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Division of Family and
Children Services
Application for Benefits
YOU MUST HAND DELIVER, FAX or MAIL THE COMPLETED
APPLICATION TO YOUR LOCAL COUNTY OFFICE.
If you need help filling out this application or need help
communicating with us, ask us or call 1-877-423-4746. If you are
deaf or hard of hearing, please call GA Relay at 711. Our services
are free.
What Services Do We Offer at the Division of Family and Children
Services (DFCS)? DFCS offers the following services:
Food Assistance
Food Stamps are benefits that you can use to buy food at any
store that has the EBT/Quest sign. We will subtract the price
of your food purchase from your Food Stamp account.
Cash Assistance/Employment Support Services
Temporary Assistance for Needy Families (TANF) provides
cash assistance to families with dependent children for a
limited time. Parents or caretakers who are included in the
grant are required to participate in a work program.
Cash Assistance program also provides financial assistance
to refugee households who are not eligible for the TANF
program.
Medical Assistance
Medicaid, for those who are eligible, may help pay medical
bills, doctor’s visits, and Medicare premiums.
Community Outreach Services
For more information about other DFCS services, please visit
our website at http://dfcs.dhs.georgia.gov
or call 1-877-423-
4746.
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Division of Family and
Children Services
Application for Benefits
How Do I Apply for Benefits?
Step 1. Fill out the application.
Read the questions carefully and give accurate information. Sign
and date the application.
Step 2. Turn in the application to your local office.
You will need to tear off pages 1-5, 26-33 and keep them for
yourself.
Mail, fax, or bring in pages 6-25 of this application to your local
Division of Family & Children Services (DFCS) office. You can
locate your local office at http://dfcs.georgia.gov/county-offices.
If you or the person for whom you are applying is eligible for
benefits, Food Stamp or TANF benefits will be provided from the
date that we receive the application with your name, address, and
signature on it.
If you are applying for Food Stamps, and/or Medicaid, you can file
an application for benefits with only your name, address and
signature. However, it may help us to process your application
quicker if you complete the entire form. You may use this form to
file a joint application for more than one program or for the Food
Stamp Program (FS) only. Your FS application will not be denied
solely on the basis that your application for another program has
been denied. We will make a separate eligibility determination for
your FS application. If you are in an institution and applying for
Food Stamps and SSI at the same time, the filing date of your
application is the date you are released from the institution.
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Division of Family and
Children Services
Application for Benefits
Step 3. Talk with us.
You may need to complete an interview with a worker. If so, we will
give you an appointment. This interview can be completed by
phone.
Frequently Asked Questions
How long does it take to get benefits?
Food Stamps: up to 30 days
TANF: up to 45 days
Medicaid: 10 to 60 days
You may be able to get Food Stamps within 7 days if you qualify.
See page 10.
How much will I get?
Your income, resources, and family size determine benefit
amounts. We will be able to give you specific information once we
determine your eligibility.
For Medicaid, you will receive a Medicaid card for each eligible
member.
How will I get my benefits?
For Food Stamps, you will get an Electronic Benefit Transfer (EBT)
card to access your benefits. For TANF, you will get an EPPIC
Debit Master card to access your benefits. For Medicaid, you will
receive a Medicaid card for each eligible member.
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Division of Family and
Children Services
Application for Benefits
What information will I need to provide?
It is a good idea to provide the following:
• Proof of identity for the applicant if applying for Food Stamps
and/or TANF. Proof of identity for everyone if applying for
Medical Assistance. An identification card (ID) or driver’s
license (DL).
• Proof of US citizenship/qualified immigrant status for everyone
requesting benefits. If you are applying for emergency medical
services only, you do not have to provide your SSN or
information about your immigration status.
• Social Security numbers of everyone requesting assistance.
• Proof of income for example, pay stubs, child support
payments, and income award letters.
• Proof of expenses like child care receipts, medical bills, medical
transportation costs, and child support payments.
You will be given time to return any information to our office. If you
need help getting this information, please tell us.
How do we use the applicant’s personal information?
You only have to provide Social Security Numbers (SSN) and
citizenship or immigration status for persons who want to apply for
benefits. This information will be used to check the income and
eligibility verification system (IEVS). We will also match your
information against other Federal, state and local agencies to verify
your income and eligibility, to track wage information and
participation in work activities. If a household member does not
want to give us information about their SSN, citizenship, or
immigration status, other household members may still receive
benefits.
