3 Food Supplement Program-Paper Application MD_enclosure 3

FACTS YOU SHOULD KNOW ABOUT APPLYING FOR TEMPORARY CASH
ASSISTANCE, FOOD SUPPLEMENT PROGRAM (FORMERLY FOOD STAMPS)
AND MEDICAL ASSISTANCE
Social Security Numbers

You must give us a social security number for each family member who wants benefits.

If a person who wants benefits does not have a social security number, that person must apply for
a number. We can help applicants get their numbers.

If a family member has applied for a social security number, we will not delay your application
while you wait for the number.

We use social security numbers to prove income. We do not give numbers to other agencies like
Immigration and Naturalization.

Citizenship and Immigration Status

You must tell us about the citizenship and immigration status for each family member who wants
benefits.
Information

If a family member will not tell us about citizenship, immigration status or social security number,
that person will not get benefits.

They must still give us proof of income, expenses and other things.

The other family members who give us their information will get benefits if they meet the rules.
Emergency Medical Assistance

Immigrants who are not eligible for other kinds of medical assistance and apply only for

emergency medical assistance do not have to tell us their social security number, immigration or
citizenship status.

Time Limits

Temporary Cash Assistance has time limits.

The Food Supplement Program (formerly Food Stamps) and Medical Assistance do not have a
time limit.

When Temporary Cash Assistance ends because of time limits, earnings or other reasons, you
may still get Food Supplement benefits and Medical Assistance.
Interviews

You, a responsible family member or someone you choose to represent you must come into our
office for an interview.

If you have a serious problem, or if you are working, and you cannot come to our office for an
interview, we can interview you by telephone.

You must give or send us the proof we ask for at your interview.
If you need help:
Applying for benefits, or
Have questions about information you must give us
Want to know what will happen to your benefits
Do not speak English and need free translation services

Call your case manager or call 1-800-332-6347
Si necesita ayuda para llenar el formulario favor de llamar al 1-800-332-6347.
DHR/FIA CARES 9701 Revised 9/09

Date Received

MARYLAND DEPARTMENT OF HUMAN RESOURCES
FAMILY INVESTMENT ADMINISTRATION
APPLICATION FOR ASSISTANCE
Your Name (Last, First, Middle)

Home Telephone

Where do you live? (Number and Street)

Apt. #

(Agency use only)

Work Telephone

City

State

Mailing Address (If different from home)

Zip Code

Cell Telephone

What language do you speak? □ English □ Spanish □ Other ___________________________________
If you do not speak English and need free translation services, call your case manager or call 1-800-332-6347.
What type of assistance do you need now? (Check all that you need)
□ Cash Assistance
□ Child Care Services
□ Food Supplement Program (Food Stamps)
□ Medical Assistance - Do you have any unpaid medical bills from the past 3 months? □ Yes □ No
Do you have any of these problems?
□ Utility shut off □ Eviction or foreclosure □ No place to stay □ No heat □ No food □ Cannot afford child care □ other:_____________
Are you or anyone in your household pregnant? □ Yes □ No If yes, who?________________________ Due Date___________
Are you or anyone in your household disabled? □ Yes □ No If yes, who? ________________________ Disability?___________
What type of assistance do you or any household members receive now
or in the past? (Check Now if you are currently receiving this assistance)
Under what name?
Now
1.
1.
Now

2.

2.

Now

3.

3.

If you are applying for the Food Supplement Program (FSP) you can complete all of the form and give it to us now. You may also
fill in your name, address, sign this page and give the page to us. You can then finish the rest of the application at home and bring or
mail it back to the office. You will not get any benefits until we receive the entire form and interview you.
Your Food Supplement benefit is based on the date you sign this application and give it to the department of social services.
You may get Food Supplement benefits right away if you meet one of the following conditions:
 Your household’s monthly rent or mortgage and utilities are more than your household’s income and resources.
 Your household’s gross monthly income is less than $150, and your resources, such as bank accounts, are $100 or less.
 Your household is a migrant or seasonal farm worker household.
If you qualify to get Food Supplement benefits right away, you will receive them within 7 days from the date you sign the form;
however, you will not get expedited Food Supplement benefits, if eligible, until we get a completed application form and interview you.
YOUR SIGNATURE
DATE

