Department Of Workforce Services (Page 6 of 7) in pdf

Page 6

DWS Supportive Services Information

any

Please read the following information and ask questions on

part you do not understand.

In accordance with federal law, U.S. Department of Agriculture (USDA) policy, and U.S. Department

of Health and Human Services (DHHS) policy, we are prohibited from discriminating on the basis of

race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy,

discrimination is prohibited also on the basis of religion or political beliefs. To file a complaint of

discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, Room 326-W,

Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call

(202)720-5964 (voice and TDD). Write HHS, Director, Office for Civil Rights, Room 506-F, 200

Independence Avenue, S.W., Washington, D.C. 20201 or call (202)619-0403 (voice) or (202)619-

3257 (TDD). USDA and HHS are equal opportunity providers and employers.

We will give you a brochure containing all your rights and responsibilities.

You may request a fair hearing verbally or in writing if you disagree with the decision made on this

application.

The Department of Workforce Services may contact you, or have someone contact you, about the

effectiveness of services you received.

Equal Opportunity Employer/Program. Auxiliary aids and services are available upon request to

individuals with disabilities by calling (801) 526-9240 or 1-866-621-5011. Persons with speech or

hearing impairments may call the State Relay at 711, or Spanish Relay Utah at 1-888-346-3162.

You are required to follow all program rules.

Fraudulent participation in any program may result in criminal or civil action or administrative claims.

Depending on the programs you applied for, you agree to cooperate with the state of Utah to

establish and collect alimony and child support for your family.

If you are approved for financial assistance, you will need to sign over to the Office of Recovery

Services any child support, medical support, or alimony you would have received on behalf of your

household during the time you are getting assistance. Child support and alimony will be used to

offset the costs of providing financial assistance for your household.

If you choose a license-exempt child care provider, the state of Utah does not regulate or monitor

the child care. Additional information about how to choose a quality child care provider is available.

You will not receive advance notice of a food stamp benefit decrease if approved for financial

assistance.

Title VI of the Civil Rights Acts of 1964 allows us to ask for racial/ethnic information. You do not

have to give us racial/ethnic information. However, giving us this information will help us to follow

the Federal Civil Rights Law. If you do not want to give us this information, it will have no effect on

your case. If you do not give us the information, the worker will enter an answer.

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Adoption: If you want information about help with an adoption, please let your worker know.

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If you are in an institution and apply for Food Stamps and SSI at the same time, the filing date for

Food Stamps would be the date of release from the institution.

Department Of Workforce Services Page 6