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Division of Family and
Children Services
Application for Benefits
If you are applying for emergency medical services only, you
do not have to provide your SSN or information about your
immigration status.
Can someone else apply for me?
For Food Stamps and Medicaid, you may ask someone to apply for
you.
For TANF, anyone can apply but the parent or caretaker must be
interviewed.
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Division of Family and
Children Services
Application for Benefits
(Complete this application and return it to your LOCAL
COUNTY DFCS office.)
What Am I Applying For: (Check all that apply)
Food Stamps
The Food Stamp Program provides monthly benefits to low-
income households to help pay for the cost of food. The
program also provides nutrition education and helps eligible
households to meet their food and nutritional needs.
Temporary Assistance for Needy Families (TANF)
Temporary Assistance for Needy Families (TANF) provides
temporary monthly cash payments, single cash payments, or
other support services, to strengthen eligible families with
children. If you are the child’s parent, or the caretaker who
would like to be included in the grant, we will require you to
participate in a work program.
Refugee Cash Assistance
The Refugee Cash Assistance program provides financial
assistance to refugee households who are not eligible for the
TANF program. The term refugee includes refugees, Cuban/
Haitian Entrants, victims of human trafficking, Amerasians, and
unaccompanied refugee minors.
Medicaid
Medicaid offers medical coverage to elderly, blind or disabled
adults, pregnant women, children, and families. When you
apply, we will look at all Medicaid programs and decide which
ones you may be eligible to receive.
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Division of Family and
Children Services
Application for Benefits
Tell Us About the Applicant
Does the applicant or person applying on behalf of the applicant
need assistance when communicating with us? If so, check all that
apply.
( ) TTY ( ) Braille ( ) Large Print ( ) E-mail ( ) Video Relay)
( ) Sign Language Interpreter _______________
( ) Foreign Language Interpreter (specify language)
______________________
( ) Other ______________
Please fill out the chart below about the applicant
.
First Name Middle Initial Last Name
Suffix
Street Address Where You Live Apt
City State Zip Code
Mailing Address (if different)
City State Zip Code
Main Telephone Number Other Contact Number
E-Mail address (optional)
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Division of Family and
Children Services
Application for Benefits
I declare under penalty of perjury to the best of my knowledge and
belief that the person(s) for whom I am applying for benefits is/are
U.S. citizen(s) or are lawfully present in the United States. I further
certify that all of the information provided on this application is true
and correct to the best of my knowledge. I understand and agree
that DHS-DFCS, DCH and authorized Federal Agencies may verify
the information I give on this application. Information may be
obtained from past or present employers. I understand that my
information will be used to track wage information and my
participation in work activities. I will report any change in my
situation according to Food Stamp/Medicaid and/or TANF program
requirements. If any information is incorrect, benefits may be
reduced or denied and I may be subject to criminal prosecution or
disqualified from DHS programs for knowingly providing incorrect
information. I understand that I can be prosecuted if I provide false
information or hide information. I understand that if I fail to tell
DHS-DFCS about some of my expenses at my application or
renewal interview and/or fail to verify them that DHS-DFCS will not
budget that expense in calculating the amount of my food stamp
benefits.
_______________________________________________________________ _______________________
Signature Date
________________________________ ____________
Witness Signature if signed by “X” Date
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Division of Family and
Children Services
Application for Benefits
Can I Choose Someone to Apply for Food Stamps or Medicaid
for me?
Complete this section only if you want someone to fill out your
application, complete your interview, and/or use your EBT card to
buy food when you cannot go to the store. If you are applying for
Medicaid, you can choose more than one person to apply for
medical assistance on your behalf.
Name: _______________________ Phone: ________________
Address: ______________________ Apt: _______________
City: _________________ State: _______ Zip: ___________
Name: _______________________ Phone: ________________
Address: ______________________ Apt: _______________
City: _________________ State: _______ Zip: ___________
For Medicaid, do you want this individual to have a copy of your
Medicaid card? Yes No
For Office Use Only
Date Received: ___________________________
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Division of Family and
Children Services
Application for Benefits
Do I Qualify to Get Food Stamps Faster? Answer these
questions about the applicant and all household members to see if
you can get Food Stamps within 7 days.