Go to page 2
LDSS Office

FOR AGENCY USE ONLY
Programs applied for or receiving

AU ID #s

Case Manager’s Name
Application/Redetermination Date

MA #s

EXPEDITED SERVICE FOR FSP BENEFITS (CUSTOMERS SHOULD NOT WRITE IN THIS AREA – FOR AGENCY USE ONLY)
Applicants who meet the standards below are eligible to receive Food Supplement benefits within 7 days. The customer must be
interviewed, either in person or by telephone, in order to determine eligibility for expedited service. The application must be complete,
signed, and identity verified before expedited benefits can be issued.
1. Is the total household income this month, before deductions, less than $150 AND household cash/savings $100 or less? □ Yes □ No
Estimated self-reported income for this month = $__________ Household’s monthly rent or mortgage amount = $___________
Household cash and savings for all members = $__________ Appropriate utility standard (SUA, LUA or actual) = $___________
A. Total income and liquid resources = $__________
B. Total shelter costs = $___________
2. Is the total amount for B. (Total shelter costs) greater than the total for A. (Total income and liquid resources)? □ Yes
□ No
3. Are the household members destitute migrant or seasonal farm workers whose cash and savings are $100 or less? □ Yes
□ No
If the answer to any of the above questions is yes, this household is potentially eligible for Expedited FSP.
4. If there is another reason why this household should NOT be expedited, list it here: _______________________________________
I certify that I screened this applicant for expedited Food Supplement benefits and determined that the household □ was □ was not
eligible for expedited issuance at this time.
Signature of Case Manager

DHR/FIA CARES 9701 Revised 9/09

Date

1

A. HOUSEHOLD MEMBERS
Fill in the blanks for everyone that lives with you. List your own name first. Social
Security number and Citizenship are optional for members not applying for benefits.
Use the codes below to complete the Citizenship, Race and Ethnicity columns. Enter
each code that applies, using at least one code for each person.

Only Answer the questions
below for each person
who wants benefits 

U.S.
CITIZEN
(Yes or No)

LAST GRADE
COMPLETED

IN SCHOOL
(Yes or No)

RACE

ETHNICITY

DATE
OF
BIRTH
S SEX

NAME
(Last, First, Middle)

How are they
related to you?

APPLYING
FOR
(Yes or No)

Ethnicity Codes: 1= Hispanic or Latino, 2=Not Hispanic/Latino
Race Codes: you can choose one or more race code - 1=American Indian/Alaskan Native,
2=Asian, 3=Black/African American, 4=Native Hawaiian/Pacific Islander, 5=White
Citizenship/Immigration Code: 1=United States Citizen, 2=Permanent Resident, 3=Asylee,
4=Alien granted conditional entry, 5=Parolee 1 year or more, 6=Alien whose deportation is
withheld, 7=Refugee, 8=Battered alien spouse, child, or parent of child(ren)
Note: You do not have to give information about your race or ethnicity. If you do, it will
help show how we obey the Federal Civil Rights Law. We will not use this information to
decide if you are eligible. If you do not give us your race, it will not affect your
application. The case manager will enter a race code for statistical purposes only. Title
VI of the Civil Rights Act of 1964 allows us to ask for this information.
SOCIAL SECURITY NUMBER

Self

Are any of the household members a roomer or boarder? □ Yes □ No

If yes, who?_____________________________________

B. CITIZENSHIP/ IMMIGRATION STATUS
If anyone for whom you are applying is not a United States citizen, fill in this section. ONLY ANSWER THESE
QUESTIONS FOR EACH PERSON WHO WANTS BENEFITS. If you are not eligible for other kinds of Medical
Assistance and you are applying only for Emergency Medicaid, you do not have to fill-in this section.
Household member

INS Status

Sponsored Immigrant?
□ Yes □ No

Household member

US Entry date:
INS Status

INS Number:
Sponsored Immigrant?
□ Yes □ No

Household member

US Entry date:
INS Status

Household member

US Entry date:
INS Status

Household member

US Entry date:
INS Status

INS Number:
Sponsored Immigrant?
□ Yes □ No
INS Number:
Sponsored Immigrant?
□ Yes □ No
INS Number:
Sponsored Immigrant?
□ Yes □ No
INS Number:

US Entry date:

