Food (Snap) And Cash Assistance Combined Application (Page 2 of 5) in pdf

Food (Snap) And Cash Assistance Combined Application Page 2

Page 2

COMBINED APPLICATION – PART I

Revised 1/2009

Case Number:

SNAP and Cash Assistance

MEMBER INFORMATION

Has anyone in the household ever received public assistance or SNAP this month or anytime in the past?

Yes

If yes, When? ____________________ Where? _____________________________ Programs: ____________________ _______________________

INCLUDE AS HOUSEHOLD MEMBERS THE FOLLOWING PEOPLE WHO LIVE TOGETHER:

Spouses;

•

Natural, adopted, and stepchildren and other children under 18 years of age who are under parental control of a member of the household, other than a parent,

•

must be included in the same household as the parent or other parent or other person with parental control even if they purchase food and prepare meals

separately;

Natural, adopted, and stepchildren ages 18, 19, 20, and 21 must be included in the same household as the parent, even if they purchase food and prepare meals

•

separately, and is living with his or her children or is married and living with his or her spouse;

Persons who purchase and prepare meals together, except households containing elderly and disabled members who cannot purchase and prepare separately

•

can be separated into two households as long as the non-elderly/disabled household members’ income does not exceed 165 percent of Poverty level.

List yourself as person #1

List yourself as person #1. List spouse as person #2. List all of the other persons in your home even if you are not applying for them.

List yourself as person #1

Legal Name

Check One

Social

Date of Birth