Supplemental Nutrition Assistance Program (Snap) Application/recertification (Page 5 of 7) in pdf

LDSS-4826

Page 4

(Rev.8/12)

READ THE IMPORTANT INFORMATION BELOW (cont’d)

If you have an overpayment that is not paid back, it will be referred for collection in a number of ways, including automated collection by the federal government.

Federal benefits (such as Social Security) and tax refunds that you are entitled to receive may be taken to pay back the overpayment. The debt will also be

subject to processing charges.

Any expunged SNAP benefits will be put towards your overpayment. If you apply for SNAP again, and have not repaid the amount you owe, your SNAP benefits

will be reduced if you begin to get them again. You will be notified, at that time, of the amount of reduced benefits you will get.

CONSENT – I understand that by signing this application form I agree to any investigation made by the New York State Office of Temporary and Disability

Assistance or my local social services district to verify or confirm the information I have given or any other investigation made by them in connection with my

request for SNAP. If additional information is requested, I will provide it. I will also cooperate with State and Federal personnel in a SNAP Quality Control

Review.

CONSENT FOR RELEASE OF CONFIDENTIAL UNEMPLOYMENT INSURANCE (UI) INFORMATION – I authorize the New York State Department of Labor

(DOL) to release any confidential information, maintained by DOL for Unemployment Insurance (UI) purposes, to the New York State Office of Temporary and

Disability Assistance (OTDA). This information includes UI benefit claims and wage records. I understand that OTDA, along with State and local agency

employees working in local social services district offices, will use the UI information for establishing or verifying eligibility for, and the amount of, TA, MA, or

SNAP applied for in this application and for investigations to determine whether I received benefits to which I was not entitled.

SUA (STANDARD UTILITY ALLOWANCE) INFORMATION – I understand that SNAP recipients are categorically income eligible for the Home Energy

Assistance Program (HEAP). If I am not included in the annual automatic HEAP payment process for certain SNAP recipients, my household intends to apply

for a HEAP benefit within the next 12 months. If I decide not to apply for HEAP within the next 12 months, I will let my worker know.

TELEPHONE ALLOWANCE INFORMATION – I understand that SNAP recipients are eligible for a telephone allowance if they pay to use a home phone, cell

phone, phone, phone calling card or coin operated pay phone. If I do not have any cost to make phone calls, I will let my worker know.

CHANGES – I agree to inform the agency promptly of any change in my needs, income, property, living arrangement, pregnancy status or address to the best

of my knowledge or belief in accordance with my reporting requirements.

REQUIREMENT TO REPORT/VERIFY HOUSEHOLD EXPENSES – I understand that my household must report child care and utility expenses in order to get

a SNAP deduction for these expenses. I further understand that my household must report and verify rent/mortgage payments, property taxes, insurance,

medical expenses and child support paid to a non-household member in order to get a SNAP deduction for these expenses. I understand that failure to

report/verify the above expenses will be seen as a statement by my household that I/we do not want to receive a deduction for those unreported/unverified

expenses. A deduction for these expenses may make me eligible for SNAP or may increase my SNAP benefits. I understand that I may report/verify these

expenses at any time in the future. This deduction would then be applied to the calculation of SNAP in future months in accordance with the rules for change

reporting and processing changes.

PRIVACY ACT STATEMENT – COLLECTION AND USE OF SOCIAL SECURITY NUMBER (SSN) – The collection of SSN’s is authorized for each household

member with respect to SNAP pursuant to the Food Stamp Act of 1977 (as amended, 7 US Code 2011-2036). The information we collect will be used to

determine whether your household is eligible or continues to be eligible for benefits. 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. The information will be used to check identity, to

verify earned and unearned income, and to determine if applicants or recipients can receive money or other help. The information may be disclosed to State and

Federal agencies for official examination and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.

If you or anyone applying/recertifying does not have an SSN, a SSN must be applied for at the Social Security Agency.