DHR/FIA CARES 9701 Revised 9/09

Country of origin

Country of origin

Country of origin

Country of origin

Country of origin

2

C. AUTHORIZED REPRESENTATIVE:
You may choose a person to apply for you. You may also choose a person to get your benefits through your
Independence Card. This person can use your benefits the same way you do. If you choose someone to help you, give
us the following information about the person and check what you want this person to do.
Name (Last, First , Middle)

Relationship

Telephone Number

Number, Street

City

State

Check what you want the representative to do:
□ Complete interview for you
□ Use your Independence Card (cash)
□ Sign your application
□ Use your Food Supplement benefits

Zip Code

□ Receive your notices
□ Receive your Medical Assistance card

D. STUDENTS
Are any household members between ages 18-50 attending a school for higher education (college, vocational or technical
school)?
□ Yes □ No
Name of student _______________________________________________
School__________________________________
Is the student employed? □ Yes □ No
Is the student getting educational grants, scholarships, or loans? □ Yes □ No Amount $__________________
Amount of tuition $_________________ Books $_______________ Fees $________________ Transportation
$______________
E. RESOURCES/ASSETS
Does anyone in your household have any resources or assets such as a checking or savings account, stocks, bonds, cash
on hand, property other than where you live, prepaid burial plan, trust fund, IRA or KEOGH account? □ Yes □ No If yes,
list below:
NAME OF OWNER
(Specify if self-employed)

TYPE OF RESOURCE/ASSET

LOCATION
(Name of Bank, at home, etc.)

BALANCE/VALUE

F. TRANSFER OF ASSETS
Has anyone in your household sold, traded or given away any property, stocks, bonds, cash or other assets in the past 36
months? (60 months if a trust is involved)
Former Owner

Fair Market Value
$

Transfer
Date
Amount Received
$

Who Received the Asset?

Type of asset

Reason for Transfer

G. EARNED INCOME
Dose anyone in your household receive any income from employment? □ Yes □ No If yes, list all gross income before
deductions (such as full or part-time employment, self-employment, baby-sitting, odd jobs, day work, roomer/boarder
payments, etc.)
NAME

DHR/FIA CARES 9701 Revised 9/09

NAME OF EMPLOYER
(INCLUDE ADDRESS AND PHONE
NUMBER)

RATE OF PAY

NUMBER OF
HOURS
WORKED

AMOUNT
PER PAY
PERIOD

HOW
OFTEN
RECEIVED

3

H. DEPENDENT CARE
If anyone in your household pays someone to care for a child or disabled adult, fill in this section:
Name of Care Provider
Number

Telephone

Street

City

Number
State

Household Member Receiving Care
Who Pays?
Household Member Receiving Care
Who Pays?

Name of Care Provider

Zip code
Under 2 years
old? □ Yes □ No
Cost
$
Under 2 years
old? □ Yes □ No
Cost
$

Telephone

Street

City

State

Zip code

Household Member Receiving Care

Under 2 years
old? □ Yes □ No
Cost
$
Under 2 years
old? □ Yes □ No
Cost
$

Who Pays?
Household Member Receiving Care
Who Pays?

I. CHILD SUPPORT/ALIMONY EXPENSE
Does any household member pay court ordered child support to a NON-HOUSEHOLD member? □ Yes □ No If yes, who?
(Includes current payments, arrearages, health insurance)
DEPENDENT’S NAME, ADDRESS AND PHONE NUMBER

PERSON OR AGENCY
PAID

AMOUNT PAID

HOW OFTEN
PAID

J. OTHER INCOME AND BENEFITS
If anyone in your household receives, applied for or was denied any benefit listed below, place a check in the box next to
the benefit
□ Alimony
□ Child Support
□ Social Security
□ SSI
□ Railroad Retirement
□ Veteran’s Pension/Benefit □ Unemployment Benefits
□ Education Grants or Loans
□ Worker’s Compensation
□ Pension or Retirement
□ Union Benefits
□ Disability, Sick or Maternity Benefits
□ Military Allotment
□ Money from Rental Income □ Black Lung Benefits
□ Money from Friends or Relatives
□ Lump Sum Cash Amounts □ Civil Service Annuity
□ Temporary Cash Assistance □ TDAP
□ Social Security Disability
□ Interest Dividends from Stocks, Bonds, Savings or Other Investments
□ Other ______________________________________
Do you agree to apply for all benefits you may be entitled to receive? □ Yes □ No

If you checked yes to receiving, applying for or being denied any benefits, fill in below:
HOUSEHOLD MEMBER

DHR/FIA CARES 9701 Revised 9/09

TYPE OF BENEFIT

Applied

CLAIM NUMBER

Received

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

yes

no

Amount

4

K. SHELTER COSTS – Complete if you are applying for Food Supplement Program Benefits
Is anyone in your household paying for any of the following? Check all those paid and answer the questions.
Expenses

Amount

√

How
Often?

