Supplemental Nutrition Assistance Program (Snap) Application/recertification (Page 4 of 7) in pdf

LDSS-4826

Page 3

(Rev.8/12)

LIVING ARRANGEMENTS AND EXPENSES (Cont’d)

Pay for air conditioning, either in your electric bill or as a separate fee?

Yes

Pay separately for utilities

Yes

(other than heating/cooling)

(for example, lights, cooking gas, washer/dryer fees, garbage/trash, water, initial installation of utilities).

Does anyone else pay any of these expenses for you

(some examples are Section 8 or other subsidy program)

Yes

No If yes, who pays what? ________________________________________________________________________________

Do you or does anyone living with you pay court-ordered child support?

Yes

No If yes, who _____________________________________

Name(s) of child(ren) support is being paid for ______________________________________________________________________________________________

Payment amount $_______________ Frequency of payments

_______________

(for example, weekly, bi-weekly, monthly)

Are you, and/or anyone living with you, blind/disabled or at least age 60? If so, does such person have medical bills?

Yes

No If yes, list on the page 6 what they are

for, how much and who is responsible for payment.

Are you, and/or anyone living with you, on Medicaid with a spendown?

Yes

No If yes, who __________________________ Amount $ _____________________

Are you, and/or anyone living with you

enrolled in school or training?

Yes

No If yes, who __________________ where _________________

(16 years old or older)

You may use the page 6 if you need more room or there is other information that you think we might need.

READ THE IMPORTANT INFORMATION BELOW

SNAP PENALTY WARNING – Any information you provide in connection with your application for SNAP will be subject to verification by Federal, State and

local officials. If any information is incorrect, you may be denied SNAP. You may be subject to criminal prosecution for knowingly providing incorrect information.

You will never be able to get SNAP again if you are found guilty in a court of law for the second time of buying or selling controlled substances (illegal drugs or

certain drugs for which a doctor’s prescription is required) in exchange for SNAP; or found guilty in a court of law of selling or getting firearms, ammunition or

explosives in exchange for SNAP; or found guilty in a court of trafficking in SNAP worth $500 or more. Trafficking includes the illegal use, transfer, acquisition,

alteration or possession of SNAP, authorization cards or access devices; or found guilty of committing a third Intentional Program Violation (IPV).

You will not be able to get SNAP for two years if you are found guilty in a court of law for the first time of buying or selling controlled substances (illegal drugs or

certain drugs for which a doctor’s prescription is required) in exchange for SNAP.

If you have committed your:  First IPV, you will not be able to get SNAP for one year.  Second IPV, you will not be able to get SNAP for two years.

A court could also bar you from receiving SNAP for an additional 18 months. If you make a false statement about who you are or where you live in order to get

multiple SNAP benefits, you will not be able to get SNAP for ten years (or permanently if this is the third IPV).

You may be found guilty of an IPV if you make a false or misleading statement, or misrepresent, conceal or withhold facts; or commit any act that constitutes a

violation of Federal or State law for the purpose of using, presenting, transferring, acquiring, receiving, possessing or trafficking of SNAP benefits, authorization

cards or reusable documents used as part of the Electronic Benefit Transfer (EBT) system.

You could also be fined up to $250,000, sent to jail for up to 20 years, or both.

Anyone who is fleeing to avoid prosecution, custody or confinement for a felony, or who is violating a condition of probation or parole, is not eligible to receive

SNAP.

If you get more SNAP benefits than you should have (overpayment), you must pay them back. If your case is active, we will take back the amount of the

overpayment from future SNAP benefits that you get. If your case is closed, you may pay back the overpayment through any unused SNAP benefits remaining

in your account, or you may pay cash.

Supplemental Nutrition Assistance Program (Snap) Application/recertification Page 4

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