5 Food Supplement Program-Paper Application VA_enclosure 3

Generic Clearance for Internet Panel Pretesting and Qualitative Survey Methods Testing

Food Supplement Program-Paper Application VA_enclosure 3

OMB: 0607-0978

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0607-0978 can be found here:

2023-12-20 - Extension without change of a currently approved collection

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Commonwealth of Virginia
Department of Social Services

APPLICATION FOR BENEFITS
GENERAL INFORMATION
With this application, you may apply for one or more of the following assistance programs:




Auxiliary Grants (AG)
Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)





General Relief – Unattached Child (GR)
Refugee Cash Assistance (RCA)
TANF Emergency Assistance (TANF EA)

Note that an application for TANF will be treated as an application for SNAP. Be sure to mark TANF-No SNAP in the
Household Composition section if you only want to apply for TANF.
COMPLETING THE APPLICATION
If you need help completing this application, a friend or relative or your eligibility worker can help you. If you are
completing this application for someone else, answer each question as if you were that person. If you need to change
an answer or make a correction, write the correct information nearby and put your initials and date next to the change. If
there are more than 6 people living in your home and you need more space to list everyone, tell the agency you need
extra pages. If you have a disability or have difficulty with English, you may receive extra help to make sure you get the
assistance or services you are eligible to receive.
COMPLETE AND ACCURATE INFORMATION
You must give complete, accurate, and truthful information. If you do not give needed information, we may not be able to
determine your eligibility for assistance. If you knowingly give false, incorrect or incomplete information, or fail to report
changes, you could lose your benefits and be arrested, prosecuted, fined and/or imprisoned. If you knowingly give false,
incorrect, or incomplete information in order to help someone else receive benefits, you could be arrested and
prosecuted for fraud.
FILING THE APPLICATION
You may turn in a partially completed application which contains at least your name, address, and signature (or the
signature of your authorized representative), but you must complete the rest of this application before your
eligibility can be determined. For some programs, you must also be interviewed, but you may turn in your application
before your interview. You may turn in your application any time during office hours the same day as you contact your
local agency. You have the right to turn in your application even if it looks like you may not be eligible for benefits.
VERIFICATION AND USE OF INFORMATION
Information you give on this application, including Social Security numbers (SSN), may be matched against
federal, state, and local records. These records include:




Virginia Employment Commission (VEC)
Internal Revenue Service (IRS)
Social Security Administration (SSA)





Department of Motor Vehicles (DMV)
US Citizenship and Immigration Services (USCIS)
Income and Eligibility Verification System IEVS)

Any difference between the information you give and these records will be investigated. Information from these
records may affect your eligibility and benefit amount. Information may be used to:
 determine the correctness, accuracy, and truthfulness of the application;
 verify your identity and citizenship; verify wages and salary, unemployment benefits, and unearned income, such
as Social Security and Supplemental Security Income (SSI) benefits; verify quarters of coverage under Social
Security for an alien, or to verify the status of aliens;
 prevent receipt of benefits from more than one social service agency at the same time;
 make required program changes;
 allow disclosure for official examination and to law enforcement officials to assist in apprehending persons fleeing
to avoid the law; or
 assist in SNAP claims collection actions.
Your information may also be used or disclosed to study public benefit programs, such as SNAP or TANF.
Information regarding your race and ethnicity is not required and will not affect your eligibility or benefit amount. This
information is requested to be sure that program benefits are provided without regard to race, color, or national origin.
032-03-0824-33-eng (06/2017)

SPECIAL INFORMATION FOR SNAP APPLICANTS
You may apply for SNAP benefits by leaving a completed Application for Benefits at the agency or by leaving a partially completed
application with at least your name, address, and signature, or by tearing off and leaving the half-sheet on the next page with your
name, address, and signature. You must complete the rest of this Application before your eligibility can be determined.
You must also be interviewed in the office or by telephone. You may turn in your application before you are interviewed. Th is is
important because if you are eligible for the month in which you apply, your SNAP amount will be based on the date you actually turn
in your application.

NONDISCRIMINATION STATEMENT
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and, in some cases,
religion or political beliefs.
The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability,
age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,
American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf,
hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed
form or letter to USDA by:
(1)

mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410

(2)

fax: (202) 690-7442; or

(3)

email: [email protected].

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the
USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link
for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health
and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington,
D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).
This institution is an equal opportunity provider.

INSTRUCTIONS FOR COMPLETING THE APPLICATION
1.

Do not write in shaded areas. These areas are for agency use only.

Complete SECTION A: APPLICANT INFORMATION. Complete the grid in SECTION B: Household Composition for
everyone who lives in your home, even if you are not applying for that person. You may leave questions about citizenship,
immigration and Social Security Number blank for anyone for whom you are NOT requesting assistance.

