Application For Food Stamps (Page 3 of 4) in pdf

Application For Food Stamps Page 3

FSP 901 (Rev. 8/04)

(Page 3) (English)

Information for non-citizens

You can get food stamps benefits for eligible family members. Even if you have family members who are not eligible because

of immigration status.

Example

Immigrant parents may apply for food stamp benefits for their U.S. citizen or qualified immigrant children. Even if the parents

are not eligible.

You may have a family member who is not eligible for food stamp benefits because of immigration status. If so, you do not

have to provide information about them. You do not need to provide their:



immigration status information.



social security numbers.



or documents.

You do have to provide their



proof of income.



resources.

Using food stamp benefits



will not affect your immigration status.



will not affect the immigration status of your family.

Immigration information is



private.



confidential.



We will contact the Bureau of Citizenship and Immigration Services only for the status of the applicant.

Statement of Understanding/Penalty Warning

I am applying for assistance.

I know that the information I provide on this application is subject to verification by:



Federal officials.



State officials.



Local officials.

Verification will determine if your information is true. It will include matching by computer with other agencies.

I understand that if I knowingly provide incorrect information:



I may be reduced or denied benefits.



I may be subject to criminal prosecution.



I may be disqualified from the program.

I agree the information I give on this form may be verified.



By the Division of Family Development.



By the County Welfare Agency.



By authorized Federal Agencies.

The information given at my interview will also be verified.

I agree that information may be obtained from:



my past employers.



my present employers.

This information is also subject to audit and program reviews.

To the best of my knowledge, I certify under penalty of perjury:



that the information on this form is true.



all the other information provided is true. (Information given to County Welfare office.)

Application For Food Stamps Page 3

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