1. Are you or any household member a migrant or seasonal farm
worker? Yes No If yes, who: _____________________
2. Total Gross earned income that will be received for this
month: $ _________________
Employer Name __________________________________
Employment Begin Date _____________
Employment End Date_______________
Rate of Pay __________ Hours Worked Weekly _________
wk/bi-wk/semi-mo/mo (circle one)
3. Total Gross unearned income that will be received for this
month: $ _________________
Type of Unearned Income ____________ Amount _______
wk/bi-wk/semi-mo/mo (circle one)
Type of Unearned Income ____________ Amount _______
wk/bi-wk/semi-mo/mo (circle one)
4. Total earned and unearned income for this month: $ ______
5. How much money do you and all household members have
in cash or in the bank? $ _________________
6. What is the monthly amount of your rent, mortgage, property
taxes, and/or homeowners insurance? $ _________
7. What is the total amount of your electric, water, gas, and/or
other utilities this month? $ ___________ (Exclude past
due and late fee amounts in the total)
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Division of Family and
Children Services
Application for Benefits
Tell Us about the Applicant and All Household Members
Please fill out the chart below about the applicant and all
household members. The following federal laws and
regulations: The Food and Nutrition Act of 2008, 7 U.S.C. §
2011-2036, 7. C.F.R. § 273.2, 45 C.F.R. § 205.52, 42 C.F.R. §
435.910, and 42 C.F.R. § 435.920, authorize DFCS to request
you and your household members social security number(s).
Anyone who is living in your household and is not applying for
benefits may be treated as a non-applicant. Non-applicants do
not have to give us information about their social security number,
citizenship, or immigration status and are not eligible for benefits.
Other household members may still be able to receive benefits, if
they are otherwise eligible. If you want us to decide whether any
household members are eligible for benefits, you will still need to
tell us about their citizenship or immigration status and give us their
social security number (SSN). You will still need to tell us about
their income and resources to determine the eligibility and benefit
level of the household. We will not report any non-applicant
household members to the United States Citizenship and
Immigration Services (USCIS) Systematic Alien Verification for
Entitlements (SAVE) system if they do not give us their citizenship
or immigration status. However if immigration status information
has been submitted on your application, this information may be
subject to verification through the SAVE system and may affect the
household’s eligibility and benefit level. We will match your
information with other Federal, state, and local agencies to verify
your income and eligibility. This information may also be given to
law enforcement officials to use to catch people who are running
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Division of Family and
Children Services
Application for Benefits
from the law. If your household has a Food Stamp claim, the
information on this application, including SSN, may be given to
Federal and State agencies and private claims collection agencies
for them to use in collecting the claim. We will not deny benefits to
applicant household members because other household members
fail to provide their SSN, citizenship, or immigration status.
NAME
Relationship
to You
Is this person
applying for benefits?
Birth Date(m/d/y)
Social Security
Number (applicant
only)
Sex (M/F)
Hispanic/ Latino?
(optional)
Race Code (optional)
See Code below
Are you a U.S.
citizen, qualified
alien /immigrant?
(Applicant Only)
First,
Middle
Initial, Last
Y/N
Y/N
Y/N
SELF
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Division of Family and
Children Services
Application for Benefits
Tell Us More about the Applicant and All Household Members
We need more information about the applicant and all household
members in order to decide who is eligible for benefits. Please
answer only the questions about the benefits you want to receive
on the page below.
1. Has anyone received any benefits in another county or state?
Yes No
If yes:
Who: __________________
Where: __________________________________
When: ___________________________________
2. Has anyone been convicted of giving false information about
where they live and who they are to get multiple FS benefits in
more than one area after 8/22/96? (For Food Stamps only)
Yes No
If yes:
Who: __________________
Race Codes (Choose all that apply):
AI – American Indian/Alaska Native AS – Asian
BL – Black/African American WH – White
HP – Native Hawaiian/Pacific Islander
By providing Race/Ethnicity information, you will assist us in
administering our programs in a non-discriminatory manner. Your
household is not required to give us this information and it will not
affect your eligibility or benefit level.
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Division of Family and
Children Services
Application for Benefits
Where: _________________
When: ___________________________________
3. Did anyone in your household voluntarily quit a job or voluntarily
reduce his/her work hours below 30 hours per week within 30
days of the date of application? (For Food Stamps and TANF
only) Yes No
If yes, who quit?