Answer the questions in SECTION C: INCOME for everyone for whom you are applying. In addition, if you are applying for
TANF, also provide income information for children age 18 or under, even if you are not applying for that child, and for the
stepparent of the children for whom you are applying.

Answer the questions in SECTION D: RESOURCES for everyone for whom you are applying unless you are applying only for
TANF.

After completing Sections A through D, answer the questions in the sections indicated below, depending on the type of
assistance you are requesting.
TANF
SNAP

Section E, page 5
Section G, page 6

TANF Emergency Assistance
Auxiliary Grants

Read CHANGE REPORTING AND PENALTIES on pages 9-10.

Read and complete the last page of this application. Be sure to sign and date the application.
ii

Section F, page 6
Section H, pages 7-8

EXPEDITED SERVICE FOR SNAP BENEFITS
Your household may qualify for Expedited Service and receive SNAP benefits within 7 days if you are eligible and if
your gross monthly income is less than $150 and liquid resources are $100 or less; or your monthly shelter bills are
higher than your household’s gross monthly income plus your liquid resources; or if someone in your household is a
migrant or seasonal farm worker with little or no income and resources. GIVE THE INFORMATION BELOW SO
YOUR ELIGIBILITY FOR EXPEDITED SERVICE CAN BE DETERMINED.

Name: ____________________________________

Date of Birth: ____________________________

Address: __________________________________

Social Security Number: ___________________

_________________________________________

Telephone Number: ______________________

_________________________________________
Signature:

______________________________________
Date

Total income received/expected this month before deductions
Total cash, money in checking/savings accounts, CDs, etc.
Total rent or mortgage for this month
Utility expenses for this month
Which utilities do you pay? (check all that apply)
 Heat
 Lights  Telephone  Electricity for Air Conditioning
 Water  Sewer  Garbage
 Other
Is anyone in your household a migrant or seasonal farm worker?

$______________
$______________
$______________
$______________

 YES

 NO

COMMONWEALTH OF VIRGINIA VOTER REGISTRATION AGENCY CERTIFICATION
If you are not registered to vote where you live now, would you like to apply to register to vote here today?
(Please check only one)
 I am already registered to vote at my current address, or I am not eligible to register to vote and do not need an
application to register to vote.
 Yes, I would like to apply to register to vote. (Please fill out the voter registration application form)
 No, I do not want to register to vote.
If you do not check any box, you will be considered to have decided not to register to vote at this time. Applying
to register to vote or declining to register to vote will not affect the assistance or services that you will be provided by
this agency.
If you decline to register to vote, this fact will remain confidential. If you do register to vote, the office where your
application was submitted will be kept confidential, and it will be used only for voter registration purposes.
If you would like help filling out the voter registration application form, we will help you. The decision whether to
seek or accept help is yours. You may fill out the application form in private if you desire.
If you believe that someone has interfered with your right to register or to decline to register to vote, your
right to privacy in deciding whether to register or in applying to register to vote, you may file a complaint
with: Secretary of the Virginia State Board of Elections, Washington Building, 1100 Bank Street,
Richmond, VA 23219-3497, Telephone (804) 864-8901.
__________________________________ _________________________________ _______________________
Applicant Name

Signature
for agency use only

Voter Registration form completed:
 Yes
 No
Voter Registration form given to applicant for later mailing (at applicant’s request)
 Yes
 No
___________________________________________ _______________________________
Agency Staff Signature
Date:
iii

Date

AGENCY USE ONLY
CASE NAME
CASE NUMBER
LOCALITY

SCREENER

DATE

EXPEDITED SERVICE DETERMINATION
Income < $150 + resources ≤ $100

 YES

 NO

Income + resources < shelter bills

 YES

 NO

 YES

 NO

 YES

 NO

For migrant or seasonal farm workers:
Resources ≤ $100 and ≤ $25 is expected in next 10 days from new income;
OR
Resources ≤ $100 and $0 income is expected from a terminated source for the
rest of this month or next month.

EXPEDITE IF YES TO ANY OF THE ABOVE.

Commonwealth of Virginia
Department of Social Services

Case Name

AGENCY USE ONLY
Case Number

Date Received

Date of Interview:

APPLICATION FOR BENEFITS

Interviewer

Program (s)

Locality
 In office
 Telephone

A. APPLICANT INFORMATION
Your Contact Information
Your Name (last, first, middle initial)
Your Street Address (include apartment number)

City, State, ZIP

Your Mailing Address (if different from your street address)

City, State, ZIP

In what city or county do you live?

Email Address

Primary Telephone Number

Alternate Telephone Number

Directions to your home if there is no street address.

