Ldss 4942 Form – Fill Out and Use This PDF

LDSS-4942 (Rev. 10/16)

NYSOTDA

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

AUTHORIZED REPRESENTATIVE REQUEST FORM

If you are blind or seriously visually impaired and need this application/form in an alternative format, you may request one from your social services district. For additional information regarding the types of formats available, contact your social services district or visit www.otda.ny.gov.

If you are blind or seriously visually impaired, would you like to receive

written notices in an alternative format?		____ Yes		____ No
If Yes, check the type of format you would like:			___ Large Print
___ Data CD	___ Audio CD ___ Braille, if you assert that none of the
other alternative formats will be equally effective for you.

If you require another accommodation, please contact your social services district.

Applicant/Recipient Case Number:

AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to apply for SNAP benefits for you. You can also authorize someone to use your SNAP benefit card to buy food for you. If you would like to authorize someone for either of these purposes, you must do so in writing. You may do so by printing the person’s name, address and phone number below and signing the next page of this form.

Authorized Representative Telephone Number:

I authorize the above designated individual to act as my representative until I revoke this authorization for the purposes checked below. I understand that if I do not check any of the boxes below, my authorized representative will be authorized to perform all of the functions listed next to the boxes. I understand that I may revoke all or part of this authorization at any time by notifying my local district in writing.

SNAP PENALTY WARNING – Any information you provide in connection with your application for SNAP will be subject to verification by Federal, State and local officials. If any information is incorrect, you may be denied SNAP. You may be subject to criminal prosecution if you knowingly provide incorrect information which affects eligibility or the amount of benefits. Anyone who is violating a condition of probation or parole or anyone who is fleeing to avoid prosecution, custody or confinement for a felony, and is actively being pursued by law enforcement, is not eligible to receive SNAP benefits.

LDSS-4942 (Rev. 10/16)

SNAP AUTHORIZED REPRESENTATIVE REQUEST FORM

SNAP PENALTY WARNING (continued)

If a SNAP household member is found to have committed an Intentional Program Violation (IPV), the member will not be able to get SNAP benefits for a period of:

∙12 months for the first SNAP-IPV;

∙24 months for the second SNAP-IPV;

∙24 months for the first SNAP-IPV, that is based on a court finding that the individual used or received SNAP benefits in a transaction involving the sale of a controlled substance. (Illegal drugs or certain drugs for which a doctor’s prescription is required.)

∙120 months if found to have made a fraudulent statement about who you are or where you live in order to get multiple SNAP benefits

simultaneously, unless permanently disqualified for a third IPV.

Additionally, a court may bar an individual from participating in SNAP for an additional 18 months.

Permanent disqualification of an individual for:

∙The first SNAP-IPV based on a court finding of using or receiving SNAP benefits in a transaction involving the sale of firearms, ammunition or explosives;

∙The first SNAP-IPV based on a court conviction for trafficking SNAP benefits for a combined amount of $500 or more (Trafficking includes the illegal use, transfer, acquisition, alteration or possession of SNAP authorization cards or access devices);

∙The second SNAP-IPV based on a court finding that an individual used or received SNAP benefits in a transaction involving the sale of a controlled substance. (Illegal drugs or certain drugs for which a doctor’s prescription is required);

∙All third SNAP Intentional Program Violations.

Any person convicted of a felony for knowingly using, transferring, acquiring, altering or possessing SNAP authorization cards or access devices may be fined up to $250,000, imprisoned up to 20 years or both. The individual may also be subject to prosecution under the applicable Federal and State laws.

You may be found ineligible for SNAP or found to have committed an IPV if:

∙You make a false or misleading statement, or misrepresent, conceal or withhold facts in order to qualify for benefits or receive more benefits; or

∙Purchase a product with SNAP benefits with the intent of obtaining cash by intentionally discarding the product and returning the container for the deposit amount; or

∙Commit or attempt to commit any act that constitutes a violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of SNAP benefits, authorization cards or reusable documents used as part

of the Electronic Benefit Transfer (EBT) system.

Additionally the following is not allowed and, you may be disqualified from receiving SNAP benefits and/or be subject to penalties for actions that include:

∙Using or have in your possession EBT cards that do not belong to you, without the card owner’s consent; or

∙Using SNAP benefits to buy nonfood items, such as alcohol or cigarettes, or to pay for food previously purchased on credit; or

∙Allowing someone else to use your electronic benefit transfer (EBT) card in exchange for cash, firearms, ammunition, explosives, or drugs or to purchase food for individuals who are not members of the SNAP household.

Note: Both the applicant and/or authorized representative are subject to the above penalties.

As an authorized representative I acknowledge the information set forth above.