2011 Poverty Guidelines - SafetyNet Alliance859-824-6324 Kenton Co. Action Ministries 4375 Boron St....

2011 Poverty Guidelines

Poverty Thresholds for 2011 by Size of Family and Number of Related Children Under 18 Years

Related children under 18 years

Size of family unit None One Two Three Four Five Six Seven Eight+

One person (unrelated individual)..

Under 65 yrs.…….................. 11,702

Over 65 yrs..…………............. 10,788

Two people............................... Householder under 65 yrs.…... 15,063 15,504

Householder over 65 yrs..……. 13,596 15,446

Three people............................ 17,595 18,106 18,123

Four people.............................. 23,201 23,581 22,811 22,891

Five people............................... 27,979 28,386 27,517 26,844 26,434

Six people................................. 32,181 32,309 31,643 31,005 30,056 29,494

Seven people........................... 37,029 37,260 36,463 35,907 34,872 33,665 32,340

Eight people............................. 41,414 41,779 41,027 40,368 39,433 38,247 37,011 36,697

Nine people or more................. 49,818 50,059 49,393 48,835 47,917 46,654 45,512 45,229 43,487

Source: U.S. Census Bureau.

Kentucky Commodity Program

Commodities Monthly Tracking *Make tally marks to show how many individuals received info about this specific benefit.*

Jan 2012: # of Single Adults Assisted (ages 18-65):

# of Adults with Families:

# of Children Assisted (under 18):

# of Seniors Assisted (over 65):

Total (unduplicated) Individuals Assisted:

Feb 2012: # of Single Adults Assisted (ages 18-65):





Mar 2012: # of Single Adults Assisted (ages 18-65):





Commodities Monthly Tracking April 2012: # of Single Adults Assisted (ages 18-65):





May 2012: # of Single Adults Assisted (ages 18-65):





June 2012: # of Single Adults Assisted (ages 18-65):





Commodities Monthly Tracking July 2012: # of Single Adults Assisted (ages 18-65):





Aug 2012: # of Single Adults Assisted (ages 18-65):





Sept 2012: # of Single Adults Assisted (ages 18-65):





Commodities Monthly Tracking Oct 2012: # of Single Adults Assisted (ages 18-65):





Nov 2012: # of Single Adults Assisted (ages 18-65):





Dec 2012: # of Single Adults Assisted (ages 18-65):





Commodities Information

The Emergency Food Assistance Program (TEFAP) is a federally funded program whose

purpose is to provide supplemental food to low income households. The amount of TEFAP

funding received in our area is based on the on the percent of low income households and the

unemployment rate. Households whose total monthly income is less than 130% of the poverty

rate, the same scale used to determine eligibility for food stamps, may receive each month a

package of predetermined foods. The TEFAP program also provides food to local soup kitchens.

There is no income requirement to receive a meal at a soup kitchen.

Commidities Household Income Eligibility (Effective 03-27-11)

Household Size Annual Monthly Weekly

1 $14,157 $1,180 $273

2 $19,123 $1,594 $368

3 $24,089 $2,008 $464

4 $29,055 $2,422 $559

5 $34,021 $2,836 $655

6 $38,987 $3,249 $750

7 $43,953 $3,663 $846

8 $48,919 $4,077 $941

For Each

Additional

Family Member

Add

+$4,966 +$414 +$96

*** Based on 130 Percent Federal Poverty Income Guidelines ***

To learn more about TEFAP you can contact a distribution site or soup kitchen in your county.

Please note that you can only receive TEFAP commodities one (1) time per month – you can not

visit multiple TEFAP sites in your county in the same month or your household will be

disqualified from the program. There is no visit restriction on soup kitchens.

Soup Kitchens

Kenton County Campbell County

Parish Kitchen 143 Pike St.

Covington, KY 41012 859-581-7745

Transitions 305 Pleasure Isle

Erlanger, KY 41018 859-359-4500

Henry Hosea House 901 York St.

Newport, KY 41071 859-261-5857

Welcome House 205 W Pike St.

Covington, KY 41011 859-292-7907

Women's Crisis Center

835 Madison Ave. Covington, KY 41011

859-491-3335

Commodities Information

Commodities Distribution Center

Campbell Co.

Brighton Center 799 Anne St.

Newport, KY 41072 859-491-8303

Care Mission, Inc. 11093 Alexandria Pike

Alexandria, KY 41001

Holy Spirit Outreach 8th and York St.

Newport, KY 41071 859-261-0818

Main Street Care Ministry 11093 Alexandria Pike

Alexandria, KY 41001

859-694-1222

Salvation Army Newport 340 W 10th St

Newport, KY 41071

859-431-1063

St. John Lutheran Church 5977 Lower Tug Fork Rd.

Melbourne, KY 41059

Pendleton Co. Carroll Co.

Community Action Commission 311 Park St.

Falmouth, KY 41040

859-654-4054

Southside Church 20 Southside Church Rd.

Falmouth, KY 41040 859-654-8827

Community Action Commission 1302 Highland Ave.

Carrollton, KY 41008

502-732-5253

Gallatin Co. Grant Co.

Community Action Commission 432 W. Main St.

Warsaw, KY 41005

859-567-4660

Sparta Baptist 138 KY Highway 467 W

Sparta, KY 41086

859-643-5611

Community Action Commission 134 N Main St

Williamstown, KY 41097

859-824-6324

Kenton Co.

Action Ministries 4375 Boron St.

Covington, KY 41015

859-261-3649

Be Concerned 714 Washington St.

Covington, KY 41011

859-291-1340

Needy Neighbors 110 Boone St.

Bromley, KY 41016

859-261-8858

United Ministries 525 Graves Ave.

Erlanger, KY 41018

859-727-0300

Boone Co. Owen Co.

Community Action Commission 7938 Tanners Gate

Florence, KY 41042

859-586-9250

Community Action Commission 1095 Main St.

Owenton, KY 40359

502-484-2116

Kentucky Children’s Health

Insurance Program

KCHIP Monthly Tracking *Make tally marks to show how many individuals received info about this specific benefit.*
















KCHIP Monthly Tracking April 2012: # of Single Adults Assisted (ages 18-65):















KCHIP Monthly Tracking July 2012: # of Single Adults Assisted (ages 18-65):















KCHIP Monthly Tracking Oct 2012: # of Single Adults Assisted (ages 18-65):















KCHIP Information

Kentucky Children's Health Insurance Program (KCHIP) is free or low cost health

insurance for children.

KCHIP is for children under the age of 19 who do not have health insurance and whose

family income is below 200 percent of the federal poverty level.

KCHIP Covers:

KCHIP can also cover:

What does KCHIP cost?

o A KCHIP co-payment is required for prescription medicine. Pharmacy co-

payments range from $1 to $3 per prescription, depending on the type of medicine

you receive.

o A co-payment of $6 may be charged for emergency room visits that are not true

emergencies.

o If you cannot pay the co-pay at the time of service, you still owe it.

o Some KCHIP members are charged a monthly premium. Families can receive a

10 percent discount for paying premiums in advance for three or six months.

Families with children in the KCHIP program with incomes more than

150% of the federal poverty level are charged a premium.

If your child is newly approved for KCHIP, you will receive a

premium bill that you must pay before your child's KCHIP card

can be mailed to you. A new applicant must pay the first two

months' premiums before benefits begin.

Total costs to you will not be more than $450 a year. This includes all co-

payments and premiums.

Doctor visits Hospital Stays Emergency services Outpatient hospital services Mental health services Lab tests and X-rays Vision exams Hearing services Immunizations Dental, hearing and eye checkups

Glasses Immunizations Well-child checkups Physical therapy Speech therapy

KCHIP Information

How long will it take to find out if my child is eligible?

o The local DCBS office has 30 calendar days from the date your application is

processed to determine eligibility. Processing your application may take longer if

any required information is missing, incomplete or inaccurate. However,

coverage for children determined eligible for KCHIP begins on the date the

application is received.

What do KCHIP health care cards look like?

o Each KCHIP member receives a white wallet-size plastic card. Keep this card as

long as you receive KCHIP benefits.

How do I use my KCHIP card?

o Always take the card with you when your child receives health care services to

avoid having to pay for the service. Don't ever let anyone else use your child's

card. If you lose your child's card, contact your caseworker.

How long does coverage last?

o If no changes in family income or family size, benefits will continue for 12

months.

You will receive a KCHIP renewal form in the mail.

http://kidshealth.ky.gov/NR/rdonlyres/8DF06BDD-46ED-4EBE-9F66-B104F7FD5180/0/KyHealthChoicescard.pdf

KCHIP Information

Important Numbers and How to Apply

KCHIP toll-free hotlines:

(877) KCHIP-18 (877-524-4718)

(877) KCHIP-19 (877-524-4719) for the deaf and hard of hearing.

(800) 662-5397 if Spanish language services are needed.

To find out if a medical service you need is covered, call (800) 635-2570.

Mail completed applications to: KCHIP PO Box 55270 Lexington, KY 40555-5270

Or fax your application to (859) 246-2890

If you prefer, visit your local Department for Community Based Services Office to apply

for KCHIP. Be sure to take all required information and documentation with you.

o Local DCBS offices:

Boone County: Victory Center

8311 US Hwy 42, 1st floor Florence, KY 41042 (859) 371-6900

Campbell County: Watertower Square, 4th Flr 601 Washington Avenue Newport, KY 41071 (859) 292-6700

Carroll County: P.O. Box 368 1720 Highland Ave. Carrollton, KY 41008 (502) 732-4271

Gallatin County: PO Box 555 100 West Market Street Warsaw, KY 41095 (859) 567-7281

Grant County: 120 North Main Street Williamstown, KY 41097 (859) 824-5202

Kenton County: 20 East Seventh Street 3rd Floor Covington, KY 41011 (859) 292-6600

Owen County: 75 Duke Avenue Owenton, KY 40359 (502) 484-3458

Pendleton County: 500 Market Street Falmouth, KY 41040 (859) 654-6123

For more information or to print out an application go to http://kidshealth.ky.gov/en/

https://apps.chfs.ky.gov/Office_Phone/index.aspx

http://kidshealth.ky.gov/en/

KCHIP Application Checklist

Proof of income Provide copies of pay stubs for the last two months or a letter from your employer

stating your wages, your employer's name, address, phone number and an original

signature. If you are self-employed, send a copy of your last income tax return.

If you receive unearned income, provide the most recent award letter or other

proof of the amount of your unearned income. Examples of unearned income

include: KTAP, disability, pension, child support, alimony, cash gifts, annuities,

interest, Social Security, veteran's benefits, etc.

