Georgia Department of Human Services Application for Benefits

Georgia Department Of Human Services Application For Benefits-PDF Download

  • Date:11 Jan 2020
  • Views:65
  • Downloads:0
  • Pages:9
  • Size:490.01 KB

Share Pdf : Georgia Department Of Human Services Application For Benefits

Download and Preview : Georgia Department Of Human Services Application For Benefits


Report CopyRight/DMCA Form For : Georgia Department Of Human Services Application For Benefits


Transcription:

Georgia Department of Human Services,Application for Benefits. In accordance with Federal law and U S Department of Agriculture USDA and U S Department of Health and Human Services. HHS policy this institution is prohibited from discriminating on the basis of race color national origin sex age or disability Under. the Food and Nutrition Act of 2008 and USDA policy discrimination is also prohibited on the basis of religion or political beliefs. To file a complaint of discrimination you may contact USDA or HHS. Write USDA Director Office of Civil Rights 1400 Independence Avenue S W Washington D C 20250 9411 or call 800 795 3272. voice or 202 720 6382 TTY, Write HHS Director Office of Civil Rights Room 509 F 200 Independence Avenue S W Washington D C 20201 or call 202 619. 0403 voice or 202 619 3257 TTY, USDA and HHS are equal opportunity providers and employers. You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program Two Peachtree Street N W Suite 19. 248 Atlanta Georgia 30303 or call 404 657 3735 or fax 404 463 3978. Under the Department of Community Health DCH policy Medicaid cannot deny you eligibility or benefits based on your race age. sex disability national origin or political or religious beliefs To report Medicaid eligibility or provider discrimination call the Georgia. Department of Community Health s Office of Program Integrity local 404 463 7590 toll free 800 533 0686. What Do the Words Used in this Application Mean, This chart explains the words we have used in this application. Caretaker A parent relative or legal guardian who applies for and receives TANF with children in his or her care. Grantee Relative A parent relative or legal guardian who applies for and receives TANF in his or her name on behalf of the. Disqualified The action taken to remove an individual from a Food Stamp or TANF case because they did not tell the. truth and received benefits that they should not have received. Electronic Benefit The system used in Georgia to pay benefits to individuals who are eligible for Food Stamps Individuals. Transfer EBT receiving assistance are issued an EBT debit card which is used to access their food stamp accounts. EPPICard debit New debit card issued by Xerox for individuals receiving cash assistance in Georgia The. MasterCard EPPICard debit MasterCard will be accepted for purchases and cash withdrawals anywhere the. MasterCard is accepted, Household Members Individuals who live in your home For Food Stamps individuals who live together and purchase and.
prepare their meals together, Income Payments such as wages salaries commissions bonuses worker s compensation disability pension. retirement benefits interest child support or any other form of money received. Migrant Farm Workers Individuals who are seasonal farm workers and move from one home base to another to work or look for. Resources Cash property or assets such as bank accounts vehicles stocks bonds and life insurance. Seasonal Farm Workers Individuals who work at certain times of the year planting picking or packing produce They are hired on a. temporary basis when a job requires more workers than the farm employs on a regular basis. Form 297 Rev 04 13 2,Georgia Department of Human Services. Application for Benefits, What Do the Words Used in this Application Mean cont d. This chart explains the words we have used in this application. Trafficking in the Trafficking SNAP benefits means. SNAP Food Stamp, Program 1 Buying selling stealing or otherwise exchanging SNAP benefits issued and accessed via EBT. cards card numbers and PIN numbers or by manual voucher and signature for CASH or consideration. other than eligible food either directly indirectly in complicity or collusion with others or acting alone. 2 The exchange of firearms ammunition explosives or controlled substances 3 Purchasing a. product with SNAP benefits that has a container requiring a return deposit with the intent of obtaining. cash by discarding the product and returning the container for the deposit amount intentionally. discarding the product and intentionally returning the container for the deposit amount 4 Purchasing. a product with SNAP benefits with the intent of obtaining cash or consideration other than eligible food. by reselling the product and subsequently intentionally reselling the product purchased with SNAP. benefits in exchange for cash or consideration other than eligible food 5 Intentionally purchasing. products originally purchased with SNAP benefits in exchange for cash or consideration other than. eligible food, Qualified Alien Immigrant A qualified alien immigrant is a person who is legally residing in the U S who falls within one of the.
