Application For Food Stamps (Page 2 of 4) in pdf

FSP 901 (Rev. 8/04)

(Page 2) (English)

4. EXPEDITED FOOD STAMPS

You may get Food Stamps within 7 days from submitting this application if:



your household has little or no income now.

(Your household is you and those who live and eat with you.);

(Examples of income are salary, Social Security and pensions)



and you file a complete application;

You may get Food Stamps within 7 days if:



your household (household is you and those who live, purchase food together and eat with you) income, cash and

resources are less than your monthly rent or mortgage and utilities. (Utilities are gas, electric, water and phone.)



or your household has migrant or seasonal farm workers.



or your gross monthly income (gross monthly income is your income before taxes) is less than $150.



and your household resources are $100 or less. (Resources are the money you have in the bank or in cash. Your money in

the bank can be in a checking account or a savings account.)

A. How many people live in your household?

___________

B. What is your total household income this month? __________

C. What is your total household cash and savings? __________

D. What do you pay in rent or mortgage each month? ________

What do you pay for utilities each month? ____________

What is the total for rent or mortgage plus utilities? _______

5. Are you, or is anyone in your household



a fleeing felon?

[ ] Yes

[ ] No



a probation violator?

[ ] Yes

[ ] No



a parole violator?

[ ] Yes

[ ] No



convicted of a drug charge

[ ] Yes

[ ] No

6. This application is for Food Stamps. Below are other programs for which you may want to apply. These are at the

CWA. Please check other programs for which you want to apply.

( ) Cash Assistance

( ) Medical Assistance

( ) Refugee Resettlement

7. Please indicate if you need any of the following accommodations.

( ) Translator _________ What Language? ___________________

( ) Signing

( ) Visually Impaired

( ) Other, Please explain ___________________________________________________________________________

If you are denied expedited service, but feel that you are entitled to it



You may request a conference with the County Welfare Agency.



The conference will be within 2 working days of the date of your request.

The Use of Your Social Security Number (SSN)

To apply, you MUST give us your SSN or apply for one. This is as required by P.L. 97-98.

WE USE SOCIAL SECURITY NUMBERS TO:



check that you are who you say you are.



keep you from getting more aid than you have a right to.



check other computer and government records to make sure you qualify.

We check social security, BCIS and Employment records.

If those records do not match what you say, it may affect whether



you qualify.



how much food stamps you get.

Application For Food Stamps Page 2

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