If you receive child support, include copies of checks and a statement from the

non-custodial parent or the child support collection agency in your county

Proof of expenses for child care or disabled adult living in the home Send copies of receipts or a statement from your child care provider

Health insurance information If anyone in your family has health insurance that pays for doctor's office visits

and hospital care, please provide: Name of insurance company Group number and policy number Effective date Name of policy holder Names of people who are covered

Proof of citizenship For children born outside Kentucky, provide a birth certificate, U.S. passport,

adoption papers or other proof of citizenship. You can request birth certificates

from state vital records offices

Proof of identity All applicants must provide proof of identity, such as:

Copy of current state driver's license School photo ID Military dependant ID ID issued by state, federal or local government with photo

If you do not have these documents or the child is younger than 16, you may

provide other acceptable proof of identity such as: School record including report card Day care or nursery school record Health clinic, doctor or hospital record

http://www.cdc.gov/nchs/w2w.htm

Kentucky Transitional Assistance Program

K-Tap Monthly Tracking

*Make tally marks to show how many individuals received info about this specific benefit.*

















April 2012: # of Single Adults Assisted (ages 18-65):
















July 2012: # of Single Adults Assisted (ages 18-65):
















Oct 2012: # of Single Adults Assisted (ages 18-65):















K-TAP Information

----

Kentucky Transitional Assistance Program (K-TAP) is the monetary assistance program

that provides financial and medical assistance to needy dependent children in Kentucky

and the parents, or relatives, with whom the children are living.

K-TAP also helps families find jobs or get training that leads to a job.

A family can only get K-TAP for 60-months (5 years) in a lifetime.

o Each month a family gets K-TAP counts toward the 60-month limit. A family

does not have to get K-TAP for 60-months straight. For example, a family can

get K-TAP for 24-months and stop. Later, the family can get 36-more months.

K-TAP payments to families are based on family size and income.

What happens when a K-TAP person goes to work?

o The K-TAP check does not always stop. The earnings may not be counted for

two months.

o When the earnings are counted in the K-TAP case, certain deductions are allowed.

o A family member may also get help with things needed in order to keep working.

What happens if K-TAP is discontinued due to work?

o The family may still get some help such as Medicaid or food stamp benefits.

o The family may get Work Incentive reimbursements for up to nine months.

Child care assistance may be received as long as the family meets the guidelines for the

Child Care Assistance Program.

K-TAP Income Limits & Guidelines

----

Family Members Monthly gross income limits Maximum payment amounts

1 $742 $186

2 $851 $225

3 $974 $262

4 $1096 $328

5 $1218 $383

6 $1340 $432

7 $1462 $482

Must be a resident of the State of Kentucky, a U.S. citizen or qualified alien.

Must be unemployed or under employed (working for very low wages).

Must be a parent/relative caregiver who is responsible for children up to the age of 18 (or

19 years old if meeting the school attendance requirement).

K-TAP How to Apply

----

To apply contact your local Community Based Services office:










For additional information on K-TAP visit http://chfs.ky.gov/dcbs/dfs/KTAP.htm

K-TAP information line: 502-564-7050

http://chfs.ky.gov/dcbs/dfs/KTAP.htm

K-TAP How to Apply

----

** Take all of this information with you when you apply for K-TAP**

Identification Card

Birth Certificates for everyone in the household

Social Security cards for everyone in the household

Lease or rental agreement

All current utility bills

Proof of income for the last 2 months

If applicable: Current checking and/or savings statement

Medicare Monthly Tracking

















Medicare Information

----

Medicare is health insurance for people 65 and older, people under 65 with certain

disabilities and any age person with End-Stage Renal Disease.

Medicare has 4 parts: Part A- Hospital Coverage, Part B- Medical Insurance, Part C-

Medicare Advantage plan and Part D- Prescription Drug Coverage.

Part A Hospital Coverage

Helps cover:

o Inpatient care in hospitals (such as critical access hospitals, inpatient

rehabilitation facilities, and long-term care hospitals)

o Inpatient care in a skilled nursing facility (not custodial or long term care)

o Hospice care services

o Home health care services

o Inpatient care in a Religious Nonmedical Health Care Institution

What does it cost?

o If you or your spouse paid Medicare taxes while working you usually do not pay a

monthly premium. This is called Premium free Part A.

o If you are not eligible for premium-free Part A, you may be able to buy Part A if

you meet one of these conditions:

You're 65 or older, you're entitled to (or enrolling in) Part B, and you

meet the citizenship or residency requirements.

You're under 65, disabled, and your premium-free Part A coverage ended

because you returned to work.

In most cases, if you choose to buy Part A, you must also have

Part B and pay monthly premiums for both.

You will pay up to $461 each month in 2012 if you don’t receive

premium-free Part A.

If you pay a late enrollment penalty, this amount is higher.

Part A covers:

o Blood- In most cases, the hospital gets blood from a blood bank at no charge, and

you won't have to pay for it or replace it. If the hospital has to buy blood for you,

you must either pay the hospital costs for the first 3 units of blood you get in a

calendar year or have the blood donated by you or someone else.

o Home Health Services- Limited to medically-necessary part-time or intermittent

skilled nursing care, or physical therapy, speech-language pathology, or a

continuing need for occupational therapy. A doctor must order your care, and a

Medicare-certified home health agency must provide it. Home health services

may also include medical social services, part-time or intermittent home health

aide services, durable medical equipment, and medical supplies for use at home.

You must be homebound, which means that leaving home is a major effort.


o Hospice Care- For people with a terminal illness. Your doctor must certify that

you are expected to live 6 months or less. Coverage includes drugs for pain relief

and symptom management; medical, nursing, social services; and other covered

services as well as services Medicare usually doesn’t cover, such as grief

counseling. A Medicare-approved hospice usually gives hospice care in your

home (or other facility like a nursing home).

Medicare covers some short-term inpatient stays for pain and symptom

management that can’t be addressed in the home. These stays must be in a

Medicare-approved facility, such as a hospice facility, hospital, or skilled

nursing facility. Medicare also covers inpatient respite care which is care

you get in a Medicare approved facility so that your usual caregiver can

rest. You can stay up to 5 days each time you get respite care. Medicare

will pay for covered services for health problems that aren’t related to

your terminal illness. You can continue to get hospice care as long as the

hospice medical director or hospice doctor recertifies that you are

terminally ill.

o Hospital Stays (Inpatient) - Includes semi-private room, meals, general nursing,

drugs as part of your inpatient treatment, and other hospital services and supplies.

Examples include inpatient care you get in acute care hospitals, critical access

hospitals, inpatient rehabilitation facilities, long-term care hospitals, inpatient care

as part of a qualifying clinical research study, and mental health care. This does

not include private-duty nursing, a television or telephone in your room (if there

is a separate charge for these items), or personal care items like razors or slipper

socks. It also does not include a private room, unless medically necessary. If you

have Part B, it covers the doctor and emergency room services you get while you

are in a hospital.

o Skilled Nursing Facility Care- Includes semi-private room, meals, skilled nursing

and rehabilitative services, and other services and supplies (only after a 3-day

minimum inpatient hospital stay for a related illness or injury). To qualify for care

in a skilled nursing facility, your doctor must certify that you need daily skilled

care like intravenous injections or physical therapy. Medicare does not cover

long-term care or custodial care in this setting.

Part B Medical Insurance

Helps cover:

o Medically-necessary services like doctors' services

o Outpatient care

o Home health services

o Other medical services

o Also covers some preventive services

What does it cost?

o You pay Part B premium each month. Most people pay a standard premium

amount. For 2012, premiums were $99.90.


Costs for Part B services depend on whether you have Original Medicare

or are in a Medicare health plan. For some services, there are no costs, but

you may have to pay for the doctor’s visit. If the Part B deductible applies,

you must pay all costs until you meet the yearly Part B deductible before

Medicare begins to pay its share. Then, after your deductible is met, you

typically pay 20% of the Medicare-approved amount of the service.

Part B covers:

o Medically-necessary services- Services or supplies that are needed to diagnose or

treat your medical condition and that meet accepted standards of medical practice.

o Preventive services- Health care to prevent illness or detect it at an early stage,

when treatment is most likely to work best

Medigap/ Medicare Supplement Insurance

o Private health insurance regulated by state insurance departments to supplement

the gaps in original Medicare.

Helps pay some of the health care costs “gaps” that Original Medicare

doesn’t cover like:

Copayments

Coinsurance

Deductibles

Some policies offer other coverage well.

You may be eligible to buy a Medigap policy if:

You have both Medicare Part A and Part B

What does it cost:

You pay a monthly premium for you Medigap policy

You pay your monthly premium for Part B

You and your spouse must each buy separate Medigap policies.

How to get help to pay medical Expenses:

o There are new programs that may help you pay part of your medical expenses. If

you qualify, you may not have to pay your Medicare premiums or out-of-pocket

expenses.

o How do I know if I qualify?

1) You must have Medicare Hospital Insurance (Part A). IF you’re not sure

whether you have it, look on your Medicare card or call Social Security

toll free, at 1-800-772-1213 to find out.

http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx


2) Your income is below certain limits. (See chart below)

(Choose your monthly income limit. Read the chart from left to right)

Your Monthly Income Limits*

Program Will Pay Program Name

$951 Individual or

$1281 Couple

Premiums, deductibles, and coinsurance Medicare

Part B Premiums

Qualified Medicare Beneficiary (QMB)

$1137 Individual or

$1533 Couple

Medicare Part B Premiums

Specified Low-Income Medicare

Beneficiary (SLMB)

$1277 Individual or

$1723 Couple

Medicare Part B Premiums

Qualifying Individual (QI-1)

*Income limits may possibly change in 2013.

3) Your financial resources or the things you own are below $6,940 for an

individual and $10,410 for a couple. Financial resources are items like

bank accounts, stocks, and bonds. Some things are not counted like the

home you live in, one car, funeral arrangements less than $10,000.00,

furniture, and some life insurance policies.

o How Can I Get More Information?

Call your nearest Department for Community Based Services (DCBS)

office. You can find the number in the phone book under Medicaid,

Medical Assistance, Family Support, or Community Based Services.

Boone County:

Victory Center 8311 US Hwy 42, 1st flr Florence, KY 41042 (859) 371-6900

Campbell County:

Watertower Sq, 4th flr 601 Washington Ave Newport, KY 41071 (859) 292-6700

Carroll County:

P.O. Box 368 1720 Highland Ave. Carrollton, KY 41008 (502) 732-4271

Gallatin County:

PO Box 555 100 West Market St Warsaw, KY 41095 (859) 567-7281

Grant County:

120 North Main Street Williamstown, KY 41097 (859) 824-5202

Kenton County:

20 E 7th St, 3rd flr Covington, KY 41011 (859) 292-6600

Owen County:

75 Duke Avenue Owenton, KY 40359 (502) 484-3458

Pendleton County:

500 Market Street Falmouth, KY 41040 (859) 654-6123

-or-

Call 1-800-372-2973. Someone there can help you find the right office in

your county. For deaf or hearing impaired who use a TTY/TDD call 1-

800-627-4702.


o What Papers Do I Need To Bring?