_________________________________________________
Why did he/she quit?
__________________________________________________
4. Is anyone pregnant? *Please provide proof of pregnancy if
available. Yes No
If yes:
Who: ______________________
Due Date: __________________
(This question does not apply to Food Stamp only applicants)
5. For Medicaid, does anyone have any unpaid medical bills for
the last 3 months? Yes No
(This question does not apply to Food Stamp or TANF only
applicants)
6. Is anyone disqualified from the Food Stamp or TANF Program?
Yes No
If yes:
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Division of Family and
Children Services
Application for Benefits
a. Who: ____________________________________
b. Where: __________________________________
7. Is anyone trying to avoid prosecution or jail for a felony? (Food
Stamps and TANF Only) Yes No
If yes, who: ______________________________________
8. Is anyone violating conditions of probation or parole? (For Food
Stamps and TANF only) Yes No
If yes, who: _______________________________________
9. Does anyone have a felony conviction because of behavior
related to the possession, use or distribution of a controlled drug
substance (i.e. drug felon) after 8/22/96 (For Food Stamps and
TANF only) or a violent felony (TANF only)? Yes No
If yes:
Who: _______________________________________
When: ______________________________________
a) Are you in compliance with any terms of probation related to
any sentence received as a result of a drug felony conviction?
(Food Stamps and TANF only) Yes No
b) Are you in compliance with the terms of parole related to any
sentence received as a result of a drug felony conviction? (
Food Stamps and TANF only) Yes No
c) Have you successfully completed all the terms of probation
or parole related to any drug related conviction?
(Food Stamps and TANF only) Yes No
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Division of Family and
Children Services
Application for Benefits
10. Have you or any household member been convicted of trading
Food Stamp benefits for drugs after 8/22/96? (For Food Stamps
only) Yes No
If yes:
Who: _______________________________________
When: ______________________________________
11. Have you or any household member been convicted of buying
or selling Food Stamp benefits over $500 after 8/22/96? (For Food
Stamps Only) Yes No
If yes:
Who: ____________________
When: ______________________________________
12. Have you or any household member been convicted of trading
Food Stamp benefits for guns, ammunition or explosives after
8/22/96? (For Food Stamps Only) Yes No
If yes:
Who: _____________________
When: ______________________________________
13. Has anyone used TANF funds or the EPPIC Card at the
following establishments, liquor stores, casinos, poker rooms,
adult entertainment business, bail bonds, night clubs,
salons/taverns, bingo halls, race tracks, gun/ammunition stores,
cruise ships, psychic readers, smoking shops, tattoo/piercing
shops, and spa/massage salons.? (For TANF only)
Yes No
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Division of Family and
Children Services
Application for Benefits
If yes:
Who: ________________________________________
When: _______________________________________
Tell Us about the Applicant and All Household Members
Income
Do you or anyone you are applying for receive any type of income
such as: wages, tips, bonuses, self-employment, Social
Security/Railroad Retirement, other disability, VA income, pensions,
unemployment, child support, Alimony, money from other people,
workers compensation, or any other income?
Household
Member Name
with Income
Type of Income
Employer Name
/Source of
Income
Monthly Amount
(Before
Deductions)
How Often
received
(monthly,
biweekly, weekly)
Pay Per Hour
Hours per Week
DATE
(S) PAID
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Division of Family and
Children Services
Application for Benefits
Tell Us about the Applicant and All Household Members
Expenses
Do you pay for the care of a dependent child or a disabled
adult household member? Yes No If yes, complete the
chart below. (For Food Stamps provide proof if the monthly amount
is more than $200)
Person
who
requires
care
Person
who
pays
for care
Reason
for care
Provider’s
Name/Number
Amount
paid to
Provider
How
often
paid
Do you pay transportation expenses for a dependent child or
disabled adult household member? Yes No
Are these expenses included in the dependent care expenses?
Yes No
If no, please answer this question: Total miles driven weekly:
________________________
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Division of Family and
Children Services
Application for Benefits
Does anyone 60 years of age or older or disabled have medical
expenses? Yes No If yes, complete the chart below.
Household
Member
Who Has
Expense
Type of
Expense*
Amount
Owed
Still
Owed?
Yes/No
Date
Paid
Will
Insurance
Pay?
