigating economic challenges. The MSC 0415F form is a comprehensive application designed to streamline the process of applying for various assistance services, including food, medical, child care, and cash benefits. Applicants can obtain the form through several means: downloading it from a website, having it mailed upon request, picking it up from a local self-sufficiency office, or, for SNAP food benefits, applying online. Once obtained, the form requires detailed information about income, household composition, and other eligibility criteria. The process entails filling out the application accurately, submitting it through mail, fax, or in person, and scheduling an interview with a caseworker to review the application. For those in immediate need, the form outlines criteria for expedited food benefits. Additionally, it provides specific instructions for various assistance programs, like the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF), detailing eligibility requirements and necessary documentation. The form also highlights the importance of providing Social Security numbers and legal immigration status for benefit consideration, though exceptions are made for certain situations—emphasizing the inclusive approach to assistance. Moreover, the MSC 0415F accommodates requests for the form in alternative formats and languages, ensuring accessibility to diverse applicants. This underscores the broader objective of the self-sufficiency programs: to ensure that all eligible individuals and families, regardless of background or current economic standing, can access the support they need.

QuestionAnswer
Form NameForm Msc 0415F
Form Length20 pages
Fillable?No
Fillable fields0
Avg. time to fill out5 min
Other namesform dhs 0415f printable, apps state or us forms served de0415f pdf, dhs forms oregon, forms served de0415f

Form Preview Example

SM

SELF-SUFFICIENCY PROGRAMS

Application for Services

What do I need to do to get benefits?

1.Pick up an application (DHS 0415F). You can get an application by:

•Printing one from https://apps.state.or.us/Forms/Served/de0415F.pdf;

•Calling your local self-sufficiency office to have one mailed to you;

•Picking one up at your local self-sufficiency office; or

•For SNAP food benefits only, you may apply online by going to: https://apps.state.or.us/connect

To find the closest office, dial 211 or go online to: www.oregon.gov/DHS/Offices/Pages/index.aspx.

2.Fill out the application.

•Child care, Employment Related Day Care (ERDC): For low income working families. More information can be found at the following website: http://www.oregon.gov/dhs/assistance/CHILD-CARE

To apply, fill out pages 1–5. Read pages 13–16 and sign page 16.

•Food benefits, Supplemental Nutrition Assistance Program (SNAP): Help to buy food. To apply, fill out pages 1–7. Read pages 12–16 and sign page 16. You can submit page 1 with only your name, address and signature to file a request for food benefits and start the application process. If you are eligible for food benefits, benefits will begin from this filing date.

•Medical assistance: To apply for health coverage, go online to: OregonHealthCare.gov or

call 1-800-699-9075 or 711 (TTY) Monday through Friday, 7 a.m. to 6 p.m. to request an application.

•Cash assistance, Temporary Assistance for Needy Families (TANF): For very low income families with dependent children, those who are in the late stages of pregnancy, or Refugee Cash Assistance: For refugees who are within their eight months in the United States. To apply for cash assistance, fill out the entire application.

3.Turn in the application. You can mail, fax or drop the application off at your local

self-sufficiency office (you can make a date-stamped copy for your records). If you are a newly arrived

refugee within 8 months of U.S. arrival and reside in Multnomah, Washington or Clackamas counties, turn in your application at the local refugee resettlement office. You will be served in the Refugee Case

Service Project (RCSP).

4.Make an appointment for an interview with a caseworker. We may go over the application with you in an interview. It is important to make it to your interview. If you need to reschedule, please let us know.

What if I need food benefits right away?

We may be able to give you food benefits within seven days if you qualify.

To qualify, one of the following must be true:

•Your income is less than $150 per month and your cash and bank accounts total less than $100;

•The total of your monthly income, cash and money in the bank is less than your total housing and utility costs for a month; or

•You are a migrant or seasonal farm worker and have very little money.

You must be able to show proof of your identity.

Continued on next page

DHS 0415F (07/2020), Can use prior versions

What do I need to bring to the interview?

You may need to bring:

1.Your identification;

2.Proof of your income;

3.Social Security numbers for everyone in your household who wants benefits; and

4.Proof of your legal immigration status for those persons who want benefits.

Please let us know if you need help getting the information and we may be able to help you.

When will my benefits start if I qualify?

•Cash benefits usually start based on the date we get the application. The amount of your benefits is also based upon this date.

•Food benefits usually start based on the date we get the application. The amount of your benefits is also based upon this date.

•Child care benefits start on the first day of the month in which the request is made if you qualify. However, the effective date for payment cannot be earlier than the date your provider of choice is in approved listing status with the Department of Human Services (DHS).