following categories a person lawfully admitted for permanent residence LPR under the Immigration. and Nationality Act INA Amerasian immigrant under section 584 of the Foreign Operations Export. Financing and Related Program Appropriations Act of 1988 a person who is granted asylum under. section 208 of the INA Refugees admitted under section 207 of the INA A person paroled into the US. under section 212 d 5 of the INA for at least one year A person whose deportation is being withheld. under section 243 h of the INA as in effect prior to April 1 1997 or section 241 b 3 of the INA as. amended a person who is granted conditional entry under section 203 a 7 of the INA as in effect prior. to April 1 1980 Cuban or Haitian immigrants as defined in section 501 e of the Refugee Education. Assistance Act of 1980 victims of human trafficking under section 107 b 1 of the Trafficking Victims. Protection Act of 2000 battered immigrants who meet the conditions set forth in section 431 c of the. Personal Responsibility and Work Opportunity Reconciliation Act of 1996 as amended Afghan or Iraqi. immigrants granted special immigrant status under section 101 a 27 of the INA subject to specified. conditions American Indians born in Canada living in the U S under section 289 of the INA or non. citizens of federally recognized Indian tribe under Section 4 e of the Indian Self Determination and. Education Assistance Act and Hmong or Highland Laotian tribal members that rendered assistance to. U S personnel by taking part in military or rescue operation during Vietnam Era 8 05 1964 5 07 1975. Applicant An individual who chooses to apply for or to receive public assistance benefits. Non applicant An Individual who chooses NOT to apply for or to receive public assistance benefits non applicants are. not required to provide an SSN citizenship or immigration status. Assistance Unit An assistance unit includes eligible individuals who live together and receive public assistance benefits. Form 297 Rev 04 13 3,Georgia Department of Human Services. Application for Benefits,What Am I Applying For Check all that apply. Food Stamps, The Food Stamp program helps meet the food and nutritional needs of eligible households. Temporary Assistance for Needy Families TANF, Temporary Assistance for Needy Families TANF provides temporary monthly cash payments single. cash payments or other support services to strengthen eligible families with children If you are the. child s parent or the caretaker who would like to be included in the grant we will require you to. participate in a work program,Refugee Cash Assistance.
The Refugee Cash Assistance program provides financial assistance to refugee households who are. not eligible for the TANF program The term refugee includes refugees Cuban Haitian Entrants. victims of human trafficking Amerasians and unaccompanied refugee minors. Medicaid offers medical coverage to elderly blind or disabled adults pregnant women children and. families When you apply we will look at all Medicaid programs and decide which ones you may be. eligible to receive,Tell Us About The Applicant, Does the applicant or person applying on behalf of the applicant need assistance when communicating with. us If so check all that apply, TTY Braille Large Print E mail Video Relay Sign Language Interpreter. Foreign Language Interpreter specify language Other. Please fill out the chart below about the applicant. First Name Middle Initial Last Name Suffix,Street Address Where You Live Apt. City State Zip Code,Mailing Address if different,City State Zip Code. Main Telephone Number Other Contact Number E Mail address optional. Signature Date,Witness Signature if signed by X Date.
For Office Use Only Date Received By The County,Form 297 Rev 04 13 4. Georgia Department of Human Services,Application for Benefits. Do I Qualify to Get Food Stamps Faster, Answer these questions about the applicant and all household members to see if you can get Food. Stamps within 7 days, 1 Are you or any household member a migrant or seasonal farm worker Yes No. 2 Total Gross earned income that will be received for this month. Employer Name,Employment Begin Date Employment End Date.