Yes/No
*Type of Expenses can include: (doctor visits, hospital visit,
prescriptions, Medicare or health Insurance premiums, glasses)
Does anyone 60 years of age or older or disabled have medical
expenses for transportation? Yes No
If yes, complete chart below.
Purpose of the trip
(doctor or hospital visit;
pharmacy pick-up)
Total miles
driven:
Cost of taxi, bus,
parking or lodging:
Tell Us More about the Applicant and All Household Members
Expenses
Does anyone in the household pay child support to someone
living outside of the home? Yes No
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Division of Family and
Children Services
Application for Benefits
If yes, complete the chart below.
Household
Member
Obligated to
Pay
Name of
Child for
Whom
Support is
paid
Obligated
Amount
to Pay
Actual
Amount
Paid
To Whom is
Child
Support
Paid?
Do you or any household member have shelter expenses?
Yes No
If yes, complete the chart below.
Expense
Amount
How Often?
Who paid?
Rent/Mortgage
Property
Taxes
Property
Insurance
Electricity
Gas
Garbage
Telephone
Other
Do you share monthly household expenses with anyone in the
home? Yes No
If yes, who? ___________________________________________
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Division of Family and
Children Services
Application for Benefits
Comments/Documentation________________________________
__________________________________
Paid to whom_______________ Amount paid $_______ per _____
Landlord’s Name: _____________________________________
Landlord’s address: ___________________________________
Have you received energy assistance in the last 12 months?
Yes No If yes, amount received $________________
Does someone else pay any of these household bills for you?
Yes No If yes, complete the chart below:
Who pays the bill?
What bills are paid?
What amount is paid?
To whom does this person pay
the bills?
Food Stamp Program Penalties
You may lose your benefits or be subject to criminal prosecution for
knowingly providing false information.
• Do not give false information or hide information to get benefits
that your household should not get.
• Do not use Food Stamps or EBT cards that are not yours and
do not let someone else use yours.
• Do not use Food Stamp benefits to buy nonfood items such as
alcohol or cigarettes or to pay on credit cards.
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Division of Family and
Children Services
Application for Benefits
• Do not trade or sell Food Stamps or EBT cards for illegal
items; such as firearms, ammunition or controlled substance
(illegal drugs).
Any household member who breaks any of the food stamp
rules on purpose can be barred from the Food Stamp Program
for one year to permanently, fined up to $250,000, imprisoned
up to 20 years or both. She/he may also be subject to
prosecution under other applicable Federal and State laws.
She/he may also be barred from the Food Stamp Program for
an additional 18 months if court ordered.
Any household member who intentionally breaks the rules
may not get Food Stamps for one year for the first offense, two
years for the second offense, and permanently for the third
offense.
If a court of law finds you or any household member guilty of
using or receiving food stamp benefits in a transaction
involving the sale of a controlled substance, you or that
household member will not be eligible for benefits for two
years for the first offense, and permanently for the second
offense.
If a court of law finds you or any household member guilty of
having used or received benefits in a transaction involving the
sale of firearms, ammunition or explosives, you or that
household member will be permanently ineligible to participate
in the Food Stamp Program upon the first offense of this
violation.
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Division of Family and
Children Services
Application for Benefits
If a court of law finds you or any household member guilty of
having trafficked benefits for an aggregate amount of $500 or
more, you or that household member will be permanently
ineligible to participate in the Food Stamp Program upon the
first offense of this violation.
If you or any household member is found to have given a
fraudulent statement or representation with respect to identity
(who they are) or place of residence (where they live) in order
to receive multiple Food Stamp benefits, you or that
household member will be ineligible to participate in the Food
Stamp Program for a period of 10 years.
TANF Program Penalties
In the TANF Program, an IPV (Intentional Program Violation) is an
intentional action by an individual to establish or maintain an
assistance unit’s (AU’s) eligibility, or to increase or prevent a
decrease in the AU’s benefits, by providing false or misleading
information or withholding information.
• Any household member who hides information and does not
report changes on time or does not tell the truth will lose TANF
benefits for six months for the first violation, twelve months for
the second violation and permanently for the third violation.
