ES-3100.

6 10-01

WELCOME TO THE KANSAS FOOD ASSISTANCE PROGRAM!

If you want to apply for food assistance only, please use this form. To get this assistance (also known as food stamp benefits), you will need to: (1) Fill out this entire form as completely as possible. (2) Provide proof of income and resources along with everyone's Social Security numbers. (3) Have the head of your household sign the form on page 4. You must also have an interview as part of the application process. However, if you are elderly or disabled, you do not have to come to the office for this interview. Your application will be processed within 30 days and if you are eligible, benefits will start from the date a signed application is received in our office. If you can't complete this application right now, you can simply, give us your name and address, sign at the bottom of this page, and return the form to the local SRS office. You must, however, still complete the entire form to see if you are eligible to get benefits. If you have a preferred language other than English, please check below:
Spanish Vietnamese Other_________________

For Office Use Only

Date received in agency: Case N o(s): Worker: Date Registered: Interview Date: Expedited

9 Yes 9 No

IMPORTANT!! You may be able to receive benefits within 7 days if your household has little or no income, your rent and utility bills are more than your income and resources, or you are a migrant or seasonal farm w orker. Please answer the following questions: Will your households gross incom e for this month be less than $1 50? Does your household have less than $100 in cash, checking, and savings? Is anyone in your hou sehold a m igrant or seasonal farm worke r? Shelter Expenses Current Rent/M ortgage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Current Monthly Utilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .+$ Total = $ Income & Resources Gross inco me expected this m onth . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ Total money in cash, checking & savings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .+$ $ Are your households shelter expenses more than your households expected gross income and resources? 1. List the perso n w h o is th e h ea d o f th e h ou sehold an d s ign b elow : name. First: Street Address: City: Mailing Address (if different from above): City: Home Phone: State: Work Phone: County: Zip Code: Message Phone: State: County: Zip Code: Middle: Last: Total = No Yes No No No Yes Yes Yes

Please use your legal

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SIGNATURE: 2. List yourself first and then all other persons in your home even if you are not applying for them. List anyone w ho is temporarily away from the home. Listing race or ethnic heritage is voluntary. Please use one or more the following codes: W = W hite B = Black or African American S = Asian H = Hispanic or Latino A = Am erican In dian or A laska N ative P = N ative Ha wa iian or Pa cific Islande r

Legal Name Relationship to Head of Household Want Benefits? Yes No Sex M/F

First

Middle

Last

Race - List all that apply (Optional)

U.S.

Date of Birth

Citizen? Yes No

Social Security Number

1. 2. 3. 4. 5. 6. 7. 8.

SELF

Has an yone received food stamp benefits this month or any time in the past? 9 No When? 3. Are your currently: What state?

9 Yes

If yes,

9 Single, never married 9 Married, separated

9 Married, living together 9 Divorced

9 Widowed

4. Is anyone a stu dent in high sc hool, co llege or vocationa l- technical sch ool? 9 No 9 Yes, please list name and what type of school. Name: Sch ool: Name: Sch ool: Name: Sch ool:

5. You can have som eone apply for food stamp benefits for you. If you want to do this, list him/her belo w. Name: Address:

6. You ca n also ch oos e som eon e to rec eive y our food stam p benefits for yo u. Th is pers on w ill be able to get and use your food stamp benefits. Please complete the following if you want to have someone get your food stamp benefits for you. Name: Address:

7. List anyone in your household who is disabled (including children) Name: Have they ever applied for disability benefits? If yes, what date:

The following questions are required by federal law. If you answer yes to Questions 8, 9, or 10, ONLY THAT P ERSO N ma y not get food stamp benefits. Others in the household, including children, would get food stamps, if eligible. 8. Has anyone in your household been convicted of a drug-related felony occurring after August 22, 1996?

9 No 9 Yes, list name:________________________________________________________________________

9. Is a nyone in y our ho usehold fleein g fro m felony pro sec ution or jail?

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9 No 9 Yes, list name:

10. Is anyone in your household in violation of probation or parole?

9 No 9 Yes, list nam e:

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11. Are there a ny re sou rces such as cash, ba nk/ sav ings /cre dit un ion a cco unts , certifica tes of dep osits (CDs), stocks, bonds, or real estate which anyone in your household owns or has their name on? 9 No 9 Yes, please list below. Name Type of Re source Amount or Value

Has an yone sold, traded, or given aw ay m oney, land, or other prope rty within the past 90 days? list property transferred: Equity Value:

9 No 9 Yes, please

12. Is anyon e in the hou seh old w orkin g, inclu ding self-employ ment? 9 No 9 Yes, please complete the information. Name Employer Name and Address Hourly Rate Hours Per Week How Often Paid

Has an yone be en em ployed in the last 60 days? 9 No 9 Yes, Name: Employer: _____ _ Date left:

Reason:

13. Is anyone in the household getting other income or money (such as Social Security, SSI, VA, W ork er's Com pensation, unem ployme nt benefits, other pension/retirement, child support, etc.)?

