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Application for SNAP
What Is SNAP?
The Supplemental Nutrition Assistance Program (SNAP) is a program to help you buy food for good health.
How Do I Get SNAP Benefits?
Step 1. Fill out an application.
Anyone may fill out an application. Answer as many questions as you can. If you are applying for SNAP and can’t fill out all 8 pages of the application today, be sure to fill out this page, sign it, and turn it in. Fill out and turn in the rest of the application (pages 2- 8) as soon as you can.
Step 2. Return the application to us.
You can fax or mail your application to any Department for Community Based Services (DCBS) office. Or, you can bring your application to a DCBS office when it is open. When we get your application, you will receive instructions to complete an interview. You have the right to know soon whether you will get benefits. The date we get this page with your name, address and signature starts the time that we have to determine if you are eligible for SNAP benefits. It is also the start date of SNAP benefits for you if you are eligible for benefits.
Step 3. Talk with us.
At your interview, you will need to have:
Proof of who you are, such as your driver’s license, social security card or alien documentation;
*See notice on page 2 about providing your social security number.
Proof of who lives in your home, such as a lease or written statement;
Proof that you live in Kentucky;
Proof of child care costs or child support paid;
Proof of your living expenses; and
Proof of money you have gotten in the past 60 days, including any check stubs.
*If you don’t have everything listed above, complete the interview anyway. We will help you.
Tell Us About Yourself
Do you have a physical or mental condition that requires you to have special accommodations, such as needing a sign language interpreter, during your application interview?
If yes, what do you need? _____________________________________
We can get a free interpreter for your interview if you have trouble speaking English. Do you need an interpreter during your interview? Yes NoIf yes, what language?_________________________
When Will I Get SNAP Benefits?
You may be able to get SNAP benefits by the 5th day after you apply. This is called Expedited Benefits. If you qualify for this, we need more than this page. See below about Expedited Benefits or ask us about this.
To get SNAP benefits, you will need to fill out all of this application. We need the whole application to decide if you are eligible, even if you are eligible for Expedited Benefits. The more information you give us the better job we can do. Give us all the information you can. If you need help, ask us and we will help you. You also need to turn in a copy of your ID, such as your driver’s license, social security card, or alien documentation.
Expedited Benefits – SNAP Benefits in 5 days
This is who can get SNAP benefits within 5 days:
• Households with less than $150 in gross monthly income and assets; or
• Households with rent, mortgage and utilities that are more than the household’s gross monthly income and assets; or
• Households with a migrant or seasonal farm worker and with assets of $100 or less whose income is stopping or starting.
SNAP Benefits in 30 days:
You can apply for SNAP and other benefits at the same time. But, your SNAP application will be processed separately. We have to process your SNAP application based on SNAP rules and let you know about our decision as quickly as possible, but no later than 30 days from the date we receive your signed application. You will not have your SNAP application denied just because your application for other benefits was denied or because you lost other benefits you were receiving.
You can choose to have someone help you. You don’t have to do this. But, if you do, this person can fill out your application, answer questions for you, give information at your interview, and buy your food with an EBT card. We will be able to share information with this person.
Note: In-patient Drug and Alcohol Rehabilitation Centers must designate an employee to apply for any residents.
(Last Name) (First Name) (M.I.)
(Mailing Address) (City) (State) (Zip Code)
Information About Alien Status
You can apply for SNAP benefits for part of your household even if some members may not be eligible because of their immigration status. For example, parents who do not have legal immigrant status may apply for SNAP benefits for their children who are U.S. citizens or qualified legal immigrants. Do not apply for people who don’t have legal immigrant status. We will not contact the U.S. Citizenship and Immigration Services (USCIS) about the people you don’t apply for. We must use their income and assets to see if the rest of the household can get SNAP benefits. You don’t have to give us the immigrant documents for the people you do not want SNAP benefits for. Do not apply for people who are in the country illegally, but list their name, relationship and birth date in the table on Page 3. We check the immigration status of immigrants you apply for through the Systematic Alien Verification System operated by the USCIS. The information we receive may affect your SNAP benefits.
Information About Social Security Numbers
You can choose to give us the Social Security Number of each person in your household. We can give SNAP benefits only to the people who give us their Social Security Number or proof that they have applied for a Social Security Number. You don’t have to give us the Social Security Number for the people you do not want SNAP benefits for.
You Will Not Be Discriminated Against
The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.)
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at email@example.com.
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal relay Service at (800) 877-8339; or (800) 845-6136 (Spanish).
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.
USDA is an equal opportunity provider and employer.
Tell Us About the People in Your Home
A SNAP household is a person or a group of people who live together and buy food and fix meals together. The group does not need to be related. The following people must be one SNAP household if they live together, even if they do not buy and fix meals together:
• You and your husband or wife,
• Your children who are under 22 (even if they have children of their own),
• Any parent of children under age 22,
• Other children under 18 who you take care of, and
• All other people who buy food and fix meals with you.