The misuse of the cash assistance funds or TANF DEBIT card
to withdraw cash or perform transactions at casinos, liquor
stores, adult-oriented entertainment facilities “strip clubs”,
poker rooms, bail bonds, night clubs/salons/taverns, bingo
halls, race tracks, gaming establishments, gun/ammunition
stores, cruise ships, psychic readers, smoking shops,
tattoo/piercing shops, and spa/massage salons is strictly
prohibited and will result in a loss of TANF benefits for six
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months for the first violation, twelve months for the second
violation and permanently for the third violation.
If a court of law finds you or any household member hiding
information or you do not report changes on time or do not tell
the truth and are convicted, you may not get TANF for 12
months for the first violation and permanently for the second
violation.
If a court of law finds you or any household member guilty of
giving false information about where you live so you can
receive benefits in more than one state you will be barred for
10 years.
If a court convicted you of a drug-related charge controlled
substance or a serious violent felony, on or after 1/1/97 you or
that household member will not be eligible and/or permanently
disqualified.
For All Food Stamp, TANF, and Medicaid Applicants:
I declare under penalty of perjury to the best of my knowledge and
belief that the person(s) for whom I am applying for benefits is/are
U.S. citizen(s) or are lawfully present in the United States. I further
certify that all of the information provided on this application is true
and correct to the best of my knowledge. I understand and agree
that DHS-DFCS, DCH and authorized Federal Agencies may verify
the information I give on this application. Information may be
obtained from past or present employers. I understand that my
information will be used to track wage information and my
participation in work activities.
I will report any change in my situation according to Food
Stamp/Medicaid and/or TANF program requirements. If any
information is incorrect, benefits may be reduced or denied and I
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may be subject to criminal prosecution or disqualified from DHS-
DFCS programs for knowingly providing incorrect information. I
understand that I can be prosecuted if I provide false information or
hide information.
I understand that if I fail to tell DHS-DFCS about some of my
expenses at my application or renewal interview and/or fail to verify
them that DHS-DFCS will not budget that expense in calculating
the amount of my food stamp benefits.
_______________________________________________________________ ________________________________________________
Applicant’s Signature Date
_____________________________________________________
Authorized Representative’s Signature Date
_____________________________________________________
Case Manager’s Name and Signature Date
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(Keep these documents for your information)
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 or 2)
Fax: (202) 690-7442; or 3) Email: program.intake@usda.gov.
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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.
You may also file a complaint of discrimination by contacting the
DFCS Civil Rights Program, Two Peachtree Street, N.W., Suite 19-
248, Atlanta, Georgia 30303 or call (404) 657-3735 or fax (404)
463-3978. For limited English proficient and sensory impaired
services, contact the DHS Limited English Proficiency and
711Sensory Impaired Program at: Two Peachtree Street, N.W.,
Suite 29-103 N.W., Atlanta, GA 30303 or call (404)-657-5244 or fax
(404)-651-6815.
Under the Department of Community Health (DCH) policy,
Medicaid cannot deny you eligibility or benefits based on your race,
age, sex, disability, national origin, or political or religious beliefs.
To report Medicaid eligibility or provider discrimination, call the
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Georgia Department of Community Health’s Office of Program
Integrity (local 404-463-7590) (toll free) 800-533-0686.
What Do the Words Used in this Application Mean?
This chart explains the words we have used in this application.
Caretaker
A parent, relative or legal guardian who applies for and
receives TANF with children in his or her care.
Grantee
Relative
A parent, relative or legal guardian who applies for and
receives TANF in his or her name on behalf of the
children.
Disqualified
The action taken to remove an individual from a Food
Stamp or TANF case because they did not tell the
truth and received benefits that they should not have
received.
Electronic
Benefit
Transfer
(EBT)
The system used in Georgia to pay benefits to
individuals who are eligible for Food Stamps.
Individuals receiving assistance are issued an EBT
debit card, which is used to access their food stamp
accounts.
EPPICard
debit
MasterCard
New debit card issued by Xerox for individuals
receiving cash assistance in Georgia. The EPPICard
debit MasterCard will be accepted for purchases and
cash withdrawals anywhere the MasterCard is
accepted.
Household
Members
Individuals who live in your home. For Food Stamps,
individuals who live together and purchase and
prepare their meals together.
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Income
Payments such as wages, salaries, commissions,
bonuses, worker’s compensation, disability, pension,
retirement benefits, interest, child support or any
other form of money received.
Gross
Income
A person’s total income before taking taxes or other
deductions into account.
Migrant
Farm
Workers
Individuals who are seasonal farm workers and who
move from one home base to another to work or look
for farm work.