Who Pays?

Expenses
√

Rent

Water

Mortgage

Sewer

Electric

Garbage

Gas

Wood/Coal

Oil

Property Tax

Coop/Condo
/ Assoc. fees

Homeowner’s
insurance

Telephone

Other

Amount

How
Often?

Who Pays?

Do you live in: □ Public Housing
□ Section 8 Housing
□ FMHA 515 Housing
□ Private Housing
Is heat included in your rent? □ Yes □ No
Do you pay an electric bill for lights or cooking? □ Yes □ No
If heat is not included in the rent, what is your source of heat? __________________
Do you pay for air conditioning? □ Yes □ No
Does someone help you with your utility costs? □ Yes □ No If yes, who?_________________________
Are you sharing any of the shelter costs listed above? □ Yes □ No If yes, with whom? ___________________
Your share? ________
Have you received Energy Assistance at your current address within the past 12 months? □ Yes □ No
L. MEDICAL EXPENSES – Complete Appropriate Section if Applying for Medical Assistance or Food Supplement Benefits
Medical Assistance – Do you or any household members pay medical expenses? □ Yes □ No If yes, check the
appropriate box
Food Supplement Benefits – Do you or any household members pay medical expenses for any person age 60 or over,
or any person receiving disability benefits? □ Yes □ No If yes, check the appropriate box and list the monthly amount you
pay.
DISCUSS THESE EXPENSES WITH YOUR CASE MANAGER.
□ Health/Medicare Insurance

$_______________

□ Medical/Dental Insurance

$______________

Others ____________

□ Dentures/Glasses/Hearing Aids $_______________

□ Transportation Costs

$______________

____________

□ Hospital

$_______________

□ Nursing

$______________

____________

□ Attendant Care

$_______________

□ Pharmacy Expense

$______________

____________

M. HOUSEHOLD’S DECLARATION INQUIRY – Complete if you are applying for Temporary Cash Assistance or Food
Supplement Benefits
1. Has anyone in your household ever been convicted of a felony committed on or after August 22, 1996 that involved
drugs?
□ YES
□ NO If yes, who? ___________________________________________________________________
2. Is anyone in your household currently violating parole or probation or fleeing from the police or the courts?
□ YES
□ NO If yes, who? ___________________________________________________________________
3. Has anyone in your household been convicted since August 22, 1996 in a Federal or State Court for not telling the truth
about where they lived or their identity in order to receive Food Supplement benefits or cash assistance from more than
one place in the same month?
□ YES
□ NO If yes, who? ___________________________________________________________________
4. Has a court convicted any member of your household for trafficking Food Supplement benefits of $500 or more?
□ YES □ NO If yes, who?____________________________________________________________________
5. Is anyone in your household receiving benefits under another identity or as a member of another household or in
another State?
□ YES
□ NO If yes, who?___________________________________________________________________

DHR/FIA CARES 9701 Revised 9/09

5

N. MEDICAL INSURANCE – Complete if you are applying for Medical Assistance or Temporary Cash Assistance
1. Has anyone applying dropped health insurance coverage in the past six months? □ YES □ NO
2. Does anyone applying have any health insurance? □ YES □ NO If you answered yes to question 2, fill in the section
below.
HEALTH INSURANCE POLICY NUMBER 1
POLICY HOLDER NAME