Social Security numbers (SSN) and citizenship.

If you are applying for someone else and not for yourself, we do not need your SSN or citizenship status.

People who are not U.S. citizens may still qualify for certain benefits. If you do not have an SSN yourself, other family members who do have SSNs may still qualify. Page 13 tells why DHS collects each SSN and what each SSN is used for.

Social Security numbers are not required for Refugee Cash Assistance.

You can get this document in other languages, large print, braille or a format you prefer. To request this form in another format or language, contact your local office or 711 for TTY. For a list of local offices please see www.oregon.gov/DHS/Offices/Pages/index.aspx.

DHS 0415F (07/2020), Can use prior versions

 

Branch:

Case number:

Worker ID:

Case name:

 

Agency

 

 

 

 

 

use

 

 

 

 

 

Expedited service? Appointment date/time: Receptionist ID:

MA notice

only:

 

 

 

 

 

Yes No

Please ask if you need help filling out this form.

Date of request:

Filing date:

Language I speak: ___________________________________________________________________

Let us know if you need: An interpreter A sign language interpreter

Written materials translated (what language): ____________________________________________

Materials in: Braille

Large print

Audio tape

Computer disk Oral presentation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tell us about you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name

 

 

(last, first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Maiden(or other names used)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security number

 

 

 

Phone or message number (check one) Email

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address (if different)

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

ZIP code

 

 

 

 

 

 

 

 

 

Signature of applicant (filing date for food only). All programs, sign page 16 to complete request.

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To complete your application for food benefits, fill in pages 1–7 and sign page 16.

1.

I am applying for: Child care Domestic violence help Food

 

Cash for families

Refugee Cash Assistance (RCA)

2.

Do you plan to stay in Oregon?

Yes No

3.Has anyone you are applying for received services from another state within the last 30 days?

Yes No If yes, where?__________________________ Date last received: ______________

4.

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

Yes

No

5.

Do you usually buy food and eat with everyone you live with?

Yes

No

 

If no, who buys their food separately?___________________________________________________

Do you have an immediate need?

1.Please answer the following for you and anyone you are applying for:

a)

Does anyone have income of $150 or more a month?

Yes

No

b)

Does anyone have $100 or more in cash, checking or savings accounts?

Yes

No

c)Are your monthly rent and utility payments more than your monthly income,

 

cash and money in your bank accounts?

Yes

No

 

d) Is anyone a migrant or seasonal farm worker?

Yes

No

 

If yes, does anyone have $100 or more in cash, checking or savings?

Yes

No

 

Will you get income of $25 or more in the next 10 days?

Yes

No

2.

Do you need a place to live?

Yes

No

3.

Do you have an eviction or foreclosure notice?

Yes

No

4.

Do you have or expect to get a utility shut-off notice?

Yes

No

5.

Do you need to get away from an abusive or unsafe situation?

Yes

No

6.

Does your partner make you afraid by threatening, yelling or physically hurting you?

Yes

No

1DHS 0415F (07/2020), Can use prior versions

1. Tell us about the people in your household

Please complete below for everyone in your household. You

Please answer below for those who want benefits.

 

 

 

 

 

 

 

can choose not to give your ethnic group and racial heritage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

information. It will not affect your eligibility. This information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

helps us follow Title VI of the Civil Rights Act of 1964.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

 

Single Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

 

Yes

No

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

 

White

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

 

Single Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

 

White

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Is anyone in your household pregnant?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes No

 

If yes, who? _________________________________________ Due date: __________________

3. Is anyone in the military, a veteran or a spouse/dependent of someone who is?

 

 

 

Yes No

4.For cash benefits, would you like to talk with someone about concerns you have with your

children? (Such as acting out, school problems, medical needs or finding child care.)

Yes No

5.List anyone who wants benefits and is a high school, college, trade or vocational student.

 

 

Student 1

 

Student 2

Name of student:

 

 

 

 

Name of school/training program:

 

 

 

 

Type of student:

High school GED Graduate

High school GED Graduate

 

Vocational

Undergraduate

Vocational

Undergraduate

 

 

 

 

 

Credits:

 

 

 

 

Student last term, this term or both?

Last term

This term Both

Last term

This term Both

 

 

 

 

 

Apply for or get financial aid?

Apply

Getting

Apply

Getting

2DHS 0415F (07/2020), Can use prior versions

Additional space for other people living with you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please complete below for everyone in your household. You

Please answer below for those who want benefits.