What is the primary language spoken in your household?
 English
 Spanish
 Cambodian

 Vietnamese
 Farsi
 Haitian-Creole

 Laotian
 Chinese
 Korean

 Somali
 Kurdish
 Arabic

 French
 German
 Japanese

 Other (specify):
_________________

Primary Method of Correspondence
If you would like to receive either text or email messages notifying you that some notices about your benefits may be accessed
electronically through CommonHelp (www.CommonHelp.Virginia.gov), select one of the choices below. List either a cell telephone
number or an email address. Once you choose a preferred electronic method of correspondence, it will be used for all programs on the
case for which you have applied. If you do not choose to be notified by text or email, you will receive all written correspondence
through the U.S. mail.
If you are completing this application on behalf of another individual as an authorized representative, all correspondence to you will be
mailed. The applicant may contact the local department of social services to learn how to change the method of correspondence.
 Text

 Email Cell Phone Number ________________________

Email Address __________________________________

 YES  NO 1. Have you or anyone for whom you are applying ever applied for, or received, or are currently receiving any benefits
from a social services agency, including SNAP (Food Stamps), TANF, Medicaid, General Relief, Auxiliary Grant,
Foster Care, Adoption Assistance, or Refugee Cash Assistance? If YES, enter the information below.
Applicant’s Name

Social Security Number

When

From What County, City, or State

Type of Benefits Received

 YES  NO 2. Have you or anyone for whom you are applying ever been convicted of making false or misleading statements
about your identity or address to receive TANF, SNAP, or Medicaid in two or more states at the same time? If
YES, give date and place of conviction.___________________________________________________________
 YES  NO 3. Have you or anyone for whom you are applying ever been disqualified from participating in TANF, SNAP, or
Medicaid? If YES, give date and place of all disqualifications._______________ __________________________
 YES  NO 4. Are you or anyone for whom you are applying in violation of parole or probation or fleeing capture to avoid
prosecution or punishment of a felony? If YES, explain_____________________ _________________________
 YES  NO 5. Do you or anyone in your home have a felony conviction for drugs after August 22, 1996 for ( ) Use? ( )
Possession? ( ) Distribution of drugs? (check all that apply) If YES, who?_______ ______________________
Did the court assign ( ) Periodic Testing? ( ) Drug Treatment? ( ) Other Action?  YES  NO
If YES, have you finished the plan or are you cooperating?  YES  NO

032-03-0824-33-eng (06/2017)

B. HOUSEHOLD COMPOSITION: This section includes information about everyone living in your home, even if you are not applying
for that person. You may leave the Social Security Number blank if you are not applying for assistance for the person. List yourself first.

1
Name (last, first, middle initial)

Self
Relationship to You

Social Security Number:_________________________

City, State, Country of Birth:_____________________________

 Male

Gender:

 Female

Birth Date (mm-dd-yyyy)

Are you a U.S. citizen?  Yes  No

Marital Status:  Married

 Never Married

If No, immigration status: ____________________________

 Separated

 Widowed

US Residency Date: __/____/____

 Divorced

Highest Grade Completed:____

Alien Registration Number:_________________________

School Name if a Student: _______________________

Are you disabled or pregnant?  Yes  No

Are you a veteran or dependent?  Yes  No :

Are you temporarily living away from home?  Yes  No

Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____
Reason for being away:

 None
 TANF

 AG  GR  RCA  SNAP
 TANF EA  TANF--No SNAP

Providing the following information is voluntary and will not affect eligibility. Please check all that apply.
Ethnicity:
 Hispanic/Latino  Not Hispanic/Latino
Racial Heritage:
 White  Black/African American  Asian  Asian & Black/African American
 Asian & White
 American Indian/Alaskan Native  Black/African American & White  American Indian/Alaskan Native & White
 Native Hawaiian/Other Pacific Islander  American Indian/Alaskan Native & Black  Other/Unknown
2
Name (last, first, middle initial)

Relationship to Applicant

Social Security Number:_________________________

City, State, Country of Birth:_____________________________

 Male

Gender:

 Female

Birth Date (mm-dd-yyyy)

Is this person a U.S. citizen?  Yes  No

Marital Status:  Married

 Never Married

If No, immigration status: ____________________________

 Separated

 Widowed

US Residency Date: __/____/____

 Divorced

Highest Grade Completed:____
School Name if a Student: _______________________

Alien Registration Number:_________________________
Is this person disabled or pregnant?  Yes  No

Is this person a veteran or dependent?  Yes  No :

Is this person temporarily away from home?  Yes  No

Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____

 None
 TANF

Reason for being away:

 AG  GR  RCA  SNAP
 TANF EA  TANF--No SNAP

Relationship to Applicant

Social Security Number:_________________________

City, State, Country of Birth:_____________________________

 Male

Gender:

 Female

Birth Date (mm-dd-yyyy)