On the chart below, fill in the boxes for each of the people who live in your home. If you do not want to get benefits for someone, answer “no” to the first question below and fill in only their name, their relationship to you, and their date of birth.
We have to ask for ethnicity and race to assure that program benefits are distributed without regard to race, color, or national origin, but you don’t have to answer. Your answer won’t affect how many benefits you get or how soon you get them. If you choose to answer, use the following coding:
* Ethnicity **Race (Choose all that apply)
H = Hispanic or Latino
N = Not Hispanic or Latino
First Name, M. I.,
M or F
Note: By signing on page 7, I agree that all required members of my household will follow the work and training rules.
Does anyone have a Kentucky EBT card? Yes No Who? ______________________
List anyone age 18 or over who is in college or trade school: ______________________________
Is anyone getting SNAP benefits from another state? Yes No What state? _______________
Has anyone in your home been convicted of giving wrong information about who you are or where you live to get or try to
get SNAP benefits in more than one household at a time since 8/22/96? Yes No Who? __________________
Is anyone a fleeing felon or probation/parole violator?
Has anyone been convicted of a drug felony since 8/22/96? Yes No Who? ________________
Has anyone in your home been convicted of buying, selling or trading more than $500 in SNAP benefits since 8/22/96? Yes No Who? ____________________
Has anyone in your home been convicted of trading SNAP benefits for firearms, ammunition, or explosives since
8/22/96? Yes No Who? ____________________
Have you or anyone in your home been convicted of trading SNAP benefits for drugs after 8/22/96?
Yes No Who? ____________________
To get the most SNAP benefits you can, tell us about your bills. Failure to report or give proof of any expenses will be seen as a statement by your household that you do not want to receive a deduction for the unreported expenses. Below, tell us about the bills your household pays.
Shelter and Utilities
How much is your household’s share of the following expenses:
If you pay taxes or insurance separate from your mortgage, list amounts below:
Check the boxes next to the utility bills you have to pay:
Check here if any of the utility bills you have to pay are for heating or air conditioning.
Check here if you got energy assistance (LIHEAP) in the past year at your current address.
If you have medical costs, not paid by insurance, for anyone who is disabled or over age 59, tell us. These could be doctor or hospital bills, medicine, transportation, health insurance premiums, or other medical expenses.
Who pays: ____________________________ Amount: $_________ per month
If you have day care expenses for a child or an adult who lives with you, tell us.
Who gets care: _______________________ Who pays for the care: ________________________
Amount: $_________ per month
If anyone is paying court-ordered child support, tell us.
Who pays: _____________________________ Amount: $_________ per month
Help Paying Expenses
If you get help with any of your expenses, tell us:
Which Expense Was Paid?
What Assets Do People in Your Household Have?
List the total money everyone has in:
Cash $ ______________ Bank/Credit Union Accounts $ _______________
Stocks, bonds, savings certificates, or other assets
What Money Do People in Your Household Get?
List the person’s name and the monthly amount. If you leave a space blank, we will take that to mean there is no money of this kind. Attach another sheet if needed.
Where the Money Comes From
Who Gets The Money
Amount per Month
Employer (if applicable)
Money From Work Before Taxes (Gross)
Money From Work Before Taxes (Gross) 2nd Job
Self-Employment or Odd Jobs
Social Security or SSI
Veterans Benefits, Pensions or Retirement
Unemployment or Worker’s Compensation
Child Support or Alimony
Money from Friends or Relatives
Has anyone been hired for a job but not paid yet?
Has anyone quit a job in the last 30 days?
Is anyone a migrant or seasonal farm worker?
Is anyone on strike?
Please read this information and sign and date page 7.
Follow these rules:
Do not sell food purchased with SNAP benefits.
Anyone who breaks SNAP rules:
May not get SNAP benefits for 1 year for the first time, 2 years for the second time, and forever for the third time;
May be fined up to $250,000 or jailed up to 20 years, or both; and
If a court finds you guilty of buying, selling or trading more than $500 in SNAP benefits, you may not get SNAP benefits forever.
If a court finds you guilty of trading SNAP benefits for firearms, ammunition, or explosives, you will lose benefits forever.
If a court finds you guilty of trading SNAP benefits for controlled substances, you will lose benefits for two years the first time and forever the second time.
You will not get SNAP benefits for 10 years if you are found guilty of getting or trying to get SNAP benefits in more than one household at a time. This penalty happens if you give wrong information about who you are or where you live.
In addition to the these penalties, a court can also stop you from getting SNAP benefits for another eighteen months if you are convicted of a felony or misdemeanor violation of the rules listed above.