 

 

 

 

 

 

 

can choose not to give your ethnic group and racial heritage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

information. It will not affect your eligibility. This information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

helps us follow Title VI of the Civil Rights Act of 1964.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash

Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

Single

Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

 

 

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

Yes

No

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

White

 

 

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

 

 

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

 

 

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash

Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

Single

Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

 

 

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

Yes

No

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

White

 

 

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

 

 

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

 

 

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash

Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

Single

Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

 

 

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

Yes

No

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

White

 

 

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

 

 

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

 

 

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* If you need additional space, see the back of this sheet.

DHS 0415F (07/2020), Can use prior versions

Additional space for other people living with you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please complete below for everyone in your household. You

Please answer below for those who want benefits.

 

 

 

 

 

 

 

can choose not to give your ethnic group and racial heritage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

information. It will not affect your eligibility. This information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

helps us follow Title VI of the Civil Rights Act of 1964.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash

Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

Single

Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

 

 

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

Yes

No

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

White

 

 

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

 

 

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

 

 

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash

Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

Single

Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

 

 

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

Yes

No

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

White

 

 

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

 

 

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

 

 

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check below the benefits for this person:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

None

Food

Child care

 

 

 

 

 

 

 

 

 

 

 

 

 

Full name (last,

first, middle initial)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cash

Domestic violence help

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a disability?

Yes

 

No

 

Date of birth (mm/dd/yyyy)

Relationship (mother, son)

For food and cash benefits, does this person have an

Sex:

Male

Female

 

 

 

 

outstanding arrest warrant?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marital status:

Married

 

Single

Widowed

Last grade completed: _____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Divorced

Married, but separated

 

 

Social Security number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ethnicity: Hispanic/Latino

 

Not Hispanic/Latino

U.S. citizen:

 

 

 

 

 

 

 

 

Yes

No

 

 

If no complete the information below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Racial heritage: Asian

 

White

 

 

Alien Resident number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Native Hawaiian/Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of birth: _____________________________________

 

American Indian/Alaska Native

 

 

 

 

 

 

(City/state or country)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Black or African American

 

 

Date of U.S. entry: ______ Date of Oregon entry: _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*If you need additional space, please make copies or ask for the DHS 0415X.

DHS 0415F (07/2020), Can use prior versions

Agency use only

Branch: Case number:

Worker ID:

Case name:

Tell us about your household’s work and income.

Please answer the following for you and anyone you are applying for.

 

1. Does anyone have or expect to get any money?

Yes No

If yes, please answer questions 2 and 3. We will need proof of income for the last 30 days.

2.Money from work. Please tell us about wages, salaries and commissions for this month from jobs and self employment.

a.Self-employment means you are being paid for doing work, but you don’t have a regular employer other than yourself who gives you a paycheck and takes out taxes. Perhaps you have your own company with a separate bank account, or perhaps you do odd jobs for people who pay you in cash.

We need to know about money that has already been paid or that will be paid this month to anyone in your home who is related to you or your children. Use gross income (totals before taxes and deductions).

Does anyone in your home get money for working?

Yes No

If yes, please fill out this page.

 

 

Earned income

Job 1

Job 2

Job 3

Person working:

 

 

 

Employer’s name:

 

 

 

Employer’s phone:

 

 

 

Position title:

 

 

 

Hourly pay:

$

$

$

Hours (per week):

 

 

 

How often paid

 

 

 

(weekly, monthly):

 

 

 

Other pay:

Tips Overtime

Tips Overtime

Tips Overtime

Bonus Commission Bonus Commission Bonus Commission

 

Shift Diff. Other

Shift Diff. Other

Shift Diff. Other

Is income from

Yes

No

Yes

No

Yes

No

self-employment?

 

 

 

 

 

 

Do you have any

Yes

No

Yes

No

Yes

No

costs associated with

 

 

 

 

 

 

this business?

 

 

 

 

 

 

Income this month:

$

 

$

 

$

 

Income last month:

$

 

$

 

$

 

*If any income has recently changed or will be changing, please let us know why:

 

 

 

 

 

 

 

 

New amount:

$

 

$

 

$

 

 

 

 

 

 

 

 

Date of the change:

 

 

 

 

 

 

 

 

 

 

 

b. Has anyone lost a job or quit a job within the last 30 days?

 

Yes No

If yes, who? _____________________________________ Date of last day worked: ____________

Reason for job loss? _______________________________________________________________

Date of last pay: ___________________________________________________________________

3. Does anyone in your household work as a volunteer?Yes No If yes, name of volunteer: _________________________________ Hours per week? ____________

3DHS 0415F (07/2020), Can use prior versions

4.Please list any unearned income.

Does anyone in your home get money from places other than work?Yes No

If yes, tell us about this month’s income for anyone in your home who is related to you or your children (including expected children).