Resources
Cash, property, or assets such as bank accounts,
vehicles, stocks, bonds, and life insurance.
Seasonal
Farm
Workers
Individuals who work at certain times of the year
planting, picking or packing produce. They are hired
on a temporary basis when a job requires more
workers than the farm employs on a regular basis.
Middle
Class Tax
Relief Act
of 2012
This Act prohibits the use of cash assistance funds or
TANF Debit Cards to withdraw cash or perform
transactions at casinos, liquor stores, adult-oriented
entertainment facilities, poker rooms, bail bonds,
night clubs/salons/taverns, bingo halls, race tracks,
gaming establishments, gun/ammunition stores,
cruise ships, psychic readers, smoking shops,
tattoo/piercing shops, and spa/massage salons. The
use of cash assistance funds or the TANF Debit Card
at these businesses will constitute an intentional
program violation (fraud) on the part of the recipient.
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Applicant
An individual who chooses to apply for or receive
public assistance/benefits.
Non-
applicant
An Individual who does NOT apply for or receive
public assistance/benefits; non-applicants are not
required to provide an SSN, citizenship or immigration
status.
Assistance
Unit
An assistance unit includes eligible individuals who
live together and receive public assistance/benefits
together.
Trafficking
in the
SNAP/Food
Stamp
Program
Trafficking SNAP benefits means: (1) Buying, selling,
stealing, or otherwise exchanging SNAP benefits
issued and accessed via EBT cards, card numbers
and PIN numbers or by manual voucher and
signature, for CASH or consideration other than
eligible food, either directly, indirectly, in complicity or
collusion with others, or acting alone; (2) The
exchange of firearms, ammunition, explosives, or
controlled substances; (3) Purchasing a product with
SNAP benefits that has a container requiring a return
deposit with the intent of obtaining cash by discarding
the product and returning the container for the deposit
amount, intentionally discarding the product, and
intentionally returning the container for the deposit
amount; (4) Purchasing a product with SNAP
benefits with the intent of obtaining cash or
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consideration other than eligible food by reselling the
product, and subsequently intentionally reselling the
product purchased with SNAP benefits in exchange
for cash or consideration other than eligible food; (5)
Intentionally purchasing products originally purchased
with SNAP benefits in exchange for cash or
consideration other than eligible food; (6) Attempting
to buy, sell, steal, or otherwise affect an exchange of
SNAP benefits issued and accessed via Electronic
Benefit Transfer (EBT) cards, card numbers and
personal identification numbers (PINs), or by manual
voucher and signatures, for cash or consideration
other than eligible food, either directly, indirectly, in
complicity or collusion with others, or acting alone.
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Qualified
Alien/Immi
grant
A qualified alien/immigrant is a person who is legally
residing in the U.S. who falls within one of the
following categories: a person lawfully admitted for
permanent residence (LPR) under the Immigration
and Nationality Act (INA); Amerasian immigrant under
section 584 of the Foreign Operations, Export
Financing and Related Program Appropriations Act of
1988; a person who is granted asylum under section
208 of the INA; Refugees, admitted under section 207
of the INA; A person paroled into the US under
section 212(d)(5) of the INA for at least one year; A
person whose deportation is being withheld under
section 243(h) of the INA as in effect prior to April 1,
1997 , or section 241(b)(3) of the INA, as amended; a
person who is granted conditional entry under section
203(a)(7) of the INA as in effect prior to April 1, 1980;
Cuban or Haitian immigrants as defined in section
501(e) of the Refugee Education Assistance Act of
1980; victims of human trafficking under section
107(b)(1) of the Trafficking Victims Protection Act of
2000; battered immigrants who meet the conditions
set forth in section 431 (c) of the Personal
Responsibility and Work Opportunity Reconciliation
Act of 1996, as amended; Afghan or Iraqi immigrants
granted special immigrant status under section
101(a)(27) of the INA (subject to specified
conditions); American Indians born in Canada living in
the U.S. under section 289 of the INA or non-citizens
of federally-recognized Indian tribe under Section 4(e)
of the Indian Self-Determination and Education
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Assistance Act and Hmong or Highland Laotian tribal
members that rendered assistance to U.S. personnel
by taking part in military or rescue operation during
Vietnam Era (8/05/1964 – 5/07/1975).
