Lacap 1A Form – Fill Out and Use This PDF

The Louisiana Combined Application Project (LaCAP) 1A form is an enrollment document used by the Louisiana Department of Children and Family Services to facilitate the application process for residents seeking assistance. It covers a wide range of information, including personal details, housing expenses, and voter registration options, aiming to streamline access to various benefits. For residents of Louisiana looking to apply or renew their assistance, filling out the LaCAP 1A form correctly is crucial for eligibility and access to benefits.

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Lacap 1A Form PDF Details

The Lacap 1A form, revised as of May 2011, serves as a crucial tool within the Louisiana Department of Children and Family Services, facilitating the enrollment process for the Louisiana Combined Application Project (LaCAP). This form, diligently designed to collect comprehensive personal and household information, plays a pivotal role in determining eligibility for food assistance. It prompts applicants to provide detailed data, ranging from basic identification details to intricate questions regarding living arrangements, ethnicity, and financial responsibilities related to housing and utilities. Additionally, it addresses the necessity for an Electronic Benefit Transfer (EBT) card and explores the option of appointing an Authorized Representative. A noteworthy element of the LaCAP 1A form is its emphasis on optional disclosure of racial and ethnic information, highlighting the department's adherence to Title VI of the Civil Rights Act of 1964 and underscoring a commitment to nondiscrimination. Moreover, it intertwines with voter registration, offering applicants an easy pathway to participate in the democratic process, thereby reinforcing the importance of civic engagement among beneficiaries. The form concludes with a stern reminder of the legal ramifications associated with the submission of false information, stressing the ethical and legal obligation to provide accurate and complete data. This blend of features ensures the LaCAP 1A form is not merely an administrative requisite but a cornerstone in the pursuit of equitable access to social services in Louisiana.

Question	Answer
Form Name	Lacap 1A Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	lacap food stamps, what is lacap, lacap, lacap benefits

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LaCAP 1A

Rev. 05/11

01/10 Issue Obsolete

OFFICE USE ONLY

Date Received

Assigned to

Is an EBT card needed? Yes No

Louisiana Department of Children and Family Services

Louisiana Combined Application Project

Enrollment Form

1. Tell Us About You

First Name	Middle Initial	Last Name

Mailing Address	Apt/Lot No.	City	State	Zip Code

Home Address (If different from	Apt/Lot No.	City	State	Zip Code
mailing)

Social Security Number	Date of Birth		Parish of Residence

You can choose not to give Ethnicity and Racial information. It will not affect your eligibility. This information helps us follow Title VI of the Civil Rights Act of 1964.

2.	Ethnicity: Hispanic/Latino	Yes	No	3. Sex	Male	Female
4.	Racial Heritage (check all that apply):
	American Indian/Alaskan Native			Native Hawaiian/Pacific Islander
	Asian			White
	Black or African American

5.Do you receive Supplemental Security Income (SSI)?

6.Do you live alone?

If no, do you buy and prepare meals separately from others in your home?

If you are certified for LaCAP, will you purchase and prepare meals separately from others?

Do you live with your spouse?

Do you live with your child who is under 22 years of age?

7. Phone number where you can be reached during the day. (	)
E-mail address, if available:

Yes

8.Do you currently receive Supplemental Nutrition Program (SNAP) benefits?

Yes

9.Do you need a new Louisiana Purchase Card?

Yes

LaCAP 1A – Page 2

In order to receive the most benefits possible, you need to tell us about your housing expenses. Failure to report any of the expenses listed will be seen as a statement by your household that you do not want to receive credit for the unreported expense.

10.Do you pay rent, mortgage, or any housing expenses other than utilities?

Yes

If yes, complete the following information about the housing expenses that you pay.