►You must send proof. Tell us about money, including:

• Loans repaid to you

• Disability benefits

• Dividends or interest

• Cash assistance

• Child or spousal support

on investments

• Retirement pension

• Guardian or foster

• Worker’s compensation

• Supplemental Security

care payments

• Tribal payments

Income (SSI)

 

• Social Security benefits

• Unemployment compensation

• Educational income (such

• Veterans benefits

• Rent paid to you

as financial aid)

• Other:

 

 

 

 

 

 

 

 

 

Unearned income

1

 

 

2

 

3

Person receiving

 

 

 

 

 

 

the money:

 

 

 

 

 

 

Source/type:

 

 

 

 

 

 

Expected to continue:

Yes No

 

 

Yes No

 

Yes No

Amount received:

$

 

 

$

 

$

How often received

 

 

 

 

 

 

(weekly, monthly):

 

 

 

 

 

 

Unearned income

 

 

 

 

 

 

this month:

$

 

 

$

 

$

Unearned income

 

 

 

 

 

 

last month:

$

 

 

$

 

$

Tell us about your household’s expenses

Dependent care expenses

1. Does anyone pay for child care or care for an adult with a disability?

Yes No

If yes, who pays? ____________________________ $ ______________ a month.

 

2.If you get child care benefits, do you pay for child care costs in addition to your copay? Yes No If yes, enter monthly amount. $ ______________ a month.

Tell us about your child care needs

1.Please list information about your work schedule.

Parent 1:

Usual work hours: From ________________ a.m. / p.m. To ________________a.m. / p.m.

Usual work days: Mon. Tue. Wed. Thu. Fri. Sat. Sun.

Other schedule (describe): ______________________________________________________

Note: If your work schedule varies, give information on the days and times you have worked.

Parent 2 or spouse if in household or additional employment:

Usual work hours: From ________________ a.m. / p.m. To ________________a.m. / p.m.

Usual work days: Mon. Tue. Wed. Thu. Fri. Sat. Sun.

Other schedule (describe): ______________________________________________________

2.Please list information about your child care provider.

Care provider: __________________________ Phone number:

Second provider: _______________________ Phone number:

If you need help choosing a provider, contact: 211Info by dialing 211, text the keyword “children” to 898211, email children@211.org or visit 211Info.org.

4DHS 0415F (07/2020), Can use prior versions

3. Are you homeless?

Yes No

Homeless could mean living in an emergency shelter, shared housing with another family because of job loss or loss of your housing, in a motel, car, park, public place, campsite or other similar place.

4.Do you need child care for a foster child?

5.Is any caretaker or parent an active full-time member of the military, military reserve unit or National Guard?

6.Do you have shared custody for any of the children needing care?

7.Do you need child care while you are working and attending classes?

Yes No

Yes No

Yes No

Yes No

Class hours can only be approved if you are working and attending a school that is eligible for federal financial aid. You must give a copy of your school registration and current class schedule.

8.For child care needs, are your children’s immunization (shot) records up-to-date? Yes No

If no, contact your doctor or local health department for more information. You must agree to meet state immunization guidelines or exemptions to get child care benefits.

 

9. Is anyone in the household an active military member?

 

 

 

 

 

 

 

Yes No

 

 

If yes, who: _________________

Full time active military National Guard or Reserve Unit

 

10. Do your family’s assets exceed one million dollars ($1,000,000)?

 

 

 

 

 

 

 

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you are applying for child care only, please skip to page 13,

 

 

 

 

 

 

 

 

read pages 13─16 and sign page 16.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

To apply for food and cash please continue.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Housing expenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Do you or anyone in your household pay for housing?

 

 

 

 

 

 

Yes

No

 

 

If yes, please complete below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rent

Mortgage What is the total rent/mortgage? ___________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How much do you pay of the

Fire/hazard insurance,

 

Property tax, if separate:

 

 

 

total amount?

if separate:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$________________ per

$________________ per

 

$________________ per

 

 

 

Week

Month Year

Week Month Year

 

Week Month

Year

 

 

 

Person or company you pay rent/mortgage to:

May we contact this person/company? Yes No

 

 

 

 

 

 

 

If yes, their phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2. Do you expect to pay the same amount for housing next month?

 

 

 

 

 

 

Yes

No

 

3. Do you get help to pay for housing?

 

 

 

 

 

 

Yes

No

 

 

If yes, please complete below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Who pays

 

 

Paid to

 

 

 

 

 

 

Amount paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.If you have reported that you have no income, how are you paying your housing expenses?

