Department Of Job And Family Services Request For Cash, Medical And Food Stamp Assistance
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4DEPARTMENT OF JOB AND FAMILY SERVICES
REQUEST FOR CASH, MEDICAL AND FOOD STAMP ASSISTANCE
IMPORTANT INFORMATION ABOUT FOOD STAMPS, CASH AND MEDICAID
You have the right to file an application the day you contact the County Department of Job and Family Services (CDJFS). Any food stamp, cash or
medicaid benefits you get will go back to the date you filed if you qualify for help on that date. You can file this form with your name, signature and
address, but you must finish it and be interviewed later.
If you cannot stay to fill out this form today, give us this first page. We must have at least the household's name and address and your signature, if you
are the responsible member of the household or the household's authorized representative, so that today can be set as the application file date. You
can fill out the rest of the form at home and bring or mail it to the CDJFS office. However, we must have the completed form and conduct an interview
to decide if your household is eligible to get your first food stamps right away. If you miss the interview that the CDJFS schedules, you must contact
the CDJFS and ask to reschedule your interview. If you miss your interview and do not contact the CDJFS within 30 days from the date that you file
this form, you may be denied benefits. The CDJFS may waive the face-to-face interview if it is determined you meet a hardship condition. You can
apply for one or all programs with this form.
If English is not your primary language, or if you are hearing-impaired, the CDJFS will provide you with someone who can help you understand the
questions at the interview. This person is called an interpreter and will be provided at no cost to you; the agency will pay for the interpreter. Check
the yes box below if you need an interpreter. This interpreter should also be available at other times if you need to report changes or have questions
about your case. The agency must also provide you with services and reasonable accommodations if you have a disability. Let your caseworker know
what you need.
*****IF YOU NEED FOOD STAMP BENEFITS RIGHT AWAY, AND YOU ARE NOT CURRENTLY RECEIVING THEM, ANSWER THE QUESTIONS ON THIS PAGE AND PAGE
2 . THIS WILL HELP US DECIDE IF YOU QUALIFY TO GET FOOD STAMP BENEFITS WITHIN 24 HOURS TO 7 DAYS.*****
Street Address
City
County
State
ZIP
Phone (
)
Mailing Address (if different than street address)
City
State
ZIP
Additional phone number where we can reach you (
)
9 9 Yes
9 9 No If yes, who?
Are you applying for someone who is not living with you?
Enter the address of the person(s) you are applying for if different than the above address. Street Address
City
County
State
ZIP
Phone (
)
Primary language of the person completing this form
Primary language of the person you are applying for
9 9 Yes 9 9 No 9 9 Does not apply
If your primary language is not English, or if you are hearing-impaired, will you need an interpreter at the interview?
9 9 Yes
9 9 No If yes, who?
Is anyone in the household currently receiving cash, Medicaid or food stamp benefits?
Where (City/County/State)
9 9 Cash Assistance
9 9 Medical Assistance
9 9 Food Assistance
What are you applying for today? (Check all that apply)
Signature of Person Completing Form
Print Name
Date
JFS 07200 (Rev. 07/2002)
Page 1
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