Food (Snap) And Cash Assistance Combined Application (Page 3 of 5) in pdf

UNITED STATES VIRGIN ISLANDS

age 3

DEPARTMENT OF HUMAN SERVICES

Revised 1/2009

DIVISION OF FAMILY ASSISTANCE

SNAP /CASH PROGRAMS

YOUR RIGHTS

YOUR RIGHT TO APPLY. You have the right to request an application in person, by telephone, by fax or by mail. You have the right to file an application in person, by

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mail or by fax. The amount of benefits for the first month is based on the date the application was received by the certification office. You have the right to have your office

interview waived due to hardship and one conducted by phone or in your home. You have the right to apply for food and cash benefits at the same time. The time

limits and requirements for cash assistance have no bearing on the Supplemental Nutrition Assistance Program (SNAP).

YOUR RIGHT TO PRIVACY. You have the right to be treated in a way which does not invade one’s right to privacy.

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YOUR RIGHT TO PROGRAM INFORMATION. You have the right to examine the SNAP rules and regulations.

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YOUR RIGHT TO EXPEDITED SERVICE. You have the right to receive SNAP within a few days if you have little or no money or income.

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YOUR RIGHT TO PROPER NOTICE. You have the right to be told in writing the specific reason for denial of SNAP and the policy on which the decision is based. You

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have the right in most instances, to 10 days advance notice of the program’s intention. You have the right to have the SNAP Office make a decision and provide an

opportunity to participate if found eligible within 30 days after the filing of an application, provided you have supplied the necessary and adequate information (orally

or in writing).

YOUR RIGHT NOT TO BE DISCRIMINATED AGAINST. You have the right to fair and equal treatment and freedom from discrimination.

You have the right to

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considerate and respectful treatment from SNAP Staff.

IF YOU FEEL WE TREATED YOU DIFFERENTLY: : : : In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and

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Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food

Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs. To file a complaint of discrimination write to or call:

State Agency

Federal Agencies (SNAP Assistance)

Federal Agency (Cash Assistance)

Department of Human Services

USDA, Director

HHS, Director

Division of Family Assistance

Office of Civil Rights

Office for Civil Rights

1303 Hospital Ground

1400 Independence Avenue, SW

Room 506-F

Knud Hansen Complex – Bldg. A

Washington, D.C. 20250-9410

200 Independence Avenue, S.W.

St. Thomas USVI 00802

(800) 795-3272 (Voice)

Washington, D.C. 20201

Ph: (340) 774-2399

(202) 720-6382 (TTY)

(202) 619-0403 (voice)

(202) 619-3257 (TTY)

USDA and HHS are equal opportunity providers and employers.

ACCESS TO FREE LEGAL SERVICES. You may contact the Office of Legal Services for free legal service at:

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No. 47 Kongens Gade

No. 3017 Estate Orange Grove

Charlotte Amalie, St. Thomas

Christiansted, St. Croix

U.S. Virgin Islands 00802

U.S. Virgin Islands 00820-4375

Ph: (340) 774-6720

Ph: (340) 773-2626

Fax: (340) 777-8686

Fax: (340) 778-8593

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YOUR RESPONSIBILITIES

NOTE: If you sign this application as an Authorized Representative of a person who

NOTE: If you sign this application as an Authorized Representative of a person who i i i i s s s s r r r r e e e e q q q q u u u u e e e e s s s s t t t t i i i i n n n n g g g g o o o o r r r r r r r r e e e e c c c c e e e e i i i i v v v v i i i i n n n n g g g g a a a a s s s s s s s s i i i i s s s s t t t t a a a a n n n n c c c c e e e e , , , , y y y y o o o o u u u u a a a a r r r r e e e e a a a a g g g g r r r r e e e e e e e e i i i i n n n n g g g g t t t t o o o o a a a a s s s s s s s s u u u u m m m m e e e e a a a a l l l l l l l l o o o o f f f f t t t t h h h h e e e e f f f f o o o o l l l l l l l l o o o o w w w w i i i i n n n n g g g g

NOTE: If you sign this application as an Authorized Representative of a person who

responsibilities on behalf of that person.

When you apply for

When you apply for SNAP/CASH

SNAP/CASH

SNAP/CASH b b b b enefits, you sign an application that states: “I understand the questions on this application

SNAP/CASH

enefits, you sign an application that states: “I understand the questions on this application

enefits, you sign an application that states: “I understand the questions on this application a a a a n n n n d d d d t t t t h h h h e e e e p p p p e e e e n n n n a a a a l l l l t t t t y y y y f f f f o o o o r r r r h h h h i i i i d d d d i i i i n n n n g g g g o o o o r r r r g g g g i i i i v v v v i i i i n n n n g g g g

enefits, you sign an application that states: “I understand the questions on this application

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false information or breaking any of the rules listed in the penalty warning. My answers are correct and complete to the be

false information or breaking any of the rules listed in the penalty warning. My answers are correct and complete to the best of my knowledge.

st of my knowledge.

I understand that I may have to provide documents to prove what I have sai

I understand that I may have to provide documents to prove what I have said d d d . . . . I I I I a a a a g g g g r r r r e e e e e e e e t t t t o o o o d d d d o o o o t t t t h h h h i i i i s s s s . . . . I I I I f f f f d d d d o o o o c c c c u u u u m m m m e e e e n n n n t t t t s s s s a a a a r r r r e e e e n n n n o o o o t t t t a a a a v v v v a a a a i i i i l l l l a a a a b b b b l l l l e e e e , , , , I I I I a a a a g g g g r r r r e e e e e e e e t t t t o o o o g g g g i i i i v v v v e e e e t t t t h h h h e e e e n n n n a a a a m m m m e e e e o o o o f f f f a a a a

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perso

person or organization the Division of Family Assistance

n or organization the Division of Family Assistance D D D D F F F F A A A A Office may contact to obtain the necessary proof.”

Office may contact to obtain the necessary proof.”

perso

n or organization the Division of Family Assistance

Office may contact to obtain the necessary proof.”

This means that you are aware that the State’s attorney

This means that you are aware that the State’s attorney can prosecute you, if you or your authorized representative has given false information to get

can prosecute you, if you or your authorized representative has given false information to get SNAP/CAS

SNAP/CASH H H H

This means that you are aware that the State’s attorney

can prosecute you, if you or your authorized representative has given false information to get

SNAP/CAS

benefits. It is therefore IMPORTANT for you to answer each question TRUTHFULLY and CORRECTLY.