POLICY NUMBER

HOUSEHOLD MEMBER(S)
COVERED BY POLICY

Number

GROUP NUMBER

RELATIONSHIP OF MEMBER TO
POLICY HOLDER

HOUSEHOLD MEMBER(S)
COVERED BY POLICY

POLICY HOLDER ADDRESS
City
State

Street

RELATIONSHIP OF MEMBER
TO POLICY HOLDER

Zip Code

Telephone

Zip Code

Telephone

INSURANCE COMPANY/UNION
Insurance Company Name
Number

Street

City

State

HEALTH INSURANCE POLICY NUMBER 2
POLICY HOLDER NAME

POLICY NUMBER

HOUSEHOLD MEMBER(S)
COVERED BY POLICY

Number

GROUP NUMBER

RELATIONSHIP OF MEMBER TO
POLICY HOLDER

HOUSEHOLD MEMBER(S)
COVERED BY POLICY

POLICY HOLDER ADDRESS
City
State

Street

RELATIONSHIP OF MEMBER
TO POLICY HOLDER

Zip Code

Telephone

Zip Code

Telephone

INSURANCE COMPANY/UNION
Insurance Company Name
Number

Street

City

State

0. LIFE INSURANCE, FUNERAL PLANS or BURIAL FUNDS – Complete if you are applying for Medical Assistance or
Temporary Cash Assistance
NAME OF PERSON
INSURED

NAME OF PERSON
WHO PAYS

FACE VALUE
OR VALUE OF
PLAN

CASH
VALUE

POLICY NUMBER
OR ACCOUNT
NUMBER

COMPANY, FUNERAL HOME OR
BANK NAME

PLEASE USE THIS SPACE IF YOU NEED TO GIVE US MORE INFORMATION ABOUT ANY APPLICATION QUESTION.

If you need more space, ask for the 9701- Application for Assistance Addendum.

DHR/FIA CARES 9701 Revised 9/09

6

P. CHILD SUPPORT INFORMATION – Complete this section if you want TEMPORARY CASH ASSISTANCE OR MEDICAL
ASSISTANCE for a child who has an absent or deceased parent. Fill in a separate section for each absent or deceased parent.
#1 ABSENT PARENT (AP) INFORMATION
Name of Absent Parent (First, Middle, Last)
Relationship of absent parent to you. Check one:
□ Absent
□ Deceased
CHILD’S NAME
MARITAL STATUS OF CHILD’S PARENTS AT BIRTH
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
Social Security Number
Other Name
Date of Birth
Age
Race
Sex
□ Male □ Female
AP’s Last
Known Address
AP’s Parent's
Address

Number

Street

City

State

Zip Code

Telephone

Number

Street

City

State

Zip Code

Telephone

Driver’s License State

Birth Place (City, State)

Current or Prior Military

Paying Military Allotment? □ Yes □ No
If yes, To whom?

Dates: From:
Incarcerated

To:

Military Branch

Institution Name

□ Currently
□ Previously
□ Never
ABSENT PARENT INCOME INFORMATION
Last Known
Employer
Second
Employer

Name, Address & Telephone
Name, Address & Telephone

Other Income/Benefits:
□ Social Security
□ SSI
□ Worker’s Compensation
□ Pension/Retirement
□ Union Benefits
ABSENT PARENT COURT ORDER INFORMATION
Paying Support? To Whom?
□ YES □ NO
Court Ordered?
If yes, where was the court order issued?
□ YES □ NO
#2 ABSENT PARENT (AP) INFORMATION
Name of Absent Parent (First, Middle, Last)

□ Married
□ Married
□ Married
□ Married

AP’s Last
Known Address
AP’s Parent's
Address

Payment Amount
Can you give us a copy?
□ YES □ NO

Other Name

Check one:
□ Absent
□ Deceased
MARITAL STATUS OF CHILD’S PARENTS AT BIRTH
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
□ Divorced
□ Unknown
□ Separated
□ Never Married
Date of Birth
Age
Race
Sex
□ Male □ Female

Number

Street

City

State

Zip Code

Telephone

Number

Street

City

State

Zip Code

Telephone

Driver’s License State

Birth Place (City, State)

Current or Prior Military

Paying Military Allotment? □ Yes □ No
If yes, To whom?

Dates: From:
Incarcerated

Last Date Paid

Relationship of absent parent to you.