The local DCBS office will need to be sure you qualify for these

programs. Some of the information you will need is listed below. If you

don’t have this information now, you can get it later.

Your Medicare card

Proof of identity

Proof of all income. This includes pension checks, social security

payments, etc.

Recent bank statements

Insurance policies

Financial statements from any stocks or bonds you own

Proof of any funeral or burial policies you may have.

Part C Medicare Advantage Plan

Part C is health plans offered by private companies approved by Medicare. If you join a

Medicare Advantage Plan, the plan provides all your Part A (Hospital Insurance) and Part

B (Medical Insurance) coverage.

o To find out what types of plans are available in your area go to

www.medicare.gov, select the Health and Drug Plan button and then select

“Compare Health Plans and Medigap Policies in your area.”

Helps cover:

o Always covers emergency and urgent care.

o Must cover all the services that Original Medicare covers, except hospice care.

o May offer extra coverage such as:

Vision

Hearing

Dental

And/or health and wellness programs

Also may include Medicare prescription drug care

What does it cost?

o Each plan can charge different out-of-pocket costs and have different rules for

how you get services. Contact the plans you’re interested in for the actual plan

premium.

o Usually pay one monthly premium to the Medicare Advantage plan, in addition to

your Part B premium.

o Your out-of-pocket costs in a Medicare Advantage Plan depend on:

Whether the plan charges a monthly premium in addition to your Part B

premium.

Whether the plan pays any of the monthly Part B premiums. Some plans

offer this option, usually for an extra cost.

Whether the plan has a yearly deductible or any additional deductibles.

http://www.medicare.gov/


How much you pay for each visit or service (copayments).

The type of health care services you need and how often you get them.

Whether you follow the plan’s rules, like using network providers.

Whether you need extra coverage and what the plan charges for it.

Whether the plan has a yearly limit on your out-of-pocket costs for all

medical services.

Part D Prescription Drug Coverage

Run by private companies approved by Medicare, which can either be Medicare

Advantage Plans or separate Medicare Prescription Drug Plans.

o To find a plan in your area go to www.medicare.gov/pdphome.asp

Helps cover:

o The cost of prescription drugs.

What does it cost?

o Each plan can vary in cost and drugs covered. Contact the plan you’re interested

in for the actual plan premium.

Two types of plans offer Medicare prescription drug coverage:

o Medicare Prescription Drug Plans- These plans (sometimes called "PDPs") add

drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare

Private Fee-for-Service (PFFS) Plans, and Medicare Medical Savings Account

(MSA) Plans.

o Medicare Advantage Plans- (like an HMO or PPO) or other Medicare health plans

that offer Medicare prescription drug coverage. You get all of your Part A and

Part B coverage, and prescription drug coverage (Part D), through these plans.

Medicare Advantage Plans with prescription drug coverage are sometimes called

"MA-PDs."

Extra Help/ Low-income subsidy

o A Medicare program to help people with limited income and resources pay

Medicare prescription drug program costs, such as premiums, deductibles and

coinsurance.

You may be eligible if:

You have Medicare Part D (Prescription Drug Coverage).

Reside in one of the 50 states or the District of Columbia.1

If your yearly income and resources meet the following:

o Individual:

Annual income less than $16,245

Resources2 less than $12,510

o Married person living with a spouse and no other

dependents:



http://www.medicare.gov/pdphome.asp


1 You may still qualify if you support other family members who

live with you or if you still work.

2 Resources include money in a checking or savings account,

stocks and bonds. Resources do not include you home, car,

household items, burial plot, up to $1,500 for burial expenses (per

person) or life insurance policies.

If you qualify you will get help with:

Paying your Medicare drug plan’s monthly premium.

Paying any yearly deductible.

Paying coinsurance and copayments for prescription drugs that are

on your plan’s formulary.

No coverage gap.

No late enrollment penalty.

Apply online at www.socialsecurity.gov.

Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Apply at local Social Security office.

http://www.socialsecurity.gov/

Medicare Eligibility

----

Decide if you want Prescription Drug

Coverage (Part D)

Original Medicare

Part A (Hospital Insurance) and

Part B (Medical Insurance)

Medicare provides this coverage.

You have your choice of doctors,

hospitals, and other providers.

Generally, you or your supplemental

coverage pay deductibles and

coinsurance.

You usually pay a monthly premium

for Part B.

If you want this coverage, you must

choose and join a Medicare

Prescription Drug Plan.

These plans are run by private

companies approved by Medicare

Decide if you want Original Medicare or a Medicare Advantage Plan

Medicare Advantage Plan

(like an HMO or PPO)

Part C- Includes BOTH Part A (Hospital

Insurance) and Part B (Medical

Insurance)

Private insurance companies approved

by Medicare provide this coverage.

In most plans, you need to use plan

doctors, hospitals, and other providers,

or you pay more or all of the costs.

You usually pay a monthly premium (in

addition to your part B premium) and a

copayment or coinsurance for covered

services.

Costs, extra coverage, and rules vary by

plan.

Decide if you want

Supplemental Coverage

You may want to get coverage that fills

gaps in Original Medicare coverage.

You can choose to buy a Medigap

(Medicare Supplement Insurance)

policy from a private company.

Costs vary by policy and company.

Employers/unions may offer similar

coverage.

Step 2

Step 3

Step 2

Decide if you want Prescription Drug

Coverage (Part D)

If you want this coverage, and it’s

offered by your plan, in most cases you

must get it through your plan.

In some types of plans that don’t offer

drug coverage, you can choose and join

Medicare Prescription Drug Plan.

Step 1

Note: If you join a Medicare Advantage Plan,

you don’t need a Medigap policy. If you

already have a Medigap policy, you can’t use

it to pay for out-of-pocket costs you have

under the Medicare Advantage Plan, you can’t

be sold a Medigap policy.


----

If you or your spouse worked for at least 10 years in Medicare-covered employment and

you are 65 years or older and a citizen or permanent resident of the United States.

If you are not yet 65, you might also qualify for coverage if you have a disability or have

End-Stage Renal disease (permanent kidney failure requiring dialysis or transplant).

You may be eligible for the following programs if:

Medicare Part A:

o You are age 65 or older and you are eligible for Social Security Benefits

o You are a qualified Railroad Retirement beneficiary

o You are a dependent or a survivor of an individual age 65 or over who is entitled to

Medicare Part A benefits or dependent of an individual under age 65 who is entitled

to Social Security retirement benefits

or

o You are under age 65 and disabled

o You have permanent kidney failure, requiring dialysis or a transplant

o You have been receiving Social Security benefits for at least 24 months because you

meet the Social Security Administration’s definition of permanent and total disability

(i.e., you are unable to hold gainful employment in any job), or

o Under special circumstances, you are entitled to Railroad Retirement benefits because

of disability.

Medicare Part B:

o You are entitled to Part A hospital insurance (be entitled to Social Security or

Railroad Retirement Act retirement or disability benefits, Medicare-qualified

government employment, or end-stage renal disease benefits) and you are a citizen of

the U.S., or

o You are 65 or older, a U.S. resident, and either a U.S. citizen or an alien legally

admitted for permanent residence has continuously resided in the U.S. for at least five

years prior to your enrollment month

Medigap:

You may be eligible to buy a Medigap policy if:

You have both Medicare Part A and Part B

Medicare Part C:

o You have Part A and Part B

o You live in the service area provided

o You do not have End-Stage Renal Disease


Medicare Part D:

o You must have Medicare Part A and/or Part B.

o If you would like to get prescription drug coverage through a Medicare Advantage

Plan, you must have Part A and Part B.

o You must live in the service area of the Medicare drug plan you want to join.

Extra Help/Low-Income Subsidy

You may be eligible if:1

You have Medicare Part D (Prescription Drug Coverage).

Reside in one of the 50 states or the District of Columbia.

If your yearly income and resources meet the following:

o Individual:



o Married person living with a spouse and no other dependents:



1You may still qualify if you support other family members who

live with you or if you still work.

2Resources include money in a checking or savings account,

stocks and bonds. Resources don’t include you home, car,

household items, burial plot, up to $1,500 for burial expenses (per

person) or life insurance policies.

Medicare Important Numbers

----

1-800-MEDICARE (1-800-633-4227): To get general Medicare information and other

important numbers.

o People who are deaf or hard of hearing may call the "TTY" number,

1-800-325-0778, between 7 a.m. and 7 p.m. on business days.

Social Security: 1-800-772-1213

o To replace a Medicare card, change your address or name.

o To apply for Extra Help with Part D.

Local Social Security offices:

Campbell, Boone, Kenton, Pendleton, Grant, Gallatin: Social Security 7 Youell Street Florence, KY 41042 (513) 772-1213

Owen, Carroll: Social Security 140 Flynn Ave Frankfort, KY 40601 (502) 875-2232

For more information on Medicare and to apply online http://www.medicare.gov/.

To find out what types Medicare Advantage Plans and Medigap policies are available in

your area go to www.medicare.gov select the Health and Drug Plan button and then

select “Compare Health Plans and Medigap Policies in your area.”

To find out what types of Medicare prescription Drug coverage is in your area go to

www.medicare.gov/pdphome.asp.

For more information on Extra Help for Part D www.socialsecurity.gov.

For more information on Medigap www.medicare.gov/Publications/Pubs/pdf/02110.pdf.



http://www.medicare.gov/pdphome.asp


http://www.medicare.gov/Publications/Pubs/pdf/02110.pdf

Medicare How to Apply

----

General:

Your enrollment is usually automatic if you already receive Social Security

Benefits.

o Your card will be mailed to you about 3 months prior to your 65th

birthday.

If you do not already receive Social Security Benefits:

o Call your local Social Security office for information or call

1(800) 772-1213 3 months prior to your 65th

birthday.

Local offices:

Campbell, Boone, Kenton, Pendleton, Grant, Gallatin: Social Security 7 Youell Street Florence, KY 41042 (513) 772-1213

Owen, Carroll: Social Security 140 Flynn Ave Frankfort, KY 40601 (502) 875-2232

You may be able to enroll over the phone.

o Go to http://www.medicare.gov/ and fill out an online application 3

months prior to your 65th

birthday.

Part A and B:

Enrollment is usually automatic. Any individual who receives Social Security

benefits before age 65 or who applies for Social Security benefits at age 65 will

be automatically enrolled in Medicare. However, if you retire after age 65,

remember to enroll in Medicare at age 65 anyway because your enrollment won’t

be automatic.

Individuals who will be automatically enrolled in Medicare will receive

notification by mail from the Social Security Administration, usually three

months before your 65th

birthday.

Part A:

If you aren’t getting Social Security or RRB (Railroad Retirement Board) benefits (for

instance, because you are still working), you will need to sign up for Part A (even if you

are eligible to get it premium-free). If you need to sign up for Part A you can sign up

during these times:

o Initial Enrollment Period- when you are first eligible for Medicare. (The 7-month

period that begins 3 months before the month you turn 65, includes the month you

turn 65 and ends 3 months after you turn 65.)

o General Enrollment Period- between January 1- March 31 each year. Your

coverage will begin on July 1.