_________________________________________________________________________________

_________________________________________________________________________________

5DHS 0415F (07/2020), Can use prior versions

Utility expenses

1.Do you pay to heat/cool your home?

a)Is the heat/cool expense included in the rent/mortgage?

2.What other kind of utilities do you pay?

Water/sewer Garbage Electric Gas Phone

Yes No

Yes No

Other: __________________

Court-ordered child support expenses

1.Does anyone in your home pay court-ordered child support to someone outside your home?

If yes, please complete below.

 

Yes No

 

 

 

Person who pays support

For which child

Amount paid

 

 

 

 

 

$

 

 

 

Medical expenses

1. Is anyone you are applying for 60 or older or a person with a SSI/SSD disability?

Yes No

If yes, list any out-of-pocket medical expenses, including medical insurance expenses.

 

 

Person with the out-of-pocket expenses

Amount paid

$ __________________ a month

Tell us about your household’s resources

1.Do you, or anyone you are applying for own or have their name on any of the following?

a)Checking, savings, credit union accounts, IRA, 401K.

b)Stocks, bonds, money market accounts, CDs, trust funds.

c)Cash on hand or other: __________________________________________

If yes to any of the above, please complete below.

Yes No

Yes No

Yes No

Type

Name/location of bank

Current balance/value

Belongs to

2.

Is anyone buying, or an owner of, real estate, land or buildings you are not living on?

Yes

No

3.

Does anyone have any items of value? (Examples: car, truck, boat, etc.)

Yes

No

4.Have you or a member of your family been injured in an accident that you are

making a claim for money?

Yes No

If yes, what is the date of the injury? ____________________

 

If yes, please complete form MSC 0451, Vehicle Related Personal Injury or

 

MSC 0451NV, Non-Vehicle Related Personal Injury.

 

Agency use only

FUA

LUA

IUA

TUA

COS

6DHS 0415F (07/2020), Can use prior versions

Tell us about your out of state food benefits

1.Oregon has a 3 month time limit for SNAP benefits. This time limit is for most adults age 18–49 who are able to work and have no children in the home. They can get SNAP for only 3 months in a 3-year period. The months you received SNAP in another state may be counted towards the Oregon Time Limit.

Did you or anyone you are applying for get SNAP in another state since January 1, 2019?

If yes, please complete below.

Yes No

Person

State

If you are applying for food and child care benefits only, skip to page 12. Read pages 12–16 and sign page 16.

To apply for cash please continue.

Tell us about your time on TANF

1.Oregon has a 60 month time limit for Temporary Assistance for Needy Families (TANF). Months you received TANF in another state or from a tribal TANF program may be counted towards the Oregon Time Limit.

Did you or anyone you are applying for get TANF in another state or from a

 

tribal TANF program since 1996?

Yes No

If yes, please complete below.

 

Person

State or tribe

Months on TANF

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DHS 0415F (07/2020), Can use prior versions

Tell us about your tribal membership

1.Is anyone you are applying for a member of one of Oregon’s nine federally recognized tribes?

If yes, which tribe(s):

Yes No

Burns Paiute Tribe

Klamath Tribes

Confederated Tribes of the Coos, Lower

Confederated Tribes of Siletz

Umpqua and Siuslaw Indians

Confederated Tribes of the Umatilla

 

Coquille Indian Tribe

Indian Reservation

Cow Creek Band of Umpqua Indians

Confederated Tribes of Warm Springs

Confederated Tribes of Grand Ronde

2.Is anyone you are applying for a member of any other federally recognized tribe?

Person

Tribe

Tell us about the community in which you live

1.Do you live on one of the following?

Indian ReservationYes No If yes, which? ________________________________________________________________

Dependent Indian communityYes No If yes, which? ________________________________________________________________

Indian allotmentYes No If yes, which? ________________________________________________________________

Tell us about your household’s disabilities

1.Does anyone you are applying for have a disability that will last more than 12 months?

Yes No If yes, who? _____________________________________________________

2.Has anyone in your home applied or considered applying for disability benefits through the

Social Security Administration?

 

Yes No

If yes, was the application: Approved

Denied

Pending

8DHS 0415F (07/2020), Can use prior versions

Tell us about any parents not living in your household

Important – By applying for services, you are letting us establish paternity (legally name the child’s father) and pursue child support from parents not living in your household unless you think this parent might harm you or the child.

1.

If anyone in your household is pregnant, is the father living in the house?

Yes

No

2.

Do any of the children’s parents live outside the child’s home?

Yes

No

If yes, please list parent(s) even if the child has not been born yet. Also, list your parents if you are under 18 and not living with them. Please give as much information as possible.

a) Absent parent 1

Name (first, middle initial, last):

 

 

This is my: spouse or ex-spouse

child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

partner or ex-partner

step child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other: _________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex: Female

 

Date of birth: (month, day, year):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Social Security number (if you know it):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date this parent stopped living with child (month, day, year):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

parents.