Rate of Pay Hours Worked Weekly wk bi wk semi mo mo circle one. 3 Total Gross unearned income that will be received for this month. Type of Unearned Income Amount wk bi wk semi mo mo circle one. Type of Unearned Income Amount wk bi wk semi mo mo circle one. 4 Total earned and unearned income for this month, 5 How much money do you and all household members have in cash or in the bank. 6 How much do you and all household members pay for rent or mortgage. 7 How much do you and all household members pay for electric water gas etc. Can I Choose Someone to Apply for Food Stamps or Medicaid for me. Complete this section only if you want someone to fill out your application complete your interview and or use. your EBT card to buy food when you cannot go to the store If you are applying for Medicaid you can choose. more than one person to apply for medical assistance on your behalf. Name Phone,Address Apt,City State Zip,Name Phone,Address Apt. City State Zip, For Medicaid do you want this individual to have a copy of your Medicaid card Yes No. Form 297 Rev 04 13 5,Georgia Department of Human Services. Application for Benefits, Tell Us about the Applicant and All Household Members.
Please fill out the chart below about the applicant and all household members The following federal. laws and regulations The Food and Nutrition Act of 2008 7 U S C 2011 2036 7 C F R 273 2 45. C F R 205 52 42 C F R 435 910 and 42 C F R 435 920 authorize DFCS to request your and your. household members social security number s If anyone in your household does not want to give us. information about his or her citizenship immigration status or social security numbers then that person can be. designated as a non applicant This means that the person will not be considered an applicant and will not be. eligible for benefits However other household members may still be able to receive benefits if they are. otherwise eligible If you want us to decide whether any household members are eligible for benefits you will. still need to tell us about their citizenship or immigration status and give us their SSN You will still need to tell. us about your income and resources to determine the eligibility and benefit level of the household Individuals. will not be reported to the United States Citizenship and Immigration Services USCIS Systematic Alien. Verification for Entitlements SAVE system if they do not give us their citizenship or immigration status. However if immigration status information has been submitted on your application this information may be subject. to verification through the SAVE system and may affect the household s eligibility and benefit level. NAME Relation Is this Birth Social Security Sex Hispanic Race Are you a U S. ship person Date Number Latino Code citizen qualified. First Middle Initial Last to You applying alien immigrant. benefits Optional Optional Hmong Highland,Applicants. Y N Format Applicants See codes,Only M F Y N Below Y N. Race Codes Choose all that apply, AI American Indian Alaska Native AS Asian BL Black African American. HP Native Hawaiian Pacific Islander WH White, By providing Race Ethnicity information you will assist us in administering our programs in a non discriminatory manner Your household is not. required to give us this information and it will not affect your eligibility or benefit level. Tell Us More about the Applicant and All Household Members. We need more information about the applicant and all household members in order to decide who is eligible for. benefits Please answer only the questions about the benefits you want to receive on the page below. Form 297 Rev 04 13 6,Georgia Department of Human Services.
Application for Benefits, 1 Has anyone received any benefits in another county or state Yes No. 2 Has anyone been convicted of giving false information about where they live and who Yes No. they are to get multiple FS benefits in more than one area after 8 22 96. 3 Did anyone in your household voluntarily quit a job or voluntarily reduce his her work hours Yes No. below 30 hours per week within 30 days of the date of application. If yes who quit,Why did he she quit, 4 Is anyone pregnant Please provide proof of pregnancy if available Yes No. This question does not apply to Food Stamp only applicants. 5 For Medicaid does anyone have any unpaid medical bills for Yes No. the last 3 months, This question does not apply to Food Stamp or TANF only applicants. 248 Atlanta Georgia 30303 or call 404 657 3735 or fax 404 463 3978 Under the Department of Community Health DCH policy Medicaid cannot deny you eligibility or benefits based on your race age sex disability national origin or political or religious beliefs To report Medicaid eligibility or provider discrimination call the Georgia

Related Books