You may have to pay a higher premium for late enrollment.

o Special Enrollment Period- If you or your spouse (or family member if you are

disabled) is currently working and you are covered by a group health plan through

the employer or union.

o Special Enrollment Period for International Volunteers- If you are serving as a

volunteer in a foreign country.



Part B:

If you declined Part B when you first became eligible, you may be able to sign up during

one of these times:

o General Enrollment Period- between January 1- March 31 each year. Coverage

will begin on July 1. (You may have to pay a late enrollment penalty.)

o Special Enrolment Period- If you waited to sign up for Part B because your

spouse is currently working and you are covered by a health plan based on that

work, or if you are disabled and you or a family member is working, and you are

covered by a group health plan based on that work.

You can sign up for Part B anytime while you have group health plan

coverage based on current employment or during the 8-month period that

begins the month after the employment ends, or the group health plan

coverage ends, whichever happens first.

If you have COBRA coverage, you must enroll during the 8-month period

that begins the month after the employment ends.

This special enrolment period doesn’t apply to people with End-Stage

Renal Disease.

o Special Enrollment Period for International Volunteers- If you waited to sign up

for Part B because you had health insurance while volunteering outside of the

U.S. for a tax exempt organization for at least a year.

You can sign up during the 6-month period that begins the first month that

any one of the following happens:

You are no longer volunteering outside the U.S.

The sponsoring organization is no longer tax exempt.

You no longer have health insurance coverage outside the U.S.

Medigap

o Apply online at www.medicare.gov

o Call 1-800-MEDICARE (1-800-633-42273)

Part C:

You may be able to join by completing a paper application, calling, or enrolling on the

plan’s website or on www.medicare.gov.

You can also enroll by calling 1-800-633-4227.

You can join, switch, or drop a Medicare Advantage Plan at these times:

o When you first become eligible for Medicare (the 7-month period that begins 3

months before the month you turn age 65, includes the month you turn 65, and

ends 3 months after the month you turn 65).

o If you get Medicare due to a disability, you can join during the 3 months before to

3 months after your 25th

month of disability. You will have another chance to join

3 months before the month you turn 65 to 3 months after the month you turn 65.

o Between November 15-December 31 each year. Your coverage will begin on

January 1 of the following year, as long as the plan gets your enrollment request

by December 31.




o Between January 1- March 31 of each year. Your coverage will begin the first day

of the month after the plan gets your enrollment form. During this period, you

can’t do the following:

Join or switch to a plan with prescription drug coverage unless you already

have Medicare prescription drug coverage (Part D).

Drop a plan with prescription drug coverage.

Join, switch, or drop a Medicare Medical Savings Account Plan.

Part D:

You may be able to join by completing a paper application, calling the plan, or enrolling

on the plan’s website or on www.medicare.gov.

You can also enroll by calling 1-800-633-4227.

You can join, switch, or drop a Medicare Drug Plan at these times:

o When you first become eligible for Medicare (the 7-month period that begins 3

months before the month you turn age 65, includes the month you turn 65, and

ends 3 months after the month you turn 65).

o If you get Medicare due to a disability, you can join during the 3 months before to

3 months after your 25th

month of disability. You will have another chance to join

3 months before the month you turn 65 to 3 months after the month you turn 65.

o Between November 15-December 31 each year. Your coverage will begin on

January 1 of the following year, as long as the plan gets your enrollment request

by December 31.

o Anytime, if you qualify for Extra Help (a Medicare program to help people with

limited income and resources to pay Medicare prescription drug program cost), or

have both Medicare and Medicaid.

Extra Help/Low-income subsidy

You automatically qualify if you have Medicare and meet one of the following:

You have full Medicare coverage.

You get help from your state Medicaid program paying Part B premiums.

You get Supplemental Security Income (SSI) benefits.

Apply online at www.socialsecurity.gov.

Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).

Apply at local Social Security office.



----

SHIP

Kentucky’s State Health Insurance Assistance Program

SHIP Monthly Tracking

















SHIP Information

----

THE MISSION OF SHIP

o Our mission is to provide education and assistance for older adults to aid them in making informed decisions on programs impacting their quality of life such as Medicare, Medicaid, Social Security, insurance and other benefit programs specific to older or disabled adults.

HOW DOES IT WORK?

o The Ship Program utilizes paid and volunteer staff to provide personal counseling for Medicare recipients to help them through the often complicated and confusing red tape of Medicare, Medicaid, Part D Drug Plans Medigap Insurance and other public and private assistance programs.

o Staff and Counselors undergo regular in depth training to keep them informed on changes to programs, new programs and scams that jeopardize older and disabled adults in Kentucky

o Providing helpful and up to date information and assisting you from beginning to end our counselors make it smooth sailing to get your Medicare benefits in order.

WHO IS ELIGIBLE FOR SHIP SERVICES?

o Anyone who has Medicare and/or is age 60 and above and lives in our service area is eligible for services.

DO I HAVE TO PAY TO GET HELP?

o There are no charges for any services you receive from the SHIP Program. We are funded through a grant from the Centers for Medicare and Medicaid Services and the Older Americans Act.

WHAT KIND OF HELP CAN SHIP PROVIDE FOR ME?

o A SHIP Counselor can

Assist with applying for benefits such as Medicaid and Part D Drug Plans Provide plan comparison information for Part D Plans Assist with understanding Long Term Care and Medigap Insurance Assist with organizing and understand paperwork from hospitals, doctors, Medicare,

and insurance companies. Provide up to date information on services for older adults and make referrals for

other services as needed.

SHIP COUNSELORS CAN HELP YOU WITH:

o Medicare issues o Medicare Supplemental Insurance

o Long Term Care Insurance o Medicaid issues

o Social Security/SSI o Housing Problems

o Energy Assistance o Food Stamps

o Veterans Administration Benefits o Referrals to Prescription Drug Assistance Programs

o Understanding billings from hospitals, doctors, insurance companies

SHIP How to Apply

---- o Contact your local SHIP Counselor:

Wanda Johnson SHIP Coordinator Legal Aid of the Bluegrass 104 E 7th St Covington, KY 41011 859.957.0717

o For additional information on SHIP visit: http://www.lablaw.org/ship o Or call 1-866-516-3051

http://www.lablaw.org/ship

Supplemental Nutrition Assistance

Program

(Also known as Food Stamps)

http://www.fns.usda.gov/FSP/Default.htm

SNAP Monthly Tracking

----

















SNAP Information

----

Supplemental Nutrition Assistance Program (SNAP) helps low-income people and

families buy the food they need for good health. (Also known as Food Stamps)

The head of your household, or an authorized representative, must be interviewed by a

food benefits caseworker in the Family Support office in the county where you live.

Complete and turn in your household's application as soon as possible. Benefits begin the

date your application is received.

The amount of SNAP food stamps you will actually get depends on your income and

expenses.

Maximum Monthly Allotment

People in Household April 1, 2011-

September 30, 2012

1 $200

2 $367

3 $526

4 $668

5 $793

6 $952

7 $1,052

8 $1,202

Each additional person

+$150

*Note: This is the Maximum amount that you can receive.

Your household's food benefits will be deposited into a food benefit account each month.

Your household will receive an Electronic Benefit Transfer (EBT) card and a Personal

Identification Number (PIN) in the mail to use to access your food benefit account.

SNAP food benefits can be used just like money to purchase almost any food item.

o The following items cannot be purchased with food benefits: tobacco, alcohol, pet

food, soap and other household products, medicines, other non-food items and

ready-to-eat hot foods.

SNAP Income Limits & Guidelines

----

People in Household Monthly Gross*

Income Monthly Net**

Income 200% FPG (Families

with Children)

1 $1,174 $906 $1,805

2 $1,579 $1,215 $2,429

3 $1,984 $1,526 $3,052

4 $2,389 $1,838 $3,675

5 $2,794 $2,150 $4,299

6 $3,200 $2,461 $4,922

7 $3,605 $2,773 $5,545

8 $4,010 $3,085 $6,169

Each additional person +$406 +$312 +$624

*Gross income means total countable income, before deductions.

**Net income means countable income after allowed deductions

Must be a U.S. citizens or eligible noncitizen who buy food and prepare meals to eat at

home.

Anyone in a household who is 16 to 60 years old and can work must register for, look for

and accept work. There are some exceptions to this requirement.

A household may have no more than $2,000 in cash and bank account assets.

o If a member of the household is 60 or older, the household may have no more

than $3,000 in resources.

SNAP Important Numbers

----

Kentucky State Information/Hotline Number: 1-800-931-9112

Report lost, stolen, or damaged cards, call 1-888-979-9949. (Available 24 hours a day 7

days a week).

The first replacement card is free. For each replacement card after that, you must

pay a $5.00 fee, which can be subtracted from your food stamp benefits if you

choose. You will get a new PIN with your new card.

Assistance With Food Benefits:

EBT/Food Benefit Information

(502) 564-7050

Local SNAP offices:










For additional information visit: http://www.chfs.ky.gov/dcbs/dfs/foodstampsebt.htm

http://www.chfs.ky.gov/dcbs/dfs/foodstampsebt.htm

SNAP How to Apply

----

Fill out application and submit it to the local DCBS office:



Campbell County:

Watertower Square, 4th Flr 601 Washington Avenue Newport, KY 41071 (859) 292-6700







Once the form is received an interview will be scheduled to complete the application

process.

SNAP Application Checklist

----

** Note: You do not need to collect everything on this list. **

Identity

Birth Certificate

Driver’s license or State ID card

Work or school ID card

Health benefits ID card

Voter registration card

Residency

Utility bills (ex. electric, gas or

water)

Rental agreement or mortgage

statement that shows your

address

Immigration Status

Immigration or naturalization

papers (not required if you are

only applying for your children

who were born in the US)

Medical Expense Deduction (for households with elderly (age 60

or older) or disabled members only)

Billing statements

Itemized medical receipts (ex.

prescription drugs)

Medicare card indicating Part

“B” coverage

Repayment agreement with

physician

Earned Income

Pay stubs

Statement from employer as to

gross wages

Income tax forms

Self-employment bookkeeping

records

Unearned Income

Bank statements showing direct

deposit

Agency letter showing money

received (ex. Social Security,

SSI, VA, child support, alimony,

unemployment and retirement)

Other __________________

WIC Monthly Tracking

----

















WIC Information

----

Women, Infant and Children Program (WIC) helps families by providing assistance for

buying healthy supplemental foods from WIC-authorized vendors, nutrition education,

and help finding healthcare and other community services.

Nutrition program that helps pregnant women, new mothers and young children eat well

and stay healthy.