9 No 9 Yes, please complete.

Name Type of Income Amount How Often Received?

14. List how much your household owes each month for the following: Rent/Mortgage Property Taxes (not included in mortgage) Homeowners Insurance (not included in mortgage) Electricity (Nam e of Com pany): Gas/Prop ane (Na me of Com pany): Water/Sewer Trash Telephone Child Support/Alimo ny (Wh o is the child support/alimony for?): Child Ca re Medical Expenses (only for persons age 60 and older or who receive disability benefits. Include health insurance and M edicare prem iums).

Amount

Who Pa ys:

Does a nyone he lp you pay the ab ove expe nses? 9 No 9 Yes, list w hat expense s, w ho is pa ying , and how much is paid: 15. If you pay for heating or cooling, do you wish to use the Standard Utility Allowance? 16. Have yo u received Low Incom e Energy A ssistance (LIEAP )? Page 4 of 7

9 No 9 Yes

9 No 9 Yes

17. Do you (or will you) purchase and prepare meals separately from anyone else in the household? 9 No 9 Yes, list person(s)________________________________________________________________________

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IMPORTANT INFORMATION AND WARNINGS YOU HAVE THE RIGHT TO: C Equal treatment regardless of race, sex, color, age, disability, religion, political belief, or national origin. To file a complaint of discrimination write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity pro vider an d em ployer. C Have an interpreter provided at no cost if English is not your primary language. SRS HAS THE RIGHT TO: C Use your Social Security Number for computer matches with other organizations, such as banks, the IRS, and the Social Security Administration to verify your eligibility. C Conduct a full investigation of your eligibility including contacting employers, banks, or visiting your home. C Deny your application or prosecute for fraud if you give false information to obtain assistance. IMPORTANT!! Any member of your household who intentionally breaks the following rules may not get food stamp benefits for 1 year for the first offense, 2 years for the second offense, and permanently for the third offense; may be fined up to $250,000 or jailed up to 20 years, or both; may be barred from the Food Stamp Program for an additional 18 months if court ordered, may lose deductions; and may be prosecuted under other laws. C Don t lie or hide inform ation to get ben efits the hou seho ld should not get. C Dont use food stamp b enefits to buy non-food items, such as alcohol or cigarettes, or to pay on credit accounts. C Dont use or have in your possession improperly obtained food stamps or Vision cards. C Dont trade or sell Vision cards or use someone elses card. C If you buy, sell or trade more than $500 in Food Stamp benefits you may be barred permanently from the Food Stamp Program. If a court of law finds you guilty of trading food stamp benefits for firearms, ammunition, explosives or controlled substances, you will be subject to the following penalties: Loss of benefits fo r two years for the first offense and p erm ane ntly for th e second offense involving the sale o f a controlled substance, and Permane nt loss of benefits for the first offense involving the trading of firearms, ammun ition, or explosives. C If you are found to have ma de false or misleading statem ents about w ho you are or w here you live to ge t duplicate food stamp benefits, you may be barred from the Food Stam p Program for ten years. PLEASE READ & SIGN

C I understand the questions on this application and I understand the penalties for hiding or giving false
inform ation an d the rights a nd resp onsibilities stated in this ap plication an d as ex plained by SR S staff.

C I c ertify und er p en alty of p er ju ry th at my an sw ers are correct and complete to th e b es t of my

knowledge.

C I certify that all members of my household for whom I am applying for assistance are U.S. citizens or
are non-citizens in lawful imm igration status.

C I un dersta nd that info rm ation need ed to de term ine eligib ility m ay be v erifie d by con tacting federa l,
state, or local officials, employers, or other business or financial organizations.

C I un dersta nd that failu re to report o r verify a ny household exp enses means that I w ill not b e elig ible
for a deduction for those expenses.

C I agree to notify the local SRS office of changes in income, resources, household composition, and/or
address. AUTHORIZATION TO RELEASE INFORMATION My signature on this application authorizes employers, child care providers, financial institutions, insurance providers, benefit providers and other persons or agencies with knowledge of my circumstances to release to the Kansas Dep artm ent of So cial and R ehabilitation Services any inform ation, including confidential informa tion, nece ssary to establish my eligibility for food stamp benefits. All information provided on this application is protected by state and federa l confidentiality law s. This release is valid from the date set out below and sh all remain valid until revoke d in writing by th e undersigned. A copy of this au thorization is as valid as th e original. 1. Signature of Applicant 2. Signature of Applican ts Spouse or O the r Ad ult(s ) in H ouseh old 3. Signature of First Witness if X is Used 4. Signature of Second Witness if X is Used 5. Signature of Court-Appointed Guardian Page 6 of 7 Date Date Date Date Date

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