Number of hours each week this parent spends with the child(ren):

How many of these hours are spent in the child(ren)’s home?

If this is an absent father, has paternity been legally established? Yes No I don’t know

Do you think this parent might hurt you or the child if we try to find out

about paternity or health insurance? Yes No

List this parent’s child(ren) whom you have written about on this application.

of this page for additional

b) Absent parent 2

Name (first, middle initial, last):

 

 

This is my: spouse or ex-spouse

child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

partner or ex-partner

step child

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

other: _________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sex: Female

 

Date of birth: (month, day, year):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Social Security number (if you know it):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

State:

 

ZIP code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date this parent stopped living with child (month, day, year):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Please make copies

Number of hours each week this parent spends with the child(ren):

How many of these hours are spent in the child(ren)’s home?

If this is an absent father, has paternity been legally established? Yes No I don’t know

Do you think this parent might hurt you or the child if we try to find out

about paternity or health insurance? Yes No

List this parent’s child(ren) whom you have written about on this application.

9DHS 0415F (07/2020), Can use prior versions

Information about cash benefits

Cash benefits is also known as Temporary Assistance for Needy Families (TANF) or Refugee Cash Assistance (RCA). Cash benefits are for meeting a family’s basic needs like food, clothing,

shelter and utilities.

Most cash benefits in Oregon are issued via an Electronic Benefit Transfer (EBT) card. This is known as an Oregon Trail Card. Cash assistance benefits may not be withdrawn or spent using an

Oregon Trail Card in any:

•Liquor store. This includes retail businesses that only or mostly sell beer or wine.

•Casino, gambling casino or gaming establishment.

•Retail business that provides adult entertainment in which performers disrobe or perform in an unclothed state. This includes adult video stores that only or mostly sell or feature adult-oriented videos or movies.

•Marijuana dispensary.

These restrictions apply:

•In Oregon.

•Outside Oregon.

•On tribal lands.

These restrictions also apply to cash benefits in a private bank account.

If you are applying for cash for families:

“Assigning” payments and the state’s right to place a lien on any injury claims

To qualify for assistance, you must let DHS have money you or other members of your family, including any child born in the future, receive or have the right to receive from:

•Other people, businesses or other sources who are or may be liable to cover costs related to an injury, such as a car accident.

There is a limit on how much DHS can take. It cannot take more than the amount it has paid in cash benefits for you and your family.

By signing this form, you agree to help DHS find and obtain these payments. If you or

a family member receiving benefits is in an accident or injured by another person or business

you must tell DHS within 10 days. The state may place a lien on money from such claims.

If you are applying for cash for families:

What you need to know about “assigning support”

“Support” means money you get for you or your children, like alimony or child support.

When you get cash benefits, you are “assigning” the state the right to keep the support you or anyone in your family get from another person. The money goes to repay the state for the cash you get.

NOTE: This does not apply during any period of time you receive cash benefits from JOBS Plus, the State Family Pre-SSI/SSDI Program (SFPSS) or the Post-TANF Program; when you are a two-parent family; or when you are receiving Employment Payments.

This means that while you are getting cash benefits:

The state will keep part of the support payments (for both current and past-due payments) received for

you and members of your family. The state will not keep all your child support. The state will send you $50 of current child support received per child per month up to $200 per family per month. The state will not count this money as income when figuring your eligibility and benefits.

10

DHS 0415F (07/2020), Can use prior versions

NOTE: If you are an applicant for cash assistance and you are in SFPSS or JOBS Plus, or you are a

two-parent family, the state will generally not keep any of your child support. When determining your eligibility and benefits, $50 (per child per month up to $200 per family per month) of current child support

received will not be counted towards your monthly income.

When you leave the cash program:

•Current support payments will go to you;

•Any past-due payments for months you were on cash assistance will be kept by the state;

•Any past-due payments for months you were not on cash assistance may go to you.

Working with Child Support

While you are getting cash benefits, you will need to work with the state’s Child Support Program.

Important: You do not have to work with child support if you think it would mean danger for you or your children.

Working with child support can mean:

•Helping to locate your child’s other parent (unless you think it would mean danger for you or your children);

•Legally naming the child’s father (establishing paternity);

•Getting a support order.

Information about TANF program penalties

If you knowingly do the following to get Temporary Assistance for Needy Families (TANF) and/or Refugee Cash Assistance (RCA) you will get a penalty:

•Give false information about yourself or someone you are applying for;

•Hide information about yourself or someone you are applying for;

•Give false information about where you live.