WIC participants receive checks or vouchers to purchase specific foods each month that

are designed to supplement their diets with specific nutrients. Some states issue an

electronic benefit card to participants instead of paper checks or vouchers.

WIC foods include:

o Infant cereal, iron-fortified adult cereal, vitamin C-rich fruit or vegetable juice,

eggs, milk, cheese, peanut butter, dried and canned beans/peas, and canned fish.

Soy-based beverages, tofu, fruits and vegetables, baby foods, whole-wheat bread,

and other whole-grain options are available as well.

WIC recognizes and promotes breastfeeding as the optimal source of nutrition for infants.

For women who do not fully breastfeed, WIC provides iron-fortified infant formula.

How WIC supports breastfeeding:

o WIC mothers who breastfeed their infants are provided information and support

through counseling and breastfeeding educational materials.

o Breastfeeding mothers receive a greater quantity and variety of foods than

mothers who fully formula feed their infants, with mothers fully breastfeeding

their infants receiving the most substantial food package.

o Breastfeeding mothers are eligible to participate in WIC longer than non-

breastfeeding mothers.

o Breastfeeding mothers may receive follow-up support through peer counselors.

o Breastfeeding mothers may receive breast pumps and other aides to help support

the initiation and continuation of breastfeeding.

WIC Income Limits and Guidelines

----

1

2

3

4

5

6

7

8

For each additional

person add:

Weekly $398 $539 $680 $821 $962 $1,103 $1,244 $1,385 +$141

Bi-Weekly $795 $1,077 $1,359 $1,641 $1,923 $2,205 $2,487 $2,769 +$282

Twice-Monthly $862 $1,168 $1,474 $1,780 $2,086 $2,392 $2,698 $3,004 +$306

Monthly $1,723 $2,334 $2,945 $3,556 $4,167 $4,778 $5,389 $6,000 +$611

Annual $20,665 $27,991 $35,317 $42,643 $49,969 $57,295 $64,621 $71,947 +$7,326

*Effective April 1, 2012- March 31, 2013 – 185% of Poverty

Must be a pregnant women, new mothers, infants or children under age five.

Must provide proper ID.

Must provide proof of residence.

Must provide income information.

WIC How to Apply

----

Contact your local Health Department:

Boone County Center 7505 Burlington Pike Florence, KY 41042 (859) 363-2060

Grant County Health Center 234 Barnes Road Williamstown, KY 41097 (859) 824-5074

Campbell County Center 1098 Monmouth Street Newport, KY 41071 (859) 431-1704

Kenton County Health Center 2002 Madison Avenue Covington, KY 41014 (859) 431-3345

Carroll County Center 401 11th Street Carrollton, KY 41008 (502) 732-6641

Owen County Center 1005 Hwy 22E Owenton, KY 40359 (502) 484-5736

Gallatin County Center 204 Franklin Street P. O. Box 315 Warsaw, KY 41095 (859) 567-2844

Pendleton County Center Route 1, Box 208 Falmouth, KY 41040 (859) 654-6985

For additional information on WIC visit: http://chfs.ky.gov/dph/mch/ns/wic.htm

Or call (502) 564-3827; (800) 462-6122

http://chfs.ky.gov/dph/mch/ns/wic.htm

WIC Application Checklist

----

**Take all of this information with you when you apply for WIC**

Proof of household income Such as pay stubs, W-2 forms or current medical card

Proof of residence

Such as current bill with your address, bank statement, lease agreement, mortgage

agreement or current medical card

Proof of identity

Such as a driver's license, birth certificate, social security card, shot record or

current medical card

FS-1-spa COMMONWEALTH OF KENTUCKY (R. 2/12) Cabinet for Health and Family Services 921 KAR 3:030 Department for Community Based Services

*Si necesita ayuda para llenar este formulario, comuníquese con su oficina local de DCBS. Usted puede encontrar información acerca

de su oficina local al: https://apps.chfs.ky.gov/Office_Phone/index.aspx

Solicitud para el Programa SNAP

¿Qué es SNAP?

El Programa Suplementario de Asistencia Nutricional (SNAP, por sus siglas en inglés) es un programa que le ayuda a comprar alimentos para una buena salud. Los beneficios que usted recibe del programa SNAP se llaman beneficios para alimentos.

¿Cómo puedo obtener los beneficios del programa SNAP? Paso 1. Llene una solicitud. Cualquier persona puede llenar una solicitud. Conteste tantas preguntas como usted pueda. Si usted está solicitando los beneficios de SNAP y no puede llenar todas las 8 páginas de la solicitud hoy, asegúrese de llenar esta hoja y entregarla. Pero, por favor llene y entregue el resto de la solicitud (páginas 2-8) lo más pronto que pueda. Paso 2. Devuélvanos la solicitud. Usted puede enviar su solicitud por fax o por correo a una oficina local del Departamento para Servicios Basados en la Comunidad (DCBS, por sus siglas en inglés). O, usted puede entregar su solicitud en la oficina local de DCBS cuando ésta esté abierta. Cuando recibamos su solicitud, se programará una entrevista para usted. Usted tiene el derecho de saber pronto si recibirá beneficios o no. El día en que recibamos esta página con su nombre, dirección y su firma comienza el plazo de tiempo que tenemos para determinar si usted es elegible para los beneficios de SNAP. También, esta es la fecha de inicio de sus beneficios de SNAP si usted es elegible para ellos. Paso 3. Hable con nosotros. En la entrevista, usted tiene que mostrarnos:

• Verificación de quién es usted, tales como su licencia de conducir, tarjeta de Seguro Social o documentos de inmigración; *Ver el aviso en la página 3 acerca de proporcionar su número de Seguro Social.

• Verificación de quiénes viven en su hogar, tales como un contrato o una declaración por escrito; • Verificación de que usted vive en Kentucky; • Verificación de costos de cuidado infantil o manutención infantil pagada; y • Verificación de dinero que usted ha recibido en los últimos 60 días, incluyendo cualquier talón de cheque.

*Si usted no puede traer todo esto, acuda a su entrevista de todos modos. Nosotros le ayudaremos.

Díganos acerca de usted

Nombre Legal: _____________________________________________________________________ _________________________ (Apellido) (Primer nombre) (Inicial del segundo nombre) (Número de Seguro Social) _____ /______ /______ ________________________________________________________________________ (Fecha de nacimiento) (Dirección postal) (Ciudad) (Estado) (Código Postal) ( mes / día / año )

Condado de domicilio __________________________ Número de teléfono (____) __________ � Suyo � Cercano Si su dirección de domicilio es diferente a la dirección postal, escríbala abajo:

___________________________________________________________________________________ (Dirección) (Ciudad) (Estado) (Código Postal)

Firma/Marca (X) Testigo (Si está firmado con una X) La fecha de hoy

/ /

2 de 8

¿Tiene usted una condición física o mental que requiere que usted tenga acomodaciones especiales, tales como la necesidad de un intérprete de lenguaje de señas, durante su entrevista de solicitud? � Sí � No Si responde sí, ¿qué necesita? _____________________________________

Podemos conseguir un intérprete sin cargo alguno para su entrevista si usted tiene dificultades para hablar inglés. ¿Necesita usted un intérprete durante la entrevista? � Sí � No Si responde sí, ¿en qué idioma?________

Usted podría recibir los beneficios de SNAP para el quinto día a partir de haber hecho su solicitud. A esto se le llama Beneficios Acelerados. Si usted califica para esto, necesitaremos algo además de esta página. Vea la información acerca de Beneficios Acelerados que aparece abajo o pregúntenos acerca de esto.

Para obtener beneficios de SNAP, usted necesitará llenar toda esta solicitud. Necesitamos la solicitud completa para decidir si usted es elegible, aun si usted califica para Beneficios Acelerados. Entre más información usted nos proporcione, mejor trabajo podremos hacer. Le pedimos que nos dé toda la información posible. Si necesita ayuda, pida nuestra ayuda y se la daremos. También necesita entregar una copia de su identificación personal (ID) tales como su licencia de conducir, tarjeta de Seguro Social o documentos de inmigración.

Beneficios acelerados – Beneficios de SNAP en 5 días Los que pueden obtener beneficios de SNAP en un plazo de 5 días son:

Beneficios de SNAP en 30 días:

Usted puede elegir a alguien que le ayude. No está obligado a hacerlo. Pero, si decide hacerlo, la persona que elige podrá llenar su solicitud, responder preguntas a nombre de usted, dar información en su entrevista y comprar su comida con la tarjeta EBT. Nosotros podremos compartir información con esta persona. Nota: Los Centros de Rehabilitación de Drogas o Alcohol con pacientes internados tienen que designar a un empleado para que solicite ayuda para cualquiera de sus residentes.

Información acerca de estatus de inmigración

Usted puede solicitar beneficios de SNAP por algunos miembros de su hogar aun si otros miembros no pueden ser elegibles debido a su estatus de inmigración. Por ejemplo, los padres que no tienen un estatus de inmigrante legal pueden solicitar beneficios de SNAP para sus hijos que son ciudadanos de EE.UU. o inmigrantes legales elegibles. No solicite para las personas que no tienen un estatus de inmigración legal. No nos comunicaremos con los Servicios de Ciudadanía e Inmigración de los EE.UU. (USCIS, por sus siglas en inglés) acerca de las personas para quienes no está solicitando. Tenemos que usar los ingresos y activos de ellos para determinar si el resto de los miembros del hogar pueden obtener beneficios de SNAP. Usted no tiene que presentar los documentos de inmigración de las personas para

¿Cuándo recibiré los beneficios de SNAP?

Hogares con activos e ingresos brutos mensuales menos de $150; u

Hogares con renta, hipoteca y servicios para el hogar que están por encima de los ingresos brutos mensuales del hogar y de sus activos, u

Hogares que tienen un trabajador agrícola migrante o por temporada y con activos de $100 o menos cuyos ingresos están por cancelarse o por empezar

¿Puedo elegir a alguien que me ayude?

Representante :

____________________________________________________________________________ (Apellido) (Primer nombre) (Inicial del segundo nombre) ____________________________________________________________________________ (Dirección postal) (Ciudad) (Estado) (Código postal)

(_____)_________________ Número de teléfono

Si usted no recibe los beneficios acelerados, usted recibirá una carta diciéndole ya sea que:

Usted es elegible para los beneficios de SNAP y por cuánto, o

Usted no es elegible y por qué usted no es elegible para los beneficios de SNAP

3 de 8

quienes no quiere solicitar los beneficios de SNAP. No solicite para personas que están en el país ilegalmente, pero escriba el nombre de ellos, la relación y la fecha de nacimiento en la tabla que aparece en la página 3. Verificamos el estatus de inmigración de los inmigrantes para quienes usted solicita a través del Sistema de Verificación Sistemática de Inmigración que es administrado por la USCIS. La información que recibimos podría afectar sus beneficios de SNAP.