You will not get SNAP benefits if you are hiding or running from the law to avoid prosecution, being taken into custody, going to jail or violating a condition of parole or probation.
**Giving wrong information on purpose may result in us taking legal action against you, either criminal or civil. It might also mean we reduce your benefits or take money back from you.
What We Do With Your Information
If any information you give us is not correct, we may deny SNAP benefits. We will give your answers to law enforcement officials to catch persons fleeing to avoid the law. If you have a SNAP benefits overpayment, we will give your answers to federal and state agencies to collect the overpayment. We will deny assistance to people, if you do not give us their Social Security Number. We will use any Social Security Number given to us the same way we use the Social Security Number of persons getting assistance. We will not give your Social Security Number to the U.S. Citizenship and Immigration Services (USCIS).
The collection of this information, including the social security number (SSN) of each household member, is authorized under the Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036. The information will be used to determine whether your household is eligible or continues to be eligible to participate in the Supplemental Nutrition Assistance Program. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management.
This information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
If a SNAP claim arises against your household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.
Providing the requested information, including the SSN of each household member, is voluntary. However, failure to provide an SSN will result in the denial of SNAP benefits to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members.
We Check What You Tell Us
We use computer systems to verify your family’s income and to do computer matches with the Office of Employment and Training, the Internal Revenue Service and other matching sources. If something you told us is different from what the computer system tells us, we will check to find out what is correct. We might check your information by contacting your employer, your bank or other people. If any part of the information on this application is incorrect, SNAP benefits may be denied and you may be subject to criminal prosecution for knowingly providing incorrect information. The information you give us may be checked by federal, state, and local officials to make sure it is true. Things we might check are any listed person’s: Social Security Number, job and pay, bank account amount, amounts received from other sources like Social Security or unemployment, and alien status.
Your Signature and Understanding
The questions on this application and what can happen if I hide information or give wrong information.
I must give proof of information about my household.
The DCBS office and the Quality Control unit may contact other people or organizations to get proof of my information.
That the infor
That as an appli
That social security numbers shall be used for various state and federal matches through the Income and Eligibility Verification System (IEVS). These matches include, but are not limited to, Social Security, IRS, SSI, Wage Records, Unemployment Insurance, Child Support Enforcement records and other matches as provided for under the authority of IEVS. This information may be verified through collateral contacts when discrepancies are found. Information provided under IEVS, after verification, may affect eligibility for and amount of benefits.
I certify, under penalty of perjury, that:
My answers are correct and complete to the best of my knowledge.
My answer about citizenship or alien status of each person applying for assistance is correct.
What Do Our Terms Mean?
We use these terms in the application. This is what they mean:
How To Get A Hearing
You may ask for a hearing within 90 days from the date you receive a notice from us about your SNAP application if you disagree with something we have done to your application or benefits. You may tell your side of the story or bring a friend, relative, or lawyer to speak for you at the hearing.
How do I ask for a hearing?
Call 1-855-306-8959; OR
Attach a separate sheet of paper to explain your reason for requesting a hearing, sign and date then:
Return to any DCBS office; OR
Return to: Cabinet for Health and Family Services, Division of Administrative Hearings, Families and Children Administrative Hearings
Branch, 105 Sea Hero Road, Suite 2, Frankfort, KY 40601
Optional Release of Information
Help Us Help You!
You do not have to sign this, but it will help us get information we need to help you, without having to get your signature on specific requests.
You should know:
• We may need more information to decide if you can get assistance.
• If more information is needed from you, you will get a letter telling you what we need and the date you must get it to us.
• You are responsible to get the information or to ask us for help to get it.
• If you do not give us the information or ask for help by the due date, your application may be denied or your assistance may end.
• We may be able to use the release below to get the information we need, but you still have to provide the information we request or ask for help.
• We may attach a copy of this release to a form that asks other people or organizations (like your employer) for specific information needed about you or others in your household.
Print and sign your name below to give us permission to get needed information.
RELEASE OF INFORMATION
I hereby authorize any person or organization to give the Kentucky Department of Community Based Services requested information about me or other members of my household. A copy of this release is as valid as the original. This release does not apply to protected health information. This release is good for 12 months from the date signed.
Your Name (please print clearly)
Signature or Mark Witness (if signed by X)
Name:____________________________________ Social Security Number: _____________________
*If you need help filling out this form, call (855) 306-8959. You may locate your local office information at: https://prd.chfs.ky.gov/Office_Phone/index.aspx
8 of 8 local officials to make sure it is true. Things we might check are any listed person’s: Social Security Number, job and pay, bank account amount, amounts received from other sources like Social Security or unemployment, and alien status.
• We may be able to use the release below to get the information we need, but you still have to provide the information