The first time you do any of these things you will not get TANF for 12 months. The second time you will not get TANF for 24 months. The third time you will not be able to get TANF at all. You will also have to pay back all the TANF you were not supposed to get. Your food benefits will not go up even though you

get less in TANF if you told us something that was not true or did not tell us something that was true.

11

DHS 0415F (07/2020), Can use prior versions

Information about Supplemental Nutrition Assistance Program (SNAP) penalties

If you do the following...

You will lose food benefits...

•

Hide information or make false statements;

• 12 months for the first offense;

•

Use Electronic Benefits Transfer (EBT) cards that

• 24 months for the second offense;

 

belong to someone else;

• Permanently for the third offense.

•Use food benefits to buy alcohol or tobacco;

•Trade or sell benefits or EBT cards;

•Dump containers only for the cash redemption value;

•Resell food bought with food benefits for cash.

•

Trade food benefits for controlled substances

•

24 months for the first offense;

 

such as drugs.

•

Permanently for the second offense.

•

Trade food benefits for firearms, ammunition

•

Permanently.

 

or explosives.

 

 

• Trade, buy or sell food benefits of $500 or more.

•

Permanently.

• Give false information about who you are or where

•

10 years for each offense.

 

you live so you can get extra food benefits.

 

 

You can also be fined up to $250,000 or put in prison for up to 20 years or both,

for doing these things. You may also be charged under other federal laws.

If you knowingly do the following...

You may be...

•

Use EBT cards that are not yours;

•

Guilty of a felony or misdemeanor;

•

Transfer your EBT cards to other people;

•

Fined;

•

Acquire or possess EBT cards that are not yours.

•

Put in prison;

 

 

•

Ineligible for food benefits for a

 

 

 

period of time.

12

DHS 0415F (07/2020), Can use prior versions

Information about all programs

Our non discrimination policy

The Department of Human Services (DHS) does not discriminate against anyone. This means that

DHS will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs1, disability or sexual orientation2.

You may file a complaint if you believe DHS treated you differently for any of these reasons.

To file a complaint with the state, you can call the Governor’s Advocacy Office at 1-800-442-5238 (TTY 711) or write to their office at:

Governor’s Advocacy Office

500 Summer Street NE, E17

Salem, OR 97301

Email: DHS.info@state.or.us

“Equal opportunity is the law!”

The United States Department of Agriculture (USDA) and the United States Health and Human

Services (HHS) are equal opportunity providers and employers. Auxiliary aids and services are

available upon request to individuals with disabilities.

To file a complaint with USDA and HHS, please read the “Client Discrimination Complaint Information” form (DHS 9001). You can find this form in the “Information and Referral Packet” (DHS 6609).

Why we need your Social Security number

Social Security numbers (SSN) – Federal laws (42 USC 1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920 and 42 CFR 457.340(b)) and DHS rule (OAR 461-120-0210) require anyone applying for cash or food benefits to give DHS their SSN. If you provide an

SSN, it can speed up the application process. If someone doesn’t have an SSN, visit www.ssa.gov.

a.DHS will use your SSN to help decide if you are eligible for benefits. Your SSN will be used

to verify your income, other assets and to match with other state and federal records such as IRS, Medicaid, child support, Social Security, Unemployment benefits and other public assistance programs.

b.DHS may use your SSN to prepare aggregate information or reports requested by funding sources for the program you apply for or receive benefits from.

c.DHS may use or disclose your SSN:

•If it is needed to operate the program you apply for or receive benefits from;

•To conduct quality assessment and improvement activities;

•To verify the correct amount of payments and recover overpaid benefits;

•To make sure nobody gets benefits in more than one household.

Social Security numbers not required for Refugee Cash Assistance.

1SNAP clients are protected against political belief discrimination.

2Sexual orientation is protected by the State of Oregon, but not federal laws.

13

DHS 0415F (07/2020), Can use prior versions

Information about your rights and responsibilities

By signing below I agree that:

•I understand that if I am in the Refugee Case Services Project (RCSP), the term “DHS” includes

DHS contractors.

•I have given DHS true, correct and complete information;

•I understand that making false statements or hiding information may mean state and federal penalties,

as well as having to repay any overpayment (this includes authorized representatives for cash benefits);

•DHS can review my case. This could include coming to my home;

•I declare I am a resident of Oregon;

•I will report changes in information I give DHS when DHS requires me to;

•I have given true citizenship information about myself and the others I am applying for;

•I know that DHS will check the immigration status of people who apply for or get benefits.