Is this person a U.S. citizen?  Yes  No

Marital Status:  Married

 Never Married

If No, immigration status: ____________________________

 Separated

 Widowed

US Residency Date: __/____/____

 Divorced

Highest Grade Completed:____

Alien Registration Number:_________________________

School Name if a Student: _______________________

Is this person disabled or pregnant?  Yes  No

Is this person a veteran or dependent?  Yes  No :

Is this person temporarily away from home?  Yes  No

Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____
Reason for being away:

 None
 TANF

 AG  GR  RCA  SNAP
 TANF EA  TANF--No SNAP

HOUSEHOLD COMPOSITION (continued)
If you need more space to list your household members, please ask for another form or write the information on a separate sheet.
4
Name (last, first, middle initial)
Relationship to Applicant
Birth Date (mm-dd-yyyy)
Social Security Number:_________________________
 Male

Gender:

 Female

City, State, Country of Birth:_____________________________
Is this person a U.S. citizen?  Yes  No

Marital Status:  Married

 Never Married

If No, immigration status: ____________________________

 Separated

 Widowed

US Residency Date: __/____/____

 Divorced

Highest Grade Completed:____
School Name if a Student: _______________________

Alien Registration Number:_________________________
Is this person disabled or pregnant?  Yes  No

Is this person a veteran or dependent?  Yes  No :

Is this person temporarily away from home?  Yes  No

Program(s) Requested:
 None  AG  GR  RCA  SNAP
 TANF  TANF EA  TANF--No SNAP

Date Left___/___/_____ Expected Return Date___/____/____
Reason for being away:

Relationship to Applicant

Social Security Number:_________________________

City, State, Country of Birth:_____________________________

 Male

Gender:

 Female

Birth Date (mm-dd-yyyy)

Is this person a U.S. citizen?  Yes  No

Marital Status:  Married

 Never Married

If No, immigration status: ____________________________

 Separated

 Widowed

US Residency Date: __/____/____

 Divorced

Highest Grade Completed:____
School Name if a Student: _______________________

Alien Registration Number:_________________________
Is this person disabled or pregnant?  Yes  No

Is this person a veteran or dependent?  Yes  No :

Is this person temporarily away from home?  Yes  No

Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____

 None
 TANF

Reason for being away:

 AG  GR  RCA  SNAP
 TANF EA  TANF--No SNAP

Relationship to Applicant

Social Security Number:_________________________

City, State, Country of Birth:_____________________________

 Male

Gender:

 Female

Birth Date (mm-dd-yyyy)

Is this person a U.S. citizen?  Yes  No

Marital Status:  Married

 Never Married

If No, immigration status: ____________________________

 Separated

 Widowed

US Residency Date: __/____/____

 Divorced

Highest Grade Completed:____

Alien Registration Number:_________________________

School Name if a Student: _______________________

Is this person disabled or pregnant?  Yes  No

Is this person a veteran or dependent?  Yes  No :

Is this person temporarily away from home?  Yes  No

Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____
Reason for being away:

 None
 TANF

 AG  GR  RCA  SNAP
 TANF EA  TANF--No SNAP

C. INCOME
1.

Do you or anyone who lives with you receive or expect to receive any of the following types of money from working? Include
money from all jobs that you have now or expect to begin: full time, part time, seasonal, temporary, self-employment. Answer Yes
or No below and provide the requested information:
Yes





No





Wages/Salary
Contract Income
Vacation Pay
Commissions, Bonuses, Tips

Yes





No





a.
Name (last, first, middle initial)

Date Job Started
b.
Name (last, first, middle initial)

Employer Name, Address and Telephone Number
Pay Schedule
Rate of Pay
 Weekly
 Monthly
 Biweekly
 Twice a Month
 Other
Next Pay Date (mm-dd-yyyy)

Number of Hours Per Week

Date Job Started

No
 Domestic Work
 Self-employment
 Any other money from
working

Employer Name, Address and Telephone Number
Pay Schedule
Rate of Pay
 Weekly
 Monthly
 Biweekly
 Twice a Month
 Other
Next Pay Date (mm-dd-yyyy)

Number of Hours Per Week

 YES  NO

Yes




Earned Sick Pay
Babysitting/Adult or child care
Farming/Fishing
Odd jobs

2. Has anyone been fired, laid off, gone on sick or maternity leave, gone on strike, quit a job, or reduced hours
worked in the last 60 days? If YES, give name and explain: _________________________________________
_________________________________________________________________________________________

Do you or anyone who lives with you (including children) receive or expect to receive any of the following? Answer yes or no
below and provide the requested information.
Yes









No
 Social Security
 SSI
 VA benefits
 Child support, alimony
 Public Assistance (TANF, GR etc)
 Military Allotment
 Training allowances (WIA, etc.)
 Loans

Yes









No
 Cash gifts or contributions
 Unemployment benefits
 Room/board income
 Black Lung benefits
 Worker compensation
 Rental Income
 Inheritance
 Railroad retirement

Yes









No
 Strike benefits
 Prize winnings
 All food, clothing, utilities, or rent
 Other retirement
 Interest, dividends
 Insurance settlement
 Refugee Matching Grant
 Any other type of money

a.
Name of Person

$
Amount

Type of Money or Help

How Often Received?

b.
Name of Person

$
Amount

Type of Money or Help

How Often Received?

c.
Name of Person

$
Amount

Type of Money or Help

How Often Received?