Type of Housing Expenses	Amount Paid	How Often Paid
Type of Housing Expenses	Amount Paid	(Weekly, Monthly, Etc.)
		(Weekly, Monthly, Etc.)
Rent or Mortgage

Property Tax (if not included in mortgage
payment)
Homeowners insurance (if not included in
mortgage payment)
Other Housing Expenses (other than utilities) -
Please specify:

11.Do you pay for heating and/or air conditioning separately from your rent?

12.Do you pay for utilities other than heating, air conditioning, or telephone separately from your rent?

13.Do you pay telephone expenses separately from your rent?

14.You can name someone who can apply for or obtain information about your benefits. This person would be your Authorized Representative. You can name someone, but it is not required.

Would you like to have an Authorized Representative? If Yes, tell us about your Authorized Representative.

Yes

Name of Authorized Representative		Daytime Telephone Number

Address	City	State	Zip Code

Voter Registration

Any citizen in the State of Louisiana who has met the voter registration requirements and applies for public assistance must be provided the opportunity to register to vote.

If you are not registered to vote where you live now, would you like to apply to register to vote? Yes No

If you do not check either box, we will assume that you do not want to register to vote at this time.

Please note that the information you give to the agency will remain confidential and will be used only for voter registration purposes. Applying to register or refusing to register to vote will not affect the amount of assistance or services that you may receive from the Department of Children and Family Services. If you would like help filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Contact your worker if you need help.

LaCAP 1A – Page 3

You may file a complaint if you believe that someone has interfered with your:

●right to register to vote,

●right to decline to register to vote,

●right to privacy in deciding whether to register to vote,

●privacy in applying to register to vote, or

●right to choose your own political party or other political preference.

You may file a complaint with: Louisiana Secretary of State, P.O. Box 94125, Baton Rouge, LA 70804-9125. 1-800-825-3805

Read Carefully And Sign Below

I certify under penalty of perjury that the information I have given in this application is true, complete, and correct to the best of my knowledge. I understand that I will be subject to disqualification and prosecution and will be required to repay ineligible benefits if I knowingly give false, incorrect, or incomplete information in order to obtain or try to obtain food assistance. By signing this application, I give permission for the release of information to the Department of Children and Family Services by any persons or agencies who have knowledge of my circumstances.

Your Signature (or mark)

Date Signed

If you sign with an “X” mark, ask two people to witness the mark; if applicant is blind, ask three people to witness.

Witness

Signature of Person Who Helped You Complete this Form and His or Her Relationship to You

Signature

Relationship

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This PDF will require particular information to be filled in, therefore make sure to take your time to enter what is required:

Stage no. 1 in filling out lacap benefits

2. Given that the previous segment is complete, you need to put in the needed details in Do you receive Supplemental, If no do you buy and prepare meals, Phone number where you can be, Email address if available, benefits, Do you need a new Louisiana, Yes, Yes, Yes, Yes Yes Yes, No No No, Yes, and Yes in order to go to the 3rd step.

Step number 2 of completing lacap benefits

3. Through this stage, examine LaCAP A Page In order to receive, utilities If yes complete the, Yes, Type of Housing Expenses, Amount Paid, How Often Paid, Weekly Monthly Etc, Rent or Mortgage, Property Tax if not included in, Other Housing Expenses other than, Please specify Do you pay for, rent, Do you pay for utilities other, telephone separately from your rent, and Do you pay telephone expenses. Every one of these are required to be filled out with utmost precision.

A lot of people generally make some mistakes when completing Yes in this part. Ensure that you reread everything you enter right here.

4. To move forward, this next form section will require typing in a handful of blank fields. These include If Yes tell us about your, Name of Authorized Representative, Daytime Telephone Number, Address Voter Registration Any, Zip Code, City, State, Yes, and If you do not check either box we, which are vital to carrying on with this process.

5. While you reach the finalization of the form, there are a couple extra points to do. Particularly, LaCAP A Page You may file a, Date Signed, Witness, Witness, Witness Signature of Person Who, and Relationship must be filled out.

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Lacap 1A Form – Fill Out and Use This PDF

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