I know the information DHS gets from the United States Citizenship and Immigration

Service (USCIS) could affect who gets benefits. DHS will not contact USCIS for anyone NOT seeking benefits;

•I authorize release of my child support records from the Department of Justice (DOJ), Division of Child Support (DCS) to DHS;

•The adults under age 60 on this form who apply for food benefits (SNAP) will register for the state’s employment program. If I add people to the program in the future, they will also register;

•If I do not give DHS the Social Security number for someone who wants benefits, that person may not be able to get them;

•DHS will not use costs for shelter, medical, child care and court ordered child support to figure my benefits if I do not report them;

•DHS will request and use the Income and Eligibility Verification System (IEVS) data and this information may affect eligibility and benefit levels. This includes verification through third party contacts when

discrepancies in information are found. Third party contacts may include matching with bank, income and unemployment-benefit records

•I understand that DHS may use or disclose my SSN and the SSN of each person I apply for, for the purposes listed on page 13;

•DHS may give the information on this application to:

•Federal and state agencies who are doing reviews;

•Law-enforcement officials, to help them arrest someone who is fleeing from the law;

•Federal and state agencies and private collection agencies, if I have to repay benefits to DHS.

•DHS may use this information to administer other public assistance programs that I receive from DHS.

•I understand DHS may monitor where I use TANF cash benefits through my Oregon Trail Card or withdraw TANF cash benefits using my Oregon Trail Card. I also understand that I may not use my Oregon Trail Card to spend TANF cash benefits or withdraw TANF cash benefits at any:

•Liquor store. This includes retail businesses that only or mostly sell beer or wine.

•Casino, gambling casino or gaming establishment.

•Retail business that provides adult entertainment in which performers disrobe or perform in an unclothed state. This includes adult video stores that only or mostly sell or feature adult-oriented videos or movies.

•Marijuana dispensary.

14

DHS 0415F (07/2020), Can use prior versions

These restrictions apply:

•In Oregon.

•Outside Oregon.

•On tribal lands.

These restrictions also apply to cash benefits in a private bank account.

•I understand the person who signs this form must repay benefits to DHS when there is an overpayment in my case. Other individuals that are required to apply with me and an authorized representative could also be liable for overpayments.

•I understand I can request a copy of my application in paper or electronic form.

•People applying for cash benefits — I am giving the state the right to keep support payments, as explained on pages 10–11. I understand I do not have to work with the child support program if it would mean danger for me or my children.

•People applying for cash and food benefits — I understand I cannot get food benefits from the

Tribal Food Distribution program and the SNAP program at the same time. I also cannot get Tribal

TANF from a tribe and TANF cash benefits from DHS at the same time.

•I state under penalty for making a false statement that the statements made about persons in my home, including statements about citizenship, income, resources, property and all other information I have given DHS and their contractors are true and correct.

•I will give proof of the information I have given DHS. I will also let DHS contact other people and agencies to get proof.

•People applying for Employment Related Day Care — I understand that any child care benefits I receive will be reported to the Oregon Department of Revenue, which may affect my tax debt and/or potential return.

•I understand that as a parent I may choose to have my child care provider come to my home to provide care. If a provider does care in my home, I may be considered that person’s employer under federal law. As an employer, I would be required to meet federal minimum wage and overtime rates.

BOLI Technical Assistance for Employers Program is available:

•On the web: https://www.oregon.gov/boli/ta/Pages/index.aspx;

•Email: bolita@boli.state.or.us; and

•Phone: 971-673-0824

The federal minimum wage provisions are contained in the Fair Labor Standards Act (FLSA). For more information about the fair labor act and to determine if you are an employer:

•Visit: https://www.dol.gov/compliance/guide/minwage.htm

•Call the toll-free information and helpline: 1-866-4USWAGE (1-866-487-9243).

Please continue to page 16, read and sign.

15

DHS 0415F (07/2020), Can use prior versions

Declaration and signature

I have read and understand my rights and responsibilities as explained above and in the DHS 0415R form, and I have a copy of the form.

Full legal signature of applicant/authorized representative

 

Date

 

 

 

 

Full legal signature of other parent, spouse or other adult

 

Date

 

 

 

 

 

 

 

 

Staff witness signature

 

Date

What is the best way for us to contact you?

Phone: _________________________________________________________________________

Email: _________________________________________________________________________

Other: _________________________________________________________________________

What days and times are best for us to contact you? ________________________________________

Voter registration

If you are not registered to vote where you live now, would you like to apply to vote today?

Yes No

Applying to register to vote or declining to register will not affect the amount of assistance

you will be provided by this agency.

16

DHS 0415F (07/2020), Can use prior versions

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