 YES  NO

4. Does anyone besides the people on your case pay directly for you, help you pay, or lend you money to pay rent,
utilities, medical bills or any other bills? OR does anyone totally supply food, shelter or clothing for you or
someone else on a regular basis? If YES, give name, amount, and explain: ____________________________

 YES  NO

_________________________________________________________________________________________
5. Does anyone have a day care expense for a child, an elderly person, or an adult with a disability? If YES, give
name, amount and explain: ___________________________________________________________________

 YES  NO

_________________________________________________________________________________________
6. Does anyone pay legally obligated child support to someone who is not in the household? If YES, give name of
person paying, person supported, and amount: ___________________________________________________
_________________________________________________________________________________________
4

D. RESOURCES
You do not have to complete this section if you are only applying for TANF. Otherwise, answer for everyone for whom you are
applying. Include any resources anyone owns, or that are jointly owned with someone else, even if that person does not live with you.
List the names of all joint owners.
1. Do you or anyone who lives with you have any of the following resources or assets?
Yes







No
 Cash $_________
 401K, 403B, etc
 Individual Retirement Account (IRA)
 Deferred Compensation Plan
 Keogh Plan
 Stocks or bonds

Yes







No
 Checking, Savings
 Promissory notes
 Christmas Club
 Uniform Gift to Minor Account
 Certificate of Deposit (CD)
 Pension plans

Yes







No
 Credit Union
 Money Market Funds
 Deeds of Trust
 Retirement accounts
 Trust funds
 Other

— If Yes to any of the above, please provide the following information:
a.
Owner Name (last, first, middle initial)
Co-Owner Name (last, first, middle initial)
Name of Bank or Institution

Account Type

Account Number

$
Balance

Address of Bank or Institution
b.
Owner Name (last, first, middle initial)
Name of Bank or Institution

Co-Owner Name (last, first, middle initial)
Account Type

Account Number

$
Balance

Address of Bank or Institution
 YES  NO

2. Has anyone sold, transferred or given away any resources in the last 3 months (for SNAP) or in the last 3 years

(for Auxiliary Grants)? If YES, explain: __________________________________________________________

E. TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)

(ASK FOR AN EXTRA PAGE IF YOU NEED MORE SPACE)

1. CHILD/PARENT INFORMATION

2. IMMUNIZATION

List each child for whom you are applying. Then, list the
names of both parents.

(Answer only if applying for TANF.)

You must identify both parents in order to receive TANF.
If you intentionally misidentify a parent, you shall be
prosecuted
Child’s Name

Has the child received ALL of the immunizations required
according to the child’s age?
Check () Yes Or No Or Unknown
Yes ( )

No ( )

Unknown ( )

Yes ( )

No ( )

Unknown ( )

Yes ( )

No ( )

Unknown ( )

Yes ( )

No ( )

Unknown ( )

Mother
Father
Child’s Name
Mother
Father
Child’s Name
Mother
Father
Child’s Name
Mother
Father

F. TANF EMERGENCY ASSISTANCE
 YES 

1. Have you or your family experienced a natural disaster or fire in the past 30 days? If YES, give date and explain.
__________________________________________________________________________________________

 YES 

2. As a result of the natural disaster or fire, does anyone have emergency needs, such as replacement of clothing,
or the repair or replacement of household equipment and supplies which were destroyed?

Description and cause of emergency

G. SNAP BENEFITS (formerly Food Stamps)
1. List the name of the person who is the head of your household: ___________________________________________________.
2. An authorized representative may apply for SNAP benefits on your behalf, receive and use your SNAP benefits on your behalf, or
receive copies of your program notices. If you want to name an authorized representative, please give the information below about
the representative and what you want the representative to do on your behalf. Note that you may have only one representative who
can access your benefits.
Name, Address and Telephone Number of the Authorized Representative

 YES  NO

Check () each duty authorized for that
person
 Apply for SNAP benefits
 Receive correspondence
 Access or use SNAP benefits
 Apply for SNAP benefits
 Receive correspondence
 Access or use SNAP benefits

3. Is anyone living in your home NOT included in your SNAP application? If YES, do you and everyone for whom
you are applying usually purchase and prepare meals apart from these people? Or, do you intend to do so if
your application for SNAP benefits is approved? Check ()
 YES
 NO
4. Is anyone living in your home renting a room from you (a roomer) or being provided a room and food (a
boarder)? If YES, list names: _________________________________________________________________
5. Is anyone age 60 or older or approved to receive Medicaid because of a disability or receiving any type of
disability payment? If YES, list all current medical expenses for these people.

