Department Of Workforce Services (Page 5 of 7) in pdf

Page 5

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name) ___________________________________________, read or had read to me the statements on Pages

six (6) and seven (7) of the application. I understand those statements. I certify that the information/answers I have

given on this application are true and correct to the best of my knowledge. I also certify that the citizenship status

information I provided is correct. I understand I can be penalized by law if I commit perjury by purposely giving false

information on this application.

Your Social Security Number and all other information you give will be subject to verification by federal, state, and local

agencies. By signing this application, you are authorizing a release of information to conduct computer matches,

program reviews, and audits with INS and other federal and state agencies. Your Social Security Number 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.

Signature or Mark of Customer

Date

Signature of Authorized Representative (food stamps only)

Birth Date of Authorized Representative

The following release is optional and failure to sign will not affect your Medicaid benefits. I authorize DWS to use any

information gathered specifically for Medicaid eligibility, including medical information provided by a third party, to assist

with my employment plan. This release is effective for the time period I am receiving employment counseling services

from DWS.

______________________________Signature

_____________Date

•

Voter Registration: If you are not registered to vote where you live now, would you like to apply to register to

vote here today?……………………………………………………………………………………………

Yes

(

If you do not check either of these boxes, you will be considered to have decided not the register to vote at

this time

•

If you would like help in filling out the voter registration application form, we will help you. The decision whether

to seek or accept help is yours. You may fill out the application form in private. Applying to register or

declining to register to vote will not affect the amount of assistance that you will be provided.

•

If you believe that someone has interfered with your right to register or to decline to register to vote, your right

to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own

political party or other political preference, you may file a complaint with: Lt. Governor, State of Utah, 203 State

Capitol Building, Salt Lake City, UT, 84114.

FOR OFFICE USE ONLY

EBT Card

Reporting Requirements

Horizon Handbook

DWS Services

Medical Handouts

Office Pathway

Rights and Responsibilities

FOR OFFICE USE ONLY – CHILD CARE ONLY

Minimum work requirements

Two-parent household?

Year round school?

CCRR Needed?

Parent in training or educational program?

Type of program____________

Non-Custodial parent paying some child care?

Completion date____________

Work/class schedules and children’s school

Customer Education

schedules to determine need

Department Of Workforce Services Page 5

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