Mississippi Snap Application Form – Fill Out and Use This PDF

TEMPORARY ASSISTANCE FOR NEEDY FAMILIES(TANF)

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM(SNAP) APPLICATION

Name___________________________________		SSN_______________________________ Date of Birth________________________
Residence Address________________________________________________________________Phone______________________________
			City	State	Zip
Mailing Address__________________________________________________________________2nd Phone__________________________
			City	State	Zip
Would you like to receive notices by email?	“Yes “No		If yes, email address:________________________________________________
What benefits are you applying to receive?	“TANF		“SNAP	Before we can determine your eligibility, you must be interviewed. Due to

household hardship, a face-to-face interview may be waived in favor of a telephone interview on a case-by-case basis.

TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)

To begin your application, complete the above section and sign below. We are required to take action within 30 days from the day you give us this form.

SNAP

You may file your application immediately as long as we have your name, address and the signature of a responsible household member or your authorized representative. Benefits are provided from the day we receive this form in our office, if you are determined eligible. We are required to verify information you provide and take action within 30 days from the date your application is received, unless you are entitled to receive benefits within 7 days. YOU MAY GET SNAP WITHIN 7 DAYS if your household’s gross monthly income is less than $150 and your household’s resources such as cash, checking or savings accounts are $100 or less; or if your rent/mortgage and utilities are more than your household’s combined gross monthly income and liquid resources; or if you are a migrant or seasonal farm worker household; and you verify your identity.

1.	Has anyone in your household received any income (money, checks, gifts, etc) this month? “ Yes “No
	If yes, how much?$__________
2.	Does anyone expect to receive income later this month? “ Yes “No If yes, how much? $________________
3.	How much money does your household have in cash, checking account and savings account? $_______________

4Give the actual expense amounts: Rent/Mortgage $________Electricity $________Gas $_______Water $_______Phone $_________

5.Is your household’s only income from migrant or seasonal farm work? “ Yes “No

6.Is anyone in your household currently serving a SNAP disqualification due to fraud? “ Yes “No

7.Has any member of your household been convicted of a drug-related felony that was committed since 08/22/96? “ Yes “No

For information regarding the TANF Families First Resource Centers, contact 1 800 948 3050 or visit our website at www.mdhs.state.ms.us.

By signing and dating this application, I am giving consent for the attendance records of the children identified on this application to be disclosed by the Mississippi Department of Education to the Mississippi Department of Human Services for use by the Department of Human Services to determine compliance with school attendance requirements of the Temporary Assistance for Needy Families (TANF) Program.

Only US citizens and qualified aliens are eligible for SNAP benefits. Any non-citizens or non-qualified aliens may be left off your application for assistance. Such persons will not be reported to the Immigration and Customs Enforcement agency. Non-citizens included in your application will have eligibility determined under SNAP rules. The income and resources of all persons in your household will be considered in determining eligibility for persons included in the SNAP application.

I certify that each applicant included in my household is a U.S. citizen or alien in lawful immigration status and that the information provided is true to the best of my knowledge. I give permission for the Department of Human Services to make a full review of my case and any necessary contacts to verify my statements. I know that I could be penalized if I knowingly give false information. I certify that I received the Rights and Responsibilities handout from this agency.

___________________________________________	______________________	_________________________________
Signature of Applicant	Date	Signature of witness if signed by mark
___________________________________________	______________________	_________________________________
Signature of Authorized Representative or	Date	Signature of witness if signed by mark
Second Parent in TANF

MISSISSIPPI

MDHS-EA-900

Revised 08-01-13

Page 2

List who you are applying for beginning with the Head of Household

**Information pertaining to Ethnicity and Race are not required and will not be used in determining your eligibility or benefit level. This information will be used to help determine how effective the program is in reaching the eligible population.

***Race Codes: AL-American Indian/Alaska Native; AS-Asian; BL-Black or African American; HP-Hawaiian or Other Pacific Islander; WH-White

SNAP 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 SNAP. You are responsible for the information that anyone acting as your authorized representative gives, including any information that may be incorrect.

I would like to appoint: Name_________________________________________________

As part of the eligibility process for SNAP, I understand that certain household members including myself will be eligible to receive SNAP benefits only by following requirements to register for work, seek employment, and/or accept suitable employment, unless a work exemption is met by that household member. I understand that job seeking services are available through the MS Department of Employment Security, and that I may be required to complete job seeking requirements at a later date. I will accept an offer of suitable employment whether it was received through my own effort or through an employment and training referral. I understand that failure to comply with work registration requirements may result in disqualification of a household member or the entire household from SNAP, and that I will explain these work requirements to my household.

PENALTY WARNING: *A Social Security Number (SSN) must be provided or applied for each person for whom assistance is requested per the Food and Nutrition Act of 2008. SSNs will be verified and used for Federal and State data matches, including but not limited to, Social Security, Internal Revenue Service, VA, MS Department of Employment Security, resource/income verifications, program disqualifications, and for collection of fraud debts. State and federal laws provide for fines, imprisonment or both for any person guilty of obtaining assistance to which he/she is not entitled by willfully withholding or giving false information. Information may be verified through collateral contacts when discrepancies are found. Alien status of persons requesting benefits is subject to verification with United States Citizenship and Immigration Services (USCIS) and will require submission of certain information from this application to USCIS.

SNAP PENALTY WARNING: If your household receives SNAP, it must follow the rules listed below. Any member of your household who breaks any of these rules on purpose can be barred from SNAP for 1 year for first offense, 2 years for second offense, and permanently for third offense; fined up to $250,000, imprisoned up to 20 years or both; and subject to prosecution under other federal laws.

DO NOT give false information, or hide information to get or continue to get SNAP benefits. DO NOT trade or sell EBT cards. DO NOT alter EBT cards to get SNAP benefits you are not entitled to receive. DO NOT use SNAP benefits to buy ineligible items such as alcohol and tobacco or to pay food credit accounts. DO NOT use someone else’s SNAP benefits or EBT card for your household.

Individuals determined by a court to have committed the following program violations will be subject to the following penalties:

- If you are found to have used or received benefits in a transaction involving the sale of a controlled substance, you will be ineligible to receive SNAP benefits for a period of two years for the first offense and permanently upon the second such offense.

- If you are found to have used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you will be permanently ineligible to receive SNAP benefits upon the first occasion of such violation..

- If you have been found guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently ineligible to receive SNAP beneftis upon

the first

occasion of such violation.

-If you have been found to have made a fraudulent statement or representation with respect to your identity or place of residence in order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the Program for a period of 10 years.

In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Service (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food & Nutrition Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs.

To file a complaint of discrimination, contact USDA or HHS. 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) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.