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ES-3100.

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WELCOME TO THE KANSAS FOOD ASSISTANCE PROGRAM!

If you want to apply for food assistance only, please use this form. Toget this assistance (also known as food stamp benefits), you will need to:(1) Fill out this entire form as completely as possible.(2) Provide proof of income and resources along with everyone's Social

Security numbers.(3) Have the head of your household sign the form on page 4.

You must also have an interview as part of the application process.However, if you are elderly or disabled, you do not have to come to theoffice for this interview.Your application will be processed within 30 days and if you are eligible,benefits will start from the date a signed application is received in our office.

If you can't complete this application right now, you can simply, give us yourname and address, sign at the bottom of this page, and return the form tothe local SRS office. You must, however, still complete the entire form tosee if you are eligible to get benefits.If you have a preferred language other than English, please check below:

Spanish Vietnamese Other_________________I MPORTANT! ! You may be able to receive benefits within 7 days if your household has little or no income, your rentand utility bills are more than your income and resources, or you are a migrant or seasonal farm worker. Pleaseanswer the following questions:

Will your households gross income for this month be less than $150? No Yes

Does your household have less than $100 in cash, checking, and savings? No Yes

Is anyone in your household a migrant or seasonal farmworke r? No Yes

Shel t e r Expenses

Current Rent/M ortgage. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Current Monthly Utilities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .+$

T ot a l = $

I ncom e & Resou rces

Gross income expected this month . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $

Total money in cash, checking & sav ings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .+$

Tota l =$

Are your households she l te r expenses more than your households expected gross No Yesi ncome and resources?

1 . L i st t h e p e r so n w h o i s t h e h e a d o f t h e h o u se h o ld an d s ig n b e lo w : P le a se u se y o u r le g a lnam e .

First: Middle: Last:

Street Address:

City: State: County: Zip Code:

Mailing Address (if different from above):

City: State: County: Zip Code:

Home Phone: Work Phone: Message Phone:

For Office Use Only

Date received in agency:

Case No(s):

Worker:

Date Registered:

Interview Date:

Expedited9Yes 9 No

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SI GNATURE:

2. L is t yourse lf f i rs t and th en a ll o ther persons in your hom e even i f you are no t app ly ing fo r t hem. L is t

anyone w ho i s tempor ar i l y away f r om the home. L is t ing race or e thn ic her i tage i s vo lun t ary . P lease

use one o r m ore t h e f o l low ing codes: W = Wh i t e B = B lack o r A f r i can Am er i can S = Asi an H

= H i span i c o r Lat i no

A = Am er i can I nd i an o r A l aska Na t i ve P = Na t i ve Hawa i i an o r Pac i f i c I s l ande r

Legal Name

First Middle Last

Relationship

to Head ofHousehold

Want

Benefits?Yes No

SexM/F

Race - List

all that

apply(Optional)

Date ofBirth

U.S.

Citizen?Yes No

Social

SecurityNumber

1. SELF

2.

3.

4.

5.

6.

7.

8.Has anyone received food stamp benefits this month or any time in the past? 9 No 9 Yes If yes,

When? What state?

3 . A re you r cu r ren t l y : 9 Single, never married 9 Married, living together

9 Married, separated 9 Divorced 9 Widowed

4. I s anyone a stu dent in h igh schoo l , co l lege or vocat iona l - techn ica l schoo l? 9 No 9 Yes, please list name

and what type of school.

Name: Name: Name:

School: School: School:

5 . Y ou c an h a v e so m e o n e ap p l y f o r f oo d st a m p b e n ef i t s f o r y o u . I f y o u w a n t t o d o t h i s , l is t h i m / h e r

b e l o w .

Name: Address:

6 . You can al so choose som eone t o rece ive you r f ood s t am p bene f i t s f o r you . Th i s person w i l l be ab le t o

ge t and use you r f ood st am p b ene fi t s . P lease com p le t e t he f o l l ow ing i f you w an t t o have som eone

ge t you r f ood s t am p bene f i t s f o r you .

Name: Address:

7 . L i st anyone in you r househo ld who i s d i sab led ( i nc l ud i ng ch i l d ren )

Name:

Have they eve r appl ied fo r di sabi lity benef its ? I f yes , wha t date :

The fo l low ing quest ions are requ i red by federa l law . I f you answer y es t o Quest ions 8 , 9 , o r 10 , ONLYTHAT PERSON may not ge t food s tam p benef i t s . Others in the househo ld , inc lud ing ch i ld ren , w ou ld ge tfood s t amps, i f e l ig ib le .

8 . Has anyone i n you r househo ld been conv i c t ed o f a d rug - r el a t ed f e lony occu r r i ng a f t e r Augus t 22 ,1 9 9 6 ?

9 No 9 Yes, list name:________________________________________________________________________

9 . I s anyone i n you r househo ld f l eei ng f rom f e lony p rosecu t i on o r j a i l?

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9 No 9 Yes, list name:

10 . I s anyone i n you r househo ld in v i o l a t i on o f p roba t i on o r pa ro le?

9 No 9 Yes, list name:

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11. Are th ere any resources such as cash, bank/ sav ings/ cred i t un ion account s , cer t i f i ca t es o f depos it s

(CDs) ,

s tocks, bonds, o r rea l es ta te wh ich anyone in your hou seho ld ow ns or has the i r name on?

9 No 9 Yes, please list below.

Name Type of Resource Amount or Value

Has anyone sold, traded, or given away money, land, or other property within the past 90 days? 9 No 9 Yes, please

list property transferred: Equity Value:

12 . I s anyone i n t he househo ld w o rk i ng , i nc lud i ng sel f - em p loym en t ? 9 No 9 Yes, please complete the

information.