 YES  NO
 YES  NO

Household Member with
Medical Expense

 YES  NO

Type of Expense

Amount

Name of Doctor, Hospital, Pharmacy

6. Do you have any of the following shelter expenses? If YES, list your current expenses.
Check () here  if these expenses are for a house you do not live in.

Expense

Amount Billed

How Often Billed?

Who is Responsible for the Bill?

Rent/Mortgage
Taxes/ Insurance
Electricity
Gas/Oil/Kerosene/Coal/Wood
Water/Sewage/Garbage
Telephone
Installation
6a How do you heat your home? _______________________________________________________________
 YES  NO 6b Do you have air conditioning in your home?
 YES  NO 6c Did you receive energy/fuel assistance during this past year while living in your current home?
 YES  NO 6d Are you staying temporarily in someone else’s home, an emergency shelter, welfare hotel, other halfway house,
or a place not usually used for sleeping? If YES, how much does it cost to stay there during the month?
_______________________________________________________________________________________
If you are staying temporarily in someone else’s home, when did you move there? ______________________
6

AUXILIARY GRANTS (AG)

 YES 

Do you live in an Assisted Living Facility, an Adult Foster Care Home, a Nursing Facility, or other institution?
If YES, Date Applicant Entered_______________________
City/County and State where you lived before entering the institution ____________________.
If outside Virginia, was placement made by a government agency?  YES  NO

 YES 

Do you have a spouse who does not live in the home? If YES, enter the Spouse’s Name and address
_________________________________________________________________________________________

 YES 

Have you lived in Virginia for the past 90 days?

 YES 

Do you owe or did you pay any bills you had in the month of entry into an assisted living facility or adult foster
care?

 YES 

Do you have any unpaid medical bills for the three months before the application month?

Description of Bills

Dates of Bills

Dates Bills Paid

 YES  NO

6. Do you own any household goods or personal effects worth more than $500? If YES, list the items and their value
here. ______________________________________________________________________________________

 YES  NO

7. Do you have any burial plots, burial arrangement or trust funds for burial?

Owner(s)

Number of Plots,
Type of Arrangement:

Where

Value $

Date Acquired

Amount Owed $

 YES 

Owner(s)

 YES  NO
Owner(s)

8. Does anyone own any personal property, such as campers/trailers, non-motorized boats, utility trailers, tools,
equipment, supplies, or livestock?
Is this property used in your business
or trade, including farming?
YES ( ) NO ( )

Type

Value

Amount
Owed

Date Acquired

9. Does anyone own any real property, including life estates, inherited property, land, buildings, or mobile homes?
If YES, do you live there? Check ():  YES  NO
Type

YES ( ) NO ( ) Currently rented?
YES ( ) NO ( ) Income-producing?
YES ( ) NO ( ) Currently for sale?

Value
$

Amount
Owed
$

Date Acquired

 YES  NO 10. Does anyone own vehicles, such as cars, trucks, vans, motorboats, motor homes, recreational vehicles, or
motorcycles/mopeds?
Owner(s)

Type, Make,
Model, Year

Currently
Licensed?
 YES  NO

Vehicle ID#
License #
#
#

Value Amount
Owed
$
$

How Used

Date Acquired

 YES  NO 11. Do you own any household goods or personal effects worth more than $500, such as silver, fine china, furs,
artwork, jewelry, or other items held for their value or as an investment?
Description and Value of Items

 YES  NO 12. Does anyone have any life insurance? If YES, provide information about each policy. List each policy separately.
Attach a separate sheet if necessary.
Owner

Person Insured

Company Name

Policy Number

Owner

Person Insured

Company Name

Policy Number

Owner

Person Insured

Company Name

Policy Number

Type of Insurance
 Whole Life
 Term

Face Value
$

Cash Value
$

Type of Insurance
 Whole Life
 Term

Face Value
$

Cash Value
$

Type of Insurance
 Whole Life
 Term

Face Value
$

Cash Value
$

AUXILIARY GRANTS (AG) continued

An application for AG is also an application for Medicaid. The following questions will help determine Medicaid eligibilty
through the Department of Social Services or possible eligibility for Advanced Premium Tax Credits (APTC) for private health
insurance through the Federal Marketplace (Healthcare.gov).
 YES 

NO 13. Does anyone have health insurance? If Yes, complete the following:

Policy Holder:

Person(s) Insured:

Company Name, Address, Phone:
Coverage Type:

Begin Date:

ID Number:

Premium Amount: $

 YES 

End Date: :

NO 14. Does anyone have Medicare?