Datos acerca de los números de Seguro Social

Usted puede elegir entre presentar o no el número de Seguro Social de cada una de las personas en su hogar. Podemos proporcionarles beneficios de SNAP solamente a las personas que presenten su número de Seguro Social o que pueden comprobar que ellos han solicitado un número de Seguro Social. Usted no tiene que presentar el número de Seguro Social de las personas por las que usted no quiere recibir beneficios de SNAP.

De acuerdo con las leyes federales y las políticas del Departamento de Agricultura de los EE.UU. (USDA, por sus siglas en inglés) se prohíbe a esta institución discriminar en base a raza, color, origen nacional, sexo, edad, religión, creencias políticas, o discapacidad. Para presentar una queja de discriminación, escriba a: USDA, Director, Office Of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 o llame al (800) 795-3272 (voz) o al (202) 720-6382 (TTY). USDA es un proveedor y empleador con igualdad de oportunidades.

Díganos acerca de las personas en su hogar

Para los beneficios de SNAP, un hogar es una persona o grupo de personas que viven juntos y además compran y preparan la comida juntos. Las personas del grupo no tienen que ser familiares. Para los beneficios de SNAP, las siguientes personas tienen que ser consideradas un hogar si viven juntas aunque no compren ni preparen la comida juntas:

• Usted mismo y su cónyuge, • Sus niños menores de 22 años (aun si ellos tienen sus propios niños), • Cualquier padre de niños menores de 22 años, • Otros niños menores de 18 años a quienes usted cuida, y • Cualquier otra persona que compra y prepara la comida con usted.

Instrucciones: En la tabla que aparece abajo, llene las casillas con la información de cada una de las personas que viven en su hogar. Si usted no quiere recibir beneficios para alguien, conteste “no” en la primera pregunta que aparece abajo y sólo llene las casillas para el nombre de la persona, su relación con usted y la fecha de su nacimiento.

Si usted elige contestar las preguntas acerca de raza y origen étnico, use los siguientes códigos: * Origen étnico **Raza (Seleccione todo lo que aplica) H = Hispano o Latino B = Negro o Afroamericano N = Nativo de Hawái/Nativo de otra Isla del Pacífico N = No es Hispano ni Latino W = Blanco A = Asiático

I = Nativo Americano o Nativo de Alaska

¿Está solicitando? Sí/No

Primer nombre, inicial del segundo, apellido

Número de Seguro Social

Relación con usted

Fecha de Nacimiento MM/DD/AA

Sexo M o F

*Origen étnico

**Raza Ciudadano Sí/No

1.

Sí mismo / /

2. / /

3. / /

4. / /

5. / /

6. / /

7. / /

Usted no será discriminado

4 de 8

8. / /

Nota: Al firmar la página 7, estoy de acuerdo en que todos los miembros de mi hogar que tienen que cumplir con el requisito de trabajo y capacitación seguirán las reglas del mismo.

¿Hay alguien prófugo que ha sido condenado por un delito grave? � Sí � No ¿Quién? _____________________

¿Alguien ha sido condenado por un delito grave de drogas después del 22 de agosto de 1996? � Sí � No ¿Quién?_______

¿Hay alguien recibiendo beneficios de alimentos en otro estado? � Sí � No ¿En qué estado? ____________________

¿Alguien tiene una tarjeta EBT de Kentucky? � Sí � No ¿Quién? ______________________________________

Escriba el nombre de todos aquellos mayores de 18 años que están en la universidad o escuela vocacional:_______________

¿Qué gastos tiene su hogar?

Para obtener la mayor cantidad posible de beneficios de SNAP, díganos acerca de sus gastos. Si usted no informa o no entrega verificación de algún gasto esto será visto como una declaración de su hogar en la que usted manifiesta que no quiere recibir una deducción por los gastos que no han sido informados. En las líneas abajo díganos acerca de los gastos de su hogar.

Vivienda y servicios del hogar Cuánto le tocará pagar a su hogar de los siguientes gastos:

Alquiler: $____________ por mes

Alquiler de lote: $____________ por mes

Hipoteca: $____________ por mes

Si usted paga impuestos o seguros por separado de su hipoteca, escriba las cantidades abajo:

Impuestos sobre propiedades: $____________ por____________

Seguro de propietario de una vivienda: $____________ por____________

Marque la casilla que está al lado de las facturas de servicios para el hogar que usted tiene que pagar:

� La luz/electricidad � Agua o drenaje � Gas � Basura � Teléfono � Cargos adicionales por parte del arrendador � Otro, explique______________________

� Marque aquí si alguna de las facturas de servicios para el hogar que usted paga es para la calefacción o el aire acondicionado.

� Marque aquí si el año pasado usted recibió ayuda del programa LIHEAP en su dirección actual.

Gastos Médicos

Si usted tiene gastos médicos que no han sido pagados por el seguro de alguien que está discapacitado o que es mayor de 59 años de edad, díganos. Estos gastos pueden ser facturas del doctor o del hospital, medicinas, transporte, el pago de seguros de salud, u otros gastos médicos.

Quién paga: ____________________________ Cantidad: $_________ por mes

Guardería

Si usted tiene gastos por el cuidado de un niño o de un adulto que vive con usted, díganos.

Quién recibe el cuidado: _________________________ Quién paga por el cuidado: __________________

Cantidad: $_________ por mes

5 de 8

Manutención Infantil

Si alguien está pagando manutención infantil ordenada por la corte, díganos.

Quién paga: ____________________________ Cantidad: $_________ por mes Ayuda para pagar gastos Si usted recibe ayuda para pagar alguno de sus gastos, díganos:

¿Qué gasto fue pagado? ¿Quién lo pagó? ¿Cantidad que se pagó?

Escriba el nombre de la persona y la cantidad mensual. Si usted deja un espacio en blanco, para nosotros esto significa que no recibe ningún dinero de este tipo. Adjunte otra hoja si es necesario.

De dónde proviene el dinero Quién recibe el dinero

Cantidad mensual Empleador (si es aplicable)

Dinero derivado del trabajo antes de los impuestos (Bruto)

Dinero derivado del trabajo antes de los impuestos (Bruto) Segundo trabajo

Trabajo por cuenta propia o Trabajos irregulares

Propinas

Seguro Social o Seguridad de Ingreso Suplementario (SSI)

Beneficios para los veteranos, Pensiones o Jubilación

Desempleo o compensaciones a los trabajadores

Manutención Infantil o Pensión para ex cónyuge

Dinero proveniente de amigos o familiares

Otro

¿Alguien ha sido contratado para un trabajo pero aún no le han pagado? � Sí � No ¿Quién?

¿Alguien ha dejado el trabajo en los últimos 30 días? � Sí � No ¿Quién?

¿Es alguien trabajador agrícola migrante o por temporada? � Sí � No ¿Quién?

¿Alguien está en huelga? � Sí � No ¿Quién?

¿Qué activos tienen las personas en su hogar?

Escriba la cantidad total de dinero que cada uno tiene en:

Dinero en efectivo $ ______________ Cuentas en bancos o cooperativas de ahorro (credit unions) $ _____________

Acciones, bonos, certificados de ahorro u otros activos $_______________

Favor de leer esta información, firmar y fechar la página 7

Reglas de SNAP

¿Qué tipo de dinero reciben las personas de su hogar?

6 de 8

Siga estas reglas:

• No esconda ni dé información falsa a propósito para obtener beneficios de SNAP. • No use beneficios de SNAP para comprar cosas que no sean comida como alcohol o tabaco. • No intercambie, venda ni regale los beneficios de SNAP.

• No use para sí mismo los beneficios de SNAP de otra persona.

Sanciones del programa SNAP

Cualquier persona que quebrante las reglas descritas anteriormente:

• Podría no recibir beneficios de SNAP por 1 año en la primera infracción, 2 años en la segunda infracción y de por vida en la tercera infracción;

• Podría ser multada hasta con $250,000 o ser encarcelada hasta por 20 años, o ambos; y

• Si la corte halla que usted es culpable de comprar, vender o intercambiar más de $500 en beneficios de SNAP, usted podría no recibir beneficios de SNAP de por vida.

• Si la corte halla que usted es culpable de intercambiar beneficios de SNAP por armas de fuego, municiones o explosivos, usted perderá sus beneficios de por vida.

• Si la corte halla que usted es culpable de intercambiar beneficios de SNAP por sustancias controladas, usted perderá sus beneficios por dos años la primera vez y de por vida la segunda vez.

• Usted no recibirá beneficios de SNAP por 10 años si usted es hallado culpable de obtener o del intento de obtener beneficios de SNAP en más de un hogar al mismo tiempo. Esta penalidad sucede cuando usted entrega datos incorrectos acerca de quién es usted o en dónde vive.

**Proporcionar información incorrecta a propósito podría tener como resultado que tomemos acción legal en su contra, ya sea acción criminal o civil. Esto incluso podría significar que reduzcamos sus beneficios o que exijamos que devuelva el dinero.

¿Qué hacemos con su información?

Si alguna información que usted nos proporciona no es correcta, podríamos negar los beneficios de SNAP. Les daremos sus respuestas a oficiales de la policía para detener a los prófugos de la justicia. Si usted tiene un sobrepago de beneficios de SNAP, les daremos sus respuestas a agencias federales y estatales para que cobren el sobrepago. Negaremos la ayuda a las personas, si usted no nos entrega el número de Seguro Social de ellos. Usaremos cualquier número de Seguro Social que se nos ha entregado, de la misma manera que usamos el número de Seguro Social de las personas que están recibiendo ayuda. No le daremos su número de Seguro Social a los Servicios de Ciudadanía e Inmigración de los EE.UU. (USCIS, por sus siglas en inglés).

Ley de Privacidad

La recopilación de esta información, incluyendo el número de Seguro Social de cada miembro del hogar, está autorizada bajo la Ley de Alimentos y Nutrición de 2008, según la enmienda, 7 U.S.C. 2011-2036. La información será usada ya sea para determinar si su hogar es elegible o si continúa siendo elegible para que participe en el Programa Suplementario de Asistencia Nutricional. Verificaremos esta información por medio de programas informáticos que harán comparación de datos. Esta información también será utilizada para seguir el cumplimiento de los reglamentos del programa y para la administración del programa.

Esta información puede ser revelada a otras agencias federales y estatales para exámenes oficiales, y a los oficiales encargados del cumplimiento de la ley con el propósito de detener a prófugos de la justicia.

Si un reclamo de SNAP surge en contra de su hogar, la información en esta solicitud, incluyendo todos los números de Seguro Social, pueden ser remitidos a las agencias federales y estatales, al igual que a las agencias privadas de cobro de reclamos, para la acción de cobro de reclamos.

Proporcionar la información pedida, incluyendo el número de Seguro Social de cada miembro del hogar, es voluntario. Sin embargo, si no proporciona el número de Seguro Social, tendrá como resultado la negación de los beneficios de SNAP para cada individuo cuyo número de Seguro Social no es proporcionado. Cualquier número de Seguro Social proporcionado será utilizado y revelado de la misma manera que los números de Seguro Social de miembros del hogar que son elegibles.