Name Employer Name and AddressHourlyRate

HoursPer Week

How OftenPaid

Has anyone been employed in the last 60 days? 9 No 9 Yes, Name:

Employer: _____ _ Date left: Reason:

13. I s anyone in the househo ld get t ing o th er income or money (such as Soc ial Secur i t y , SSI , VA,

Worke r ' s

Com pensat i on , unem p loym en t benef i t s , o t he r pension / re t i r em en t , ch i l d suppo r t , e t c .)?

9 No 9 Yes, please complete.

Name Type of Income Amount How Often Received?

1 4 . L i st h o w m u c h y o u r h o u se h o ld o w e s e ac h m o n t h f o r t h e f o l l ow i n g : Amount Who Pa ys:

Rent/Mortgage

Property Taxes (not included in mortgage)

Homeowners Insurance (not included in mortgage)

Electricity (Name of Company):

Gas/Propane (Name of Company):

Water/Sewer

Trash

TelephoneChild Support/Alimony (Who is the child support/alimony for?):

Child Care

Medical Expenses (only for persons age 60 and older or who receivedisability benefits. Include health insurance and Medicare prem iums).

Does anyone help you pay the above expenses? 9 No 9 Yes, list what expenses, who is paying, and how much ispaid:

15 . I f you pay f o r hea t i ng o r cool i ng , do you w i sh t o use t he S t anda rd Ut i l i t y A l lowance? 9 No 9 Yes

16. Have you rece ived Low I ncom e Energy Assis tance (L I EAP)? 9 No 9 Yes

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17. Do you (or w i l l you) pur chase and prepare mea ls separat e ly f r om anyon e else in th e househo ld?

9 No 9 Yes, list person(s)________________________________________________________________________

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I MPORTANT I NFORMATI ON AND WARNI NGS

YOU HA VE THE RI GHT TO:C Equal treatment regardless of race, sex, color, age, disability, religion, political belief, or national origin. To file a

complaint of discrimination write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is anequal opportunity provider and employer.

C Have an interpreter provided at no cost if English is not your primary language.SRS HAS THE RI GHT TO:C Use your Social Security Number for computer matches with other organizations, such as banks, the IRS, and the

Social Security Administration to ver ify your eligibility.C Conduct a full investigation of your eligibility including contacting employers, banks, or visiting your home.C Deny your application or prosecute for fraud if you give false information to obtain assistance.

I MPORTANT! ! Any member of your household who intentionally breaks the following rules may not get food stampbenefits for 1 year for the first offense, 2 years for the second offense, and permanently for the third offense; may befined up to $250,000 or jailed up to 20 years, or both; may be barred from the Food Stamp Program for an additional18 months if court ordered, may lose deductions; and may be prosecuted under other laws.C Dont lie or hide information to get benefits the household should not get.C Dont use food stamp benefits to buy non-food items, such as alcohol or cigarettes, or to pay on credit accounts.C Dont use or have in your possession improperly obtained food stamps or Vision cards.C Dont trade or sell Vision cards or use someone elses card.C If you buy, sell or trade more than $500 in Food Stamp benefits you may be barred permanently from the Food

Stamp P rogram. If a court of law finds you guilty of trading food stamp benefits for firearms, ammunit ion, explosivesor controlled substances, you wi ll be subject to the following penalties:

Loss of benefits for two years for the first offense and permanently for the second offense involving the sale o f acontrolled substance, andPermanent loss of benefits for the first offense involving the trading of firearms, ammunition, or explosives.

C If you are found to have made false or misleading statements about who you are or where you live to get duplicatefood stamp benefits, you may be barred from the Food Stamp Program for ten years.

PLEASE READ & SI GNC I unde rs t and t he quest i ons on t h i s app l i ca t i on and I unde rs t and t he pena l t i es f o r h i d i ng o r g i v i ng f a l se

in fo rm at ion and t he r igh ts and respons ib i l i t i es sta t ed in th is app l i ca t ion and as ex p la ined by SRS s ta f f .C I cer t i f y unde r penal t y o f pe r j u ry t ha t m y answers a re cor rec t and com p le t e t o t he bes t o f m y

know ledge .C I ce rt i f y t ha t a ll m em bers o f m y househo ld f o r w hom I am app l y i ng f o r assi s t ance a re U .S. c it i zens o r

a re non -c i t i zens in l aw f u l im m ig ra t i on s t a t us .C I unde rst and t ha t i n f o rm a t i on n eeded t o de t e rm ine e l ig i b i l it y m ay be ver i f i ed by con t ac t i ng f edera l ,

s ta t e , o r loca l o f f i cia ls , employer s , o r o ther bus iness or f i n anc ia l o rgan iza t ions.C I unde rst and t ha t f a i lu re t o repo r t o r ve r i f y any househo ld expenses m eans t ha t I w i l l not b e el i g i b le

fo r a deduct ion fo r t hose expenses.C

I agree to no t i f y t he local SRS o f f i ce o f changes in incom e, resources, househo ld compos i t ion , and/ oraddress.

AUTHORI ZATI ON TO RELEASE I NFORMATI ONMy signature on this application authorizes employers, child care providers, financial institutions, insurance providers,benefit providers and other persons or agencies with knowledge of my circumstances to release to the KansasDepartment of Social and Rehabilitation Services any information, including confidential information, necessary toestablish my elig ibility for food stamp benefits. All information provided on th is application is protected by state andfederal confidentiality laws. This release is valid from the date set out below and shall remain valid until revoked inwriting by the unders igned. A copy of this authorization is as valid as the original.

1.

Signature of Applicant Date

2.

Signature of Applicants Spouse or Other Adult(s) in Household Date

3.

Signature of First Witness if X is Used Date

4.

Signature of Second Witness if X is Used Date

5.

Signature of Court-Appointed Guardian Date

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