Person Insured

Claim Number

Coverage
 Part A  Part B
 Part A  Part B

15. List the names of everyone expected to be included on the same tax return as you for this year, whether or not they live in the same
home as you. For anyone in the home that does not file taxes and does not expect to be on anyone else’s tax return, list those names
under “Non-filer(s)”.
Tax Filer:
Joint Taxpayer:
Tax Dependent(s):
Non-filer(s):

CHANGE REPORTING, RESPONSIBILITIES, AND PENALTIES
(READ THIS SECTION CAREFULLY BEFORE SIGNING THIS APPLICATION)
REPORTING CHANGES
You must report changes that occur. What you need to report and when you need to report it varies by each program as listed
below or on the next page for SNAP.
TANF/Refugee Cash Assistance: Report within 10 days, but no later than the 10th day of the month after a change occurs.
Report these changes:
 Your household income goes over 130% of the Federal poverty level. See the Change Report or the Notice of Action for
the amount or visit www.dss.virginia.gov.
 Your address changes.
 An eligible individual leaves or enters the home.
 Changes that may affect your participation in VIEW such as, changes in income, employment, education, training,
transportation, and child care.
General Relief-Unattached Child: Report the day the change occurs or the first day that the agency is open after the change
occurs. Report these changes:
 Your address changes.
 The amount of your monthly income changes.
 There are other changes that may affect eligibility.
Auxiliary Grants: Report changes within 10 days. Report these changes:
 Your address changes.
 The amount of your monthly income changes.
 There are changes in your resources, including transferring assets/property or in any motor vehicles owned.

PENALTIES FOR TANF AND REFUGEE CASH ASSISTANCE (RCA) VIOLATIONS
You must not knowingly give false information, hide information, or fail to report changes on time in order to receive TANF or
RCA, or to receive supportive or transitional services such as child care or assistance with transportation.
If you are found guilty of intentionally breaking these rules, you will be ineligible to receive TANF or RCA for yourself for 6
months (1st violation), 12 months (2nd violation), or permanently (3rd violation). In addition, you may be prosecuted under
Federal or State law.
Anyone convicted of misrepresenting his or her residence to get TANF, Medicaid, SNAP benefits or SSI in two or more states is
ineligible for TANF for 10 years.
Anyone convicted of a drug-related felony for actions that occurred after August 22, 1996, could be barred permanently.

SNAP CHANGE REPORTING, RESPONSIBILITIES, AND PENALTIES
(READ THIS SECTION CAREFULLY BEFORE SIGNING THIS APPLICATION)
You must report changes that occur for SNAP but, what you must report is tied to how long you are determined eligible for
benefits, the certification period. You must report changes that occur during the certification period within 10 days, but no later
than the 10th day of the month after the change occurs.
Changes that need to be reported during the certification period for SNAP depend on the length of the certification period.
“Simplified Reporting” applies to households that are eligible for SNAP benefits for five (5) months or longer. “Change Reporting”
applies to households that are eligible for one (1) month to four (4) months. Changes that need to be reported for each category
are listed below.
INTERIM REPORT FILING
In addition to reporting changes when they occur during the SNAP certification period, Simplified Reporting households may be
required to submit an Interim Report in the sixth or twelfth month. The Interim Report is used to determine the amount of SNAP
benefits households will receive for the second half of the certification period. The Interim Report provides a snapshot of household
circumstances that were presented at the time of application. We will ask for proof of income changes and changes in legal
obligations to pay child support. If households fail to return the completed Interim Report by the fifth of the month, SNAP benefits
for the seventh or thirteenth month may be delayed or closed. Assistance for filing the Interim Report is available by calling the
telephone number printed on the form.
REPORTING REQUIREMENTS – SIMPLIFIED REPORTING HOUSEHOLDS
Certified five months or longer, households must report::
 All the income for your household, before taxes, goes over 130% of the Federal poverty level. See the Change Report
or the Notice of Action for the amount or visit www.dss.virginia.gov.
 The number of work hours in a week goes under 20 for anyone who is 18-49 if there are no children in your SNAP
household.
REPORTING REQUIREMENTS – CHANGE REPORTING HOUSEHOLDS
Certified four months or less), households must report:
 There is a change in the number of people in your household;
 Your address changes, including shelter expenses that change resulting from the move;
 The obligation to pay child support changes or the amount paid to someone outside the household changes;
 Your liquid resources, such as bank accounts, cash, bonds, etc. are $2,250 or $3,250* or more;
 The number of work hours goes under 20 per week for persons who are between the ages of 18-50 if there are no children
in the home; or
 There are changes in income:
 There are unearned income changes of more than $50 for income sources such as Social Security, SSI, pensions,
etc.;
 There are earned income changes of more than $100 for money received from working;
 You start or stop a job: or
 Your job switches from full-time to part-time or part-time to full-time.
SNAP RESPONSIBILITIES AND PENALTIES FOR VIOLATIONS
You must not:
 give false information or hide information to get SNAP benefits;
 trade or sell EBT cards or attempt to trade or sell EBT cards;
 use SNAP benefits to buy non-food items, such as alcohol, tobacco or paper products;
 use someone else’s EBT card for your household.
 buy an item and discard the contents in order to get the return deposit for the container;
 resell a purchased product for cash or exchange a purchased product for consideration other than eligible
food; or
 purchase food on credit.
If you intentionally break any of these rules, you could be barred from getting SNAP benefits for 12 months (1 st
violation), 24 months (2nd violation), or permanently (3rd violation); fined up to $250,000, imprisoned up to 20 years, or
both; and suspended for an additional 18 months and further prosecuted under other Federal and State laws.
If you intentionally give false information or hide information about identity or residence to get SNAP benefits in more
than one locality at the same time, you could be barred for 10 years.
If you are convicted in court of trading or selling SNAP benefits of $500.00 or more, you could be barred permanently.
If you are convicted in court of trading SNAP benefits for a controlled substance, you could be barred for 24 months
for the 1st violation, permanently for the 2nd violation.
If you are convicted in court of trading SNAP benefits for firearms, ammunition, or explosives, you could be barred
permanently for the first violation.
10