Verificamos lo que usted nos dice

7 de 8

Utilizamos sistemas informáticos para verificar los ingresos de su familia y para hacer comparaciones de los datos en sistemas de otras agencias tales como la Oficina de Empleo y Capacitación, Servicios de Impuestos Internos y otras fuentes en las que se pueden hacer comparaciones. Si algo que usted nos ha dicho es diferente a lo que nos dice el sistema informático, verificaremos la información para determinar cuál es la información correcta. Es posible que verifiquemos su información al comunicarnos con su empleador, su banco u otras personas. Si alguna parte de esta solicitud es incorrecta, los beneficios de SNAP pueden ser negados y usted puede estar sujeto a las reglas de juicio criminal porque a sabiendas ha proporcionado información incorrecta. La información que usted nos proporciona puede ser verificada por oficiales federales, estatales y locales para asegurar que la información es verdadera. Entre las informaciones que se pueden verificar están: el número de Seguro Social, empleo y salario, cantidades de dinero en cuentas bancarias, cantidades recibidas de otras fuentes como el Seguro Social o desempleo, y el estatus de inmigración.

Su firma y entendimiento

Entiendo:

• Las preguntas en esta solicitud y lo que puede suceder si oculto información o doy información incorrecta.

• Tengo que proporcionar verificación de la información acerca de mi hogar.

• La oficina del Departamento para Servicios Basados en la Comunidad (DCBS, por sus siglas en inglés) y la Unidad de Control de Calidad pueden comunicarse con otras personas u organizaciones para obtener verificación de mis datos.

• Que la información que he proporcionado en la solicitud incluyendo la información relacionada con ciudadanía y estatus de inmigración está sujeta a verificación por oficiales federales, estatales y locales para determinar si la información es verdadera.

• Que como un solicitante de los beneficios de SNAP, se requiere que proporcione el número de Seguro Social de cada una de las personas que viven en mi hogar para quienes estoy solicitando beneficios. (Los números de Seguro Social y estatus de inmigración no tienen que ser proporcionados para los miembros del hogar que no están solicitando beneficios.)

• Que los números de Seguro Social serán usados para varias comparaciones estatales y federales a través del Sistema de Verificación de Ingresos y Elegibilidad (IEVS, por sus siglas en inglés). Estas comparaciones de información incluyen, pero no están limitadas al, Seguro Social, IRS, SSI, Registros de Salarios, Seguro de Desempleo, Registros de Aplicación de Manutención Infantil y otras comparaciones proporcionadas bajo la autoridad de IEVS. Esta información puede ser verificada a través de contactos colaterales cuando se encuentran discrepancias. La información proporcionada por el sistema IEVS, después de verificarla, puede afectar la elegibilidad y la cantidad de beneficios.

Certifico, bajo pena de perjurio, que:

• Mis respuestas son correctas y completas de acuerdo a mis conocimientos.

• Mi respuesta acerca de ciudadanía o estatus de inmigración de cada persona que está solicitando beneficios es correcta.

Utilizamos estos términos en la solicitud. Esto es lo que quieren decir:

Extranjero (Alien) Una persona que no es ciudadana de EE.UU.

Tarjeta EBT Una tarjeta de plástico que usted utiliza en la tienda para comprar comida.

Elegible Que reúne todos los requisitos para obtener beneficios de SNAP.

Beneficios de alimentos Los beneficios que usted recibe del programa SNAP.

Hogar Una persona o grupo de personas que viven juntos y compran y preparan la comida juntos.

¿Qué significan nuestros términos?

Firma/Marca (X) Testigo (Si está firmado con una X) La fecha de hoy

/ /

8 de 8

Control de Calidad Una unidad del Departamento para Servicios Basados en la Comunidad que revisa algunos casos de beneficios de SNAP para ver si están correctos. Si su caso es elegido, la unidad de Control de Calidad se comunicará con usted.

Reglas del trabajo y capacitación Algunas personas tienen que trabajar o asistir a capacitación para obtener

beneficios de SNAP. Si este es su caso o el caso de otras personas que viven en su hogar, tendrá que seguir las reglas acerca del trabajo y de la capacitación para obtener beneficios de SNAP.

Revelación de información opcional

¡Ayúdenos a ayudarle!

Usted no tiene que firmar esto, pero esto nos ayudará a obtener la información que necesitamos para ayudarle, sin tener que obtener su firma en solicitudes específicas.

Usted debe saber:

• Que es posible que necesitemos más información para decidir si usted puede recibir ayuda. • Si necesitamos más información de usted, recibirá una carta en la que le informamos qué es lo que necesitamos y la fecha en la que debe entregarlo. • Usted es responsable de obtener la información o de pedirnos ayuda en cómo obtenerla. • Si usted no nos entrega la información o no pide ayuda antes de la fecha de entrega, su solicitud puede ser negada o su ayuda puede terminar. • Es posible que podamos utilizar la revelación de información que aparece abajo para obtener la información que necesitamos. Pero todavía tiene que proporcionar la información que le pedimos o tiene que pedir ayuda. • Es posible que adjuntemos una copia de esta revelación a un formulario que pide a otras personas u organizaciones (como su empleador) información específica que es necesaria acerca de usted o acerca de otros miembros de su hogar.

Escriba su nombre claramente y firme abajo para darnos permiso para que obtengamos la información necesaria.

AUTORIZACIÓN PARA REVELAR INFORMACIÓN

Por medio de la presente autorizo a cualquier persona u organización a proporcionarle al Departamento para Servicios Basados en la Comunidad de Kentucky la información que requiere acerca de mí o acerca de otros miembros de mi hogar. Una copia de esta es tan válida como el original. Esta autorización no se aplica a la información de salud protegida. Esta autorización tiene una vigencia de 12 meses a partir de la fecha en que es firmada.

____________________________________ Su nombre (Por favor escriba claramente)

_________________________________ ____________________________ Firma o Marca Testigo (si se firmó con una X) ________________ Fecha

FS-1 COMMONWEALTH OF KENTUCKY (R. 2/12) Cabinet for Health and Family Services 921 KAR 3:030 Department for Community Based Services

*If you need help filling out this form, contact your local DCBS office. You may locate your local office information at:

https://apps.chfs.ky.gov/Office_Phone/index.aspx

Application for SNAP

What Is SNAP?

The Supplemental Nutrition Assistance Program (SNAP) is a program to help you buy food for good health. The benefits you receive from SNAP are called food benefits.

How Do I Get SNAP Benefits?

Step 1. Fill out an application. Anyone may fill out an application. Answer as many questions as you can. If you are applying for SNAP and can’t fill out all 8 pages of the application today, be sure to fill out this page, sign it, and turn it in. But, then please fill out and turn in the rest of the application (pages 2-8) as soon as you can.

Step 2. Return the application to us. You can fax or mail your application to a local Department for Community Based Services (DCBS) office. Or, you can bring your application to a local DCBS office when it is open. When we get your application, an interview will be set up with you. You have the right to know soon whether you will get benefits. The date we get this page with your name, address and signature starts the time that we have to determine if you are eligible for SNAP benefits. It is also the start date of SNAP benefits for you if you are eligible for benefits.

Step 3. Talk with us.

At your interview, you will need to show us: • Proof of who you are, such as your driver’s license, social security card or alien documentation;

*See notice on page 3 about providing your social security number.

• Proof of who lives in your home, such as a lease or written statement; • Proof that you live in Kentucky; • Proof of child care costs or child support paid; and • Proof of money you have gotten in the past 60 days, including any check stubs.

*If you can’t bring everything, come to the interview anyway. We will help you.

_____________________________________________________________________________________ (Street Address) (City) (State) (Zip code)

Tell Us About You

Legal Name:

_____________________________________________________________ ____________________

(Last) (First) (Middle Initial) (Social Security Number)

___ /____/____ _________________________________________________________________ (Date of Birth) (Mailing Address) (City) (State) (Zip code)

County of Residence __________________ Telephone Number (____) __________ � Yours � Nearby

If your street address is different from your mailing address, write it below:

____________________________________________________________________________ (Street Address) (City) (State) (Zip code)

Signature/Mark (X) Witness (If signed by X) Today’s Date

/ /

2 of 8

Do you have a physical or mental condition that requires you to have special accommodations, such as needing a sign language interpreter, during your application interview? � Yes � No If yes, what do you need? _____________________________________

We can get a free interpreter for your interview if you have trouble speaking English. Do you need an interpreter during your interview? � Yes � No If yes, what language?____________________

You may be able to get SNAP benefits by the 5th day after you apply. This is called Expedited Benefits. If you qualify for this, we need more than this page. See below about Expedited Benefits or ask us about this.

To get SNAP benefits, you will need to fill out all of this application. We need the whole application to decide if you are eligible, even if you are eligible for Expedited Benefits. The more information you give us the better job we can do. Give us all the information you can. If you need help, ask us and we will help you. You also need to turn in a copy of your ID such as your driver’s license, social security card, or alien documentation.

Expedited Benefits – SNAP Benefits in 5 days This is who can get SNAP benefits within 5 days:

SNAP Benefits in 30 days:

You can choose to have someone help you. You don’t have to do this. But, if you do, this person can fill out your application, answer questions for you, give information at your interview, and buy your food with an EBT card. We will be able to share information with this person. Note: In-patient Drug and Alcohol Rehabilitation Centers must designate an employee to apply for any residents.

Information About Alien Status

You can apply for SNAP benefits for part of your household even if some members may not be eligible because of their immigration status. For example, parents who do not have legal immigrant status may apply for SNAP benefits for their children who are U.S. citizens or qualified legal immigrants. Do not apply for people who don’t have legal immigrant status. We will not contact the U.S. Citizenship and Immigration Services (USCIS) about the people you don’t apply for. We must use their income and assets to see if the rest of the household can get SNAP benefits. You don’t have to give us the immigrant documents for the people you do not want SNAP benefits for. Do not apply for people who are in the country illegally, but list their

When Will I Get SNAP Benefits?

• Households with less than $150 in gross monthly income and assets; or • Households with rent, mortgage and utilities that are more than the household’s gross monthly income and assets; or • Households with a migrant or seasonal farm worker and with assets of $100 or less whose income is stopping or starting.

Can I Choose to Have Someone Help Me?

Representative :

_________________________________________________________________________ (Last Name) (First Name) (M.I.) _________________________________________________________________________ (Mailing Address) (City) (State) (Zip Code)

(_____)_________________ Phone Number

If you don’t get Expedited Benefits, you will get either a letter telling you:

You are eligible for SNAP benefits and how much, or

You are not eligible and why you are not eligible for SNAP benefits

3 of 8

name, relationship and birth date in the table on Page 3. We check the immigration status of immigrants you apply for through the Systematic Alien Verification System operated by the USCIS. The information we receive may affect your SNAP benefits.

