MDHS-EA-900: Mississippi SNAP Application (TANF and SNAP)

Enter your Name, SSN and Date of Birth.

Enter your Residence Address and Mailing Address, each with City, State and Zip. Enter your Phone, your 2nd Phone and the Contact Phone of the Alternate Person, and check Yes or No under Cell for each.

Check Yes or No for paperless notices; if yes, enter your email address and Text phone number.

Check SNAP, TANF, or both for the benefits you are applying to receive; you may file a joint application for both SNAP and TANF or may file a separate application for both programs.

Before eligibility can be determined, you must be interviewed.

Sign on the Signature of Applicant line and enter the Date; a witness signs on the Signature of witness line if you sign by mark.

An Authorized Representative or a Second Parent in TANF signs on the Signature of Authorized Representative or Second Parent in TANF line, enters the Date, and has a witness sign if signed by mark.

By signing and dating the application, you consent to the Mississippi Department of Education disclosing the attendance records of the children identified on the application to the Mississippi Department of Human Services, for use to determine compliance with school attendance requirements of the TANF Program.

Only U.S. citizens and qualified aliens are eligible for SNAP benefits. Non-citizens or non-qualified aliens may be left off your application for assistance and 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.

You certify that each applicant included in your household is a U.S. citizen or alien in lawful immigration status and that the information provided is true to the best of your knowledge.

On page 1, you give permission for the Department of Human Services to make a full review of your case and any necessary contacts to verify your statements, and consent to the release of income verification to MDHS for all household members that are 18 or above.

If you give false or incorrect information, you could be penalized, your case may be denied, and you may be subject to criminal prosecution.

You certify that you received the Rights and Responsibilities handout from this agency.

Check Yes or No: have you or anyone you are applying for received any type of earned income this month such as wages, tips, bonuses, or self-employment? If yes, enter how much.

Check Yes or No: have you or anyone you are applying for received any type of unearned income this month such as social security/railroad retirement, other disability, VA income, pensions, unemployment, child support, alimony, money from other people (cash gifts), or worker's compensation? If yes, enter how much.

Check Yes or No: do you or anyone you are applying for expect to receive income later this month? If yes, enter how much.

Check Yes or No: is your household's only income from migrant or seasonal farm work?

Check Yes or No: do you or anyone you are applying for have any type of resources such as cash on hand, checking, savings account, or savings certificates? If yes, enter how much.

Give the actual expense amounts you pay: Rent/Mortgage, Electricity, Gas, Water and Phone.

Check Yes or No: do you or anyone you are applying for pay for care of a dependent child or a disabled household member?

Check Yes or No: does anyone 60 years of age or older or disabled have medical expenses that exceed $35 such as doctor visits, hospital visits, prescriptions, Medicare premiums and health insurance premiums? (checked October 19, 2026)

Check Yes or No for each of questions 1 to 5: interpreter services; a SNAP disqualification due to fraud; hiding or running from the law for a felony crime or attempted felony crime, or violating a condition or parole or probation; a commercial boarding home; being on strike.

For question 6, select all that apply for a conviction of you or any member of your household after 08/22/96: trading SNAP benefits for drugs; receiving duplicate SNAP benefits in any State; buying or selling SNAP benefits over $500; trading SNAP benefits for guns, ammunitions, or explosives (checked October 19, 2026).

For question 7, select all that apply for a conviction of you or any member of your household after 02/07/14: aggravated sexual abuse, sexual exploitation and other abuse of children, sexual assault, or murder.

For question 8, if you are not registered to vote where you live now, check Yes or No: would you like to apply to register to vote here today? If you do not check either box, you will be considered to have decided not to register to vote at this time. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

List who you are applying for, beginning with the Head of Household, and enter each person's Name (First, Last), Relationship and Social Security Number (SSN), which must be provided or applied for each person for whom assistance is requested per the Food and Nutrition Act of 2008.

Enter the Date of Birth, Age, Sex, Hispanic (Y or N) and U.S. Citizen (Y or N). Information pertaining to Ethnicity and Race is not required and will not be used in determining your eligibility or benefit level.

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

List anyone in your household who you are not including in this application, with Name (First, Last), Relationship to Head of Household and Age.

Mark paper or electronic to receive a copy of this completed SNAP application, or mark decline a copy.

You certify under penalty of perjury that your answers to all questions about each household member, including those about citizenship or alien status, are correct and complete.

Sign or mark (X) on the Household member signature or mark (X) line and enter the Date; if signed by mark, a witness signs and enters the Date.

If your household receives SNAP, it must follow these rules. 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. 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, and imprisoned up to 20 years or both; and subject to prosecution under other federal laws (checked October 19, 2026).

For SNAP, the office is 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. For TANF, action is required within 30 days from the day you give this form.

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.