BY MY SIGNATURE BELOW, I DECLARE:


I read the information at the beginning of this application and the Change Reporting and Penalties section of this application.



I understand that if I refuse to cooperate with any review of my eligibility, including a review by Quality Assurance, my
benefits may be denied until I cooperate.



I understand that if my application is for SNAP benefits, failure to report or verify any of my expenses will be seen as a
statement by my household that I do not want to receive a deduction for these expenses.



I have given true and correct information on this application to the best of my knowledge and belief. I understand that if I give
false information, withhold information, or fail to report a change promptly or on purpose, I may be breaking the law and could
be prosecuted for perjury, larceny, and/or welfare fraud. I understand that if I help someone complete this form in order to get
benefits he or she is not entitled to receive, I may be breaking the law and could be prosecuted.



As a condition of receiving TANF, I agree to assign all of my rights to financial support paid to me and to anyone for whom I
am receive TANF. After my application for TANF is approved, I agree to give any support payments I receive to the Division
of Child Support Enforcement.



I authorize the Department of Social Services and refugee service contractors to obtain any verification necessary to both
determine and review financial assistance eligibility. This authorization is valid for one year from the date of my signature
below. I understand that this time limit does not apply as long as my medical assistance case is open or to investigations
regarding possible fraud.



As an applicant for Auxiliary Grants, I understand that my application will be evaluated for Medicaid. I agree to assign my
rights to medical support and other third-party payments to the Department of Medical Assistance Services (DMAS). I also
agree to assign the rights of anyone for whom I am applying for Auxiliary Grants to medical support and other third-party
payments to DMAS. If I do not agree to assign these rights, I will be ineligible for Medicaid.



I understand that, to the extent allowed by federal law, information about this application may be shared with agencies under
the Secretary of Health and Human Resources for Virginia. Informatin about applicants for and recipients of services may
be shared to: 1) streamline administrative processes and reduce administrative burdens on the agencies; 2) reduce
paperwork and administrative burdens on appllicants and recipients; and 3) improve access to and the quality of services
provided by the agencies.



I understand that different state agencies provide different services and benefits. Each agency must have specific
information to determine eligibility services and benefits.
 I allow  I do not allow the Department of Social Services to disclose certain information about me to other state
agencies, including information in electronic databases, for the purpose of determining my eligibility for benefits/services
provided by that agency. This disclosure will make it easier for agencies to work together efficiently to provide or coordinate
services and benefits. Agencies include, but are not limited to, the Department of Health, and the Department for Aging and
Rehabilitative Services. I can withdraw this authorization at any time by notifying my eligibility worker.
I filled in this application myself  YES

 NO. If NO, it was read back to me when completed.  YES

________________________________________
Applicant’s Signature or Mark

_________ _________________________________
Date

_________________________________________

_________

Signature of the Spouse or Authorized Representative

Date

Witness To Mark or Interpreter

 NO.

___________
Date

Complete thesection below if this application was completed for the applicant by someone else.
_____________________________________________
Name of Person Completing Application

________________________
Primary Telephone

_________

____________________________________________

Date

_________________________
Alternate Telephone

_________________________
Relationship to Applicant

Address

File Type	application/pdf
File Modified	2019-08-16
File Created	2017-06-29