Information About Social Security Numbers

You can choose to give us the Social Security Number of each person in your household. We can give SNAP benefits only to the people who give us their Social Security Number or proof that they have applied for a Social Security Number. You don’t have to give us the Social Security Number for the people you do not want SNAP benefits for.

In accordance with federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write to: USDA, Director, Office of Civil Rights, 1400 Independence Ave SW, Washington D.C. 20250-9410 or call (800) 795-3272 (Voice) or (202) 720-6382 (TTY). USDA is an equal opportunity provider and employer.

Tell Us About the People in Your Home

A SNAP household is a person or a group of people who live together and buy food and fix meals together. The group does not need to be related. The following people must be one SNAP household if they live together even if they do not buy and fix meals together:

• Yourself and your husband or wife, • Your children who are under 22 (even if they have children of their own), • Any parent of children under age 22, • Other children under 18 who you take care of, and • All other people who buy food and fix meals with you.

Instructions:

On the chart below, fill in the boxes for each of the people who live in your home. If you do not want to get benefits for someone, answer “no” to the first question below and fill in only their name, their relationship to you, and their date of birth.

If you choose to answer the questions about race and ethnicity, use the following coding: * Ethnicity **Race (Choose all that apply) H = Hispanic or Latino B = Black or African American N=Native Hawaiian/other Pacific Islander N = Not Hispanic or Latino W = White A=Asian

I =American Indian or Alaskan Native

Apply for? Yes/No

First Name, M. I., Last Name

Social Security Number (#)

Relationship to you

Birth Date MM/DD/YY

Sex M or F

*Ethnicity **Race Citizen Yes/No

1.

SELF / /

2. / /

3. / /

4. / /

5. / /

6. / /

7. / /

8. / /

You Will Not Be Discriminated Against

4 of 8

Note: By signing on page 7, I agree that all members of my household that are required will follow the work and training rules. Is anyone a fleeing felon? � Yes � No Who? ____________________

Has anyone been convicted of a drug felony since 8/22/96? � Yes � No Who? ________________

Is anyone getting food assistance from another state? � Yes � No What state? _______________

Does anyone have a Kentucky EBT card? � Yes � No Who? ___________________

List anyone age 18 or over who is in college or trade school: ________________

What Expenses Does Your Household Have?

To get the most SNAP benefits you can, tell us about your bills. Failure to report or give proof of any expenses will be seen as a statement by your household that you do not want to receive a deduction for the unreported expenses. Below, tell us about the bills your household pays.

Shelter and Utilities

How much is your household’s share of the following expenses:

Rent: $____________ per month

Lot Rent: $____________ per month

Mortgage: $____________ per month

If you pay taxes or insurance separate from your mortgage, list amounts below:

Property Taxes: $____________ per____________

Homeowner’s Insurance: $____________ per____________

Check the boxes next to the utility bills you have to pay:

� Lights/Electricity � Water �Sewage � Gas � Garbage/Trash � Telephone � Extra charges from your landlord

� Other, explain______________________

� Check here if any of the utility bills you have to pay are for heating or air conditioning.

� Check here if you got energy assistance (LIHEAP) in the past year at your current address.

Medical Expenses

If you have medical costs not paid by insurance for anyone who is disabled or over age 59, tell us. These could be doctor or hospital bills, medicine, transportation, health insurance premiums, or other medical expenses.

Who pays: ____________________________ Amount: $_________ per month

Day Care

If you have day care expenses for a child or an adult who lives with you, tell us.

Who gets care: _______________________ Who pays for the care: ________________________ Amount: $_________ per month

Child Support

If anyone is paying court-ordered child support, tell us.

Who pays: _____________________________ Amount: $_________ per month

5 of 8

Help Paying Expenses

If you get help with any of your expenses, tell us:

Which Expense Was Paid? Who Paid? Amount Paid?

List the person’s name and the monthly amount. If you leave a space blank, we will take that to mean there is no money of this kind. Attach another sheet if needed.

Where the Money Comes From

Who Gets The Money

Amount per Month Employer (if applicable)

Money From Work Before Taxes (Gross)

Money From Work Before Taxes (Gross) 2nd Job

Self-Employment or Odd Jobs

Tips

Social Security or SSI

Veterans Benefits, Pensions or Retirement

Unemployment or Worker’s Compensation

Child Support or Alimony

Money from Friends or Relatives

Other

Has anyone been hired for a job but not paid yet? � Yes � No Who?_________________

Has anyone quit a job in the last 30 days? � Yes � No Who?_________________

Is anyone a migrant or seasonal farm worker? � Yes � No Who?_________________

Is anyone on strike? � Yes � No Who?_________________

What Assets Do People in Your Household Have?

List the total money everyone has in:

Cash $ ______________ Bank/Credit Union Accounts $ _______________

Stocks, bonds, savings certificates, or other assets $_______________

Please read this information and sign and date page 7.

SNAP Rules

Follow these rules:

• Don’t hide or give wrong information on purpose to get SNAP benefits. • Don’t use SNAP benefits to buy non-food items like alcohol or tobacco. • Don’t trade, sell or give away SNAP benefits.

• Don’t use someone else’s SNAP benefits for yourself.

What Money Do People in Your Household Get?

6 of 8

SNAP Penalties

Anyone who breaks the above rules:

• May not get SNAP benefits for 1 year for the first time, 2 years for the second time, and forever for the third time;

• May be fined up to $250,000 or jailed up to 20 years, or both; and • If a court finds you guilty of buying, selling or trading more than $500 in SNAP benefits, you may

not get SNAP benefits forever. • If a court finds you guilty of trading SNAP benefits for firearms, ammunition, or explosives, you

will lose benefits forever. • If a court finds you guilty of trading SNAP benefits for controlled substances, you will lose

benefits for two years the first time and forever the second time. • You will not get SNAP benefits for 10 years if you are found guilty of getting or trying to get SNAP

benefits in more than one household at a time. This penalty happens if you give wrong information about who you are or where you live.

**Giving wrong information on purpose may result in us taking legal action against you, either criminal or civil. It might also mean we reduce your benefits or take money back from you.

What We Do With Your Information

If any information you give us is not correct, we may deny SNAP benefits. We will give your answers to law enforcement officials to catch persons fleeing to avoid the law. If you have a SNAP benefits overpayment, we will give your answers to federal and state agencies to collect the overpayment. We will deny assistance to people, if you do not give us their Social Security Number. We will use any Social Security Number given to us the same way we use the Social Security Number of persons getting assistance. We will not give your Social Security Number to the U.S. Citizenship and Immigration Services (USCIS).

Privacy Act

The collection of this information, including the social security number (SSN) of each household member, is authorized under the Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036. The information will be used to determine whether your household is eligible or continues to be eligible to participate in the Supplemental Nutrition Assistance Program. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management.

This information may be disclosed to other federal and state agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.

If a SNAP claim arises against your household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.

Providing the requested information, including the SSN of each household member, is voluntary. However, failure to provide an SSN will result in the denial of SNAP benefits to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members.

We Check What You Tell Us

We use computer systems to verify your family’s income and to do computer matches with other agencies such as the Office of Employment and Training, the Internal Revenue Service and other matching sources. If something you told us is different from what the computer system tells us, we will check to find out what is correct. We might check your information by contacting your employer, your bank or other people. If any part of the information on this application is incorrect, SNAP benefits may be denied and you may be subject to criminal prosecution rules for knowingly providing incorrect information. The information you give us may be checked by federal, state, and local officials to make sure it is true. Things we might check are any listed person’s: Social Security Number, job and pay, bank account amount, amounts received from other sources like Social Security or

7 of 8

unemployment, and alien status.

Your Signature and Understanding

I understand: • The questions on this application and what can happen if I hide information or give wrong information. • I must give proof of information about my household. • The DCBS office and the Quality Control unit may contact other people or organizations to get proof of

my information. • That the information I have provided on the application including the information concerning

citizenship and alien status is subject to verification by Federal, State and local officials to determine if the information is true.

• That as an applicant for SNAP benefits, I am required to provide a social security number for everyone who lives in my home for whom I am applying for benefits. (Social Security numbers and immigration status does not have to be provided for members that are not applying for benefits.)

• That social security numbers shall be used for various state and federal matches through the Income and Eligibility Verification System (IEVS). These matches include, but are not limited to, Social Security, IRS, SSI, Wage Records, Unemployment Insurance, Child Support Enforcement records and other matches as provided for under the authority of IEVS. This information may be verified through collateral contacts when discrepancies are found. Information provided under IEVS, after verification, may affect eligibility for and amount of benefits.

I certify, under penalty of perjury, that: • My answers are correct and complete to the best of my knowledge. • My answer about citizenship or alien status of each person applying for assistance is correct.

We use these terms in the application. This is what they mean:

Alien A person who is not a U.S. citizen.

EBT card A plastic card that you use at the grocery store to buy food.

Eligible Meeting all of the guidelines to get SNAP benefits. Food benefits The benefits you receive from SNAP.

Household A person or a group of people who live together and buy food and fix meals together.

Quality Control A DCBS unit that reviews some SNAP benefits cases to see if they are correct. If your case is chosen, the Quality Control unit will contact you.

Work and Training Rules Some people have to work or attend training to get SNAP benefits. If this is true for

you or for other people in your household, we will tell you. You will have to follow the rules about work and training to get SNAP benefits.

What Do Our Terms Mean?

Signature/Mark (X) Witness (If signed by X) Today’s Date

/ /

8 of 8

Optional Release of Information

Help Us Help You! You do not have to sign this, but it will help us get information we need to help you, without having to get your signature on specific requests.

You should know: • We may need more information to decide if you can get assistance. • If more information is needed from you, you will get a letter telling you what we need and the date you must get it to us. • You are responsible to get the information or to ask us for help to get it. • If you do not give us the information or ask for help by the due date, your application may be denied or your assistance may end. • We may be able to use the release below to get the information we need. But you still have to provide the information we request or ask for help. • We may attach a copy of this release to a form that asks other people or organizations (like your employer) for specific information needed about you or others in your household.

Print and sign your name below to give us permission to get needed information.

RELEASE OF INFORMATION

I hereby authorize any person or organization to give the Kentucky Department of Community Based Services requested information about me or other members of my household. A copy of this release is as valid as the original. This release does not apply to protected health information. This release is good for 12 months from the date signed.

_________________________________ Your Name (please print clearly)

_________________________________ _________________________ Signature or Mark Witness (if signed by X) ________________ Date

2011 Poverty Guidelines - SafetyNet Alliance859-824-6324 Kenton Co. Action Ministries 4375 Boron St....

Documents

Transcript of 2011 Poverty Guidelines - SafetyNet Alliance859-824-6324 Kenton Co. Action Ministries 4375 Boron St....