Department Of Workforce Services printable pdf download

Date Received

State of Utah

DWS-OSD 61APP

Department of Workforce Services

Rev. 07/2005

APPLICATION FOR FOOD STAMPS, FINANCIAL

ASSISTANCE, CHILD CARE, AND MEDICAL ASSISTANCE

Esta solicitud también se encuentra disponible en Español

Case #:

Expedited:

Yes

Your Information:

1. Fill out the following information for the person requesting benefits.

Name:

First

Middle

Last

Home Address:

City:

Zip:

Mailing Address:

City:

Zip:

Social Security #:

Phone #:

Birth Date:

(optional)

Signature___________________________________

Check The Services You Are Applying For:

Food Stamps

Cash/Financial Assistance

Child Care

Medical

Retroactive Medical (last 90 days)

If you want to apply for unemployment benefits, log on to jobs.utah.gov or call (888) 848-0688.

Your Rights:

IF YOU NEED HELP FILLING OUT THIS APPLICATION, WE ARE HAPPY TO HELP.

YOU HAVE THE RIGHT TO AN INTERPRETER FREE OF CHARGE.

You can turn in an application with only your name, address, and signature, but you must complete the entire

application before we can determine you eligible for benefits.

We will issue your assistance based on the date we receive your application.

For Child Care it is not mandatory for you to give your social security number or the social security numbers of

the dependents in your household. If you choose not to give this information, your child care benefits will not

be withheld or delayed if you meet all eligibility criteria.

Food Stamp and Medicaid Information for Immigrants:

You can apply for and get food stamp and Medicaid benefits for eligible family members, even if your family

includes other members who are not eligible because of immigration status. For example, immigrant parents

may apply for food stamp benefits for their U.S. citizen or qualified immigrant children, even though the

parents may not be eligible for benefits.

You do not have to provide immigration status information, social security numbers, or documents for any

family members who are not eligible for food stamp benefits because of immigrant status and who are not

asking for food stamp benefits. Family members who are not eligible for food stamp or Medicaid benefits will

still need to answer other questions about their name, relationship, income, assets, etc.

Using food stamp benefits will not affect your immigration status or the immigration status of your family.

Immigration information is private and confidential.

Use of Medicaid benefits by you or your family members should not affect your ability to apply for permanent

resident status unless you use Medicaid to pay for long-term care (nursing home or other institutionalized

care). Use of Medicaid benefits will not affect your ability to apply for citizenship unless you committed fraud in

getting those services.

Department Of Workforce Services

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