CHILD’S NAME

Social Security Number

□ Veteran’s Pension
□ Unemployment
□ Other, list__________________________________

To:

Military Branch

Institution Name

□ Currently
□ Previously
□ Never
ABSENT PARENT INCOME INFORMATION
Last Known
Employer
Second
Employer

Name & Address:

Number

Street

City

State

Zip Code

Telephone

Name & Address:

Number

Street

City

State

Zip Code

Telephone

Other Income/Benefits:
□ Social Security
□ SSI
□ Worker’s Compensation
□ Pension/Retirement
□ Union Benefit
ABSENT PARENT COURT ORDER INFORMATION
Paying Support? To Whom?
□ YES □ NO
Court Ordered?
If yes, where was the court order issued?
□ YES □ NO
DHR/FIA CARES 9701 Revised 9/09

□ Veteran’s Pension
□ Unemployment
□ Other, list___________________________________
Last Date Paid

Payment Amount
Can you give us a copy?
□ YES □ NO

7

YOUR RIGHTS AND RESPONSIBILITIES
YOU HAVE THE FOLLOWING RIGHTS

RIGHT TO WRITTEN NOTICE – We must always give you a written notice explaining your benefits
when we approve your case. We must always give you written notice when we change your
benefits, deny or close your case. You have 90 days from the notice date to ask for a hearing. If
you ask for a hearing within 10 days, you may be able to keep getting benefits while you wait for the
hearing.
RIGHT TO APPEAL – Ask for a hearing if you disagree with the Department’s decision. Your case
manager can help you write your appeal. At the hearing, you can speak for yourself or bring a
lawyer, friend or relative to speak for you.
EQUAL RIGHTS – Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of
Health and Human Services (HHS) policy state we cannot discriminate against you because of race,
color, national origin, sex, age, or disability. Under the Food and Nutrition Act and USDA policy, we
also cannot discriminate against you because of religion, political beliefs or retaliation.
If you think we have discriminated against you contact USDA or HHS. To contact USDA write
USDA, Director, Office of Civil Rights, 1400 Independence Avenue SW, Washington, DC
20250-9410. You may also call toll free, 1-866-632-9992 (voice). TDD users can contact
USDA through local relay or the Federal Relay at 1-800-877-8339 (TDD) or 1-866-377-8642
(relay voice users). To contact HHS, write Office for Civil Rights, Health and Human
Services, 150 S. Independence Mall West – Suite 372, Philadelphia, PA 19106-3499. You may
also call HHS toll free at 1-800-368-1019 (voice) or 1-800-537-7697 (TDD). You may also send
an email to [email protected]. USDA and HHS are equal opportunity providers and
employers.
For the Food Supplement Program, if you need this information in a different format (Braille,
large print, audiotape, etc.), contact the USDA’s TARGET Center at 202-720-2600 (Voice or
TDD). If you need information about this program, activity or facility in a language other than
English, contact the USDA agency responsible for the program or activity, or any USDA
office.
RIGHT TO PRIVACY – You are giving personal information in the application. We use the
information to see if you are eligible for benefits. If you do not give the information, we may deny
your application. You have a right to review, change, or correct any information. We will not show
your information or give it to others unless you give us permission or federal and state law allows us
to do so.
RIGHT TO CLAIM GOOD CAUSE – If you want Temporary Cash Assistance (TCA), you must help
the Department get child support. You may not have to help if it puts your or your family in danger.
RIGHT TO REFUSE HELP – You do not have to accept help from a religious organization if it is
against your religious beliefs.
RIGHT TO TIMELY APPLICATION PROCESSING – If you are eligible for expedited Food
Supplement Program benefits we must give you your benefits within 7 days. For the regular Food
Supplement Program and other programs, except for certain Medical Assistance programs, we must
process your application within 30 days. There are times when there is a delay in processing. If
there is a delay, we will send you a letter to tell you why there is delay in processing your application.

DHR/FIA CARES 9701 Revised 9/09

8

YOUR RIGHTS AND RESPONSIBILITIES
YOU HAVE THE FOLLOWING RESPONSIBILITIES
PROVIDE INFORMATION – You must give true and complete information. You may need to give
us proof of this information. We will keep this information private. Any delay in providing proof may
result in your case being delayed or denied.
Collecting application information, including the social security number of each household member,
is authorized under the Food and Nutrition Act of 2008, U.S.C.2011-2036, Social Security Act
§1137(f) and 42 U.S.C. §1320b-7(d). We use the information to find out if your household is eligible.
We check this information by matching computer programs.
We also use the information to see if you meet program rules. We may contact your employer, bank
or other party. We may also contact local, state or federal agencies to make sure the information is
correct. We can give your information to other federal or State agencies for official use and to law
enforcement officers who need it to find persons fleeing to avoid the law.
If you get too much in benefits:
 You may have to repay the money for the benefits, and
 We may give the application information, including social security numbers, to federal or state
agencies, as well as private claims collections agencies, for action.
Giving information is voluntary. If you do not give us information such as social security numbers for
everyone who wants help, we may deny benefits for each person who does not give a social security
number. If you do not have a social security number, we will help you get one.
REPORT CHANGES - You must report all changes within ten days unless you are part of the Food
Supplement Program simplified reporting group and are not receiving Cash Assistance or Medical
Assistance. If you want to know if you are part of this group, ask your case manager. You may tell us
about any changes in person, by telephone, or by mail to the Department.
Warning – We may deny, lower or stop your benefits if you give us wrong information or do
not report changes. A judge may fine and/or imprison you if you deliberately give wrong
information or do not report changes.
AUTHORIZED REPRESENTATIVES – In most instances, if your authorized representative gives us
wrong information, you will have to pay back any amount you are overpaid.
If your authorized representative knowingly gives us the wrong information or does not use your
benefits properly, we may disqualify the person from being an authorized representative.
If a drug and alcohol treatment center or a group living arrangement acts as your authorized
representative for your food benefits and they willfully give us wrong information about your situation,
we may prosecute the person under applicable State or federal law.

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YOUR RIGHTS AND RESPONSIBILITIES
FOOD SUPPLEMENT PROGRAM PENALTIES
Do not:
 Give false information or withhold information to get or continue to get Food Supplement Program (FSP)
benefits
 Trade or sell FSP benefits, or electronic benefit cards.
 Use FSP benefits to buy items not allowed, such as alcohol and tobacco.
 Use someone else’s FSP benefits.
 Use someone else’s Electronic Benefits Card without authorization.
Your Food Supplement Program benefits will not increase if your cash assistance case is reduced or closed
because you did not follow the rules.
If a household member deliberately breaks the rules, we may bar the person from the Food Supplement
Program.



We may bar this person for one year after the first violation.



We may bar this person for two years:
* After the second violation, or
* After the first time a court finds this person guilty of buying illegal drugs with Food Supplement Program
benefits.



We may bar this person permanently:
* After the third violation, or
* After the second time a court finds a person guilty of buying illegal drugs with FSP benefits, or
* After the first time a court finds this person guilty of buying guns, bullets, or explosives, with FSP benefits.
* After a court finds this person guilty of trafficking FSP benefits of $500 or more.



We may bar this person for ten years if found guilty of making a false statement about the person’s identity
in order to receive multiple benefits at the same time.

A judge can also fine this person up to $250,000, imprison the person for up to 20 years, or both. A
judge can also bar this person for an additional 18 months. The person may also have to face
further prosecution under other federal laws.
TCA PENALTY – If an assistance unit member is convicted of an Intentional Program Violation (IPV),
everyone in your family will lose their benefits.



 The first time, you will lose benefits for 6 months or until you repay all of the money.
 The second time, you will lose benefits for 12 months or until you repay all of the money.
 The third time, you cannot get TCA benefits again.
MEDICAID WARNING AND PENALTY - Only use Medical Assistance cards if you are eligible.

Every person convicted of “Medicaid Fraud” with a value of $500 or more in money, services, or goods is guilty
of a felony, and shall:
1. Pay back money, services or goods; or the value of those services or goods unlawfully received;
2. Be subject to a fine of no more than $10,000, imprisoned for no longer than five years, or both.
Every person convicted of “Medicaid Fraud” with a value of less than $500 in money, services or goods is guilty
of a misdemeanor, and shall:
1. Pay back money, services or goods; or the value of those services or goods unlawfully received;
2. Be fined no more than $1,000 and imprisoned for no longer than three years or both.

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YOUR RIGHTS AND RESPONSIBILITIES
READ BEFORE SIGNING:
I understand that it is important to give true information and if I do not, I am breaking the law.
I understand that I can be fined, imprisoned or have my benefits reduced for making false statements or for
pretending to be another person.
I know I can be punished for not reporting changes that may affect my eligibility or benefit amount.
I understand that if I get more Food Supplement benefits than I should, all adult members of my household are
liable for repaying the debt.
I know the Department can use the application against me in a court of law for fraud prosecution.
I know that failing to report or verify shelter, medical, or dependent care expenses or child support payments is
the same as saying I do not want a deduction for the expenses I did not verify or report.
I understand that the Department may check the information on this form to see if it is correct and may select my
case for a spot check, such as for a Quality Control Review.
I agree to allow someone from the Department to visit me at home. I will help them get all needed proofs from
any source.
I understand by signing this application:
• I accept cash assistance and/or medical assistance.
• I agree that Medicare Part B will make payments directly to doctors and medical suppliers.
• I give the Department the right to seek payment from private or public health insurance and any liable third
party. I understand that I must cooperate with the department in securing such payments. The Department
may seek payment without legal action, as long as it does not keep more than the amount Medical Assistance
paid.
• I give the Department the right to inspect, review and copy all medical records for services received through
the Medical Assistance Program.
I understand that when a person is deceased who was at least 55 years old when receiving Medical Assistance
the state may take money from the estate to repay payments made on behalf of that person. The program may
take the money only if there is no surviving spouse, unmarried child younger than 21, or blind or disabled child
(married or unmarried) of any age.
SIGNATURE SECTION
I understand that, as required by Maryland law, certain law enforcement agencies that investigate fraud can
obtain information about my application, income, benefits and other documentation as part of their investigation.
While access to my application and benefit information is normally limited (under Md. Code Ann. Human
Resources Article § 1-201), these limits do not apply to these investigative agencies. Such agencies include the
Department of Human Resources’ Office of the Inspector General. I understand that I do not need to provide
consent to these agencies in order for them to investigate any allegations of fraud against me. Any information
found as a result of the investigation may be used against me if an allegation of fraud is prosecuted.
I have read or someone has read and explained the entire application to me. I swear or affirm under penalty of
perjury, that all the information I gave is true, correct, and complete to the best of my ability, belief and
knowledge. I received a copy of my rights and responsibilities. I authorize any person, partnership, corporation,
association, or governmental agency that knows the facts about my eligibility to give that information to the
Department. I also authorize the Department to contact any person, partnership, corporation, association, or
governmental agency that has given proof of my eligibility for benefits. I certify, under penalty of perjury, that by
signing my name below, all persons for whom I am applying are U.S. citizens, lawfully admitted immigrants or
individuals in satisfactory immigration status.
Signature of Applicant I Recipient

Date

Signature of Witness (If you Signed an X)

Date

Signature of Spouse (If Applicable)

Date

Signature of Authorized Representative
(If Applicable)
Signature of Case Manager

Date

I withdraw my application for: □ Cash Assistance
Signature of Applicant, Recipient,
Authorized Representative

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Date

□ Food Supplement Program □ Medical Assistance
Date

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YOUR RIGHTS AND RESPONSIBILITIES
ASSIGNMENT OF SUPPORT RIGHTS FOR TEMPORARY CASH ASSISTANCE


I assign to the State of Maryland all rights, titles, and interest in support that I may have for
myself or for any person receiving TCA.



This includes any overdue support that has not been collected.



I agree to have the child support agency collect any support owed to me and to keep up to the
amount of TCA paid to me.



I agree to send to the State of Maryland any support l receive. If l do not turn over this support, I
will have to repay this amount to the State of Maryland. I may also be prosecuted for fraud.

When I am eligible for Medical Assistance:


I assign all rights, title, and interest in medical support and health insurance payments I may
have for myself or any person receiving Medical Assistance. This includes overdue medical
support or health insurance payments that have not been collected.



I agree to have the child support agency collect medical support payments owed to me and to
keep up to the amount of Medical Assistance payments that were made for me.



I agree to give the State of Maryland any medical support or health insurance payments I
receive.

I will cooperate to the best of my ability and knowledge with the child support agency while I am
receiving TCA and Medical Assistance
• If I do not cooperate with the child support agency, I may lose all my benefits and my case may
be closed
I HAVE READ THESE STATEMENTS OR SOMEONE READ THEM TO ME. I UNDERSTAND WHAT
THEY MEAN. BY SIGNING MY NAME BELOW, I AGREE TO FOLLOW WHAT THEY SAY.
Signature
Date
•

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