Department Of Job And Family Services Request For Cash, Medical And Food Stamp Assistance (Page 4 of 4) in pdf

Department Of Job And Family Services Request For Cash, Medical And Food Stamp Assistance Page 4

SIGNATURE OF PERSON WHO COMPLETED THIS FORM

I understand the questions on this form and the penalty for hiding or giving false information or breaking any of the rules listed in the penalty warning.

I certify, under penalty of perjury, that all my answers are correct and complete to the best of my knowledge, including information about the citizenship

or alien status of each household member applying for benefits. I understand and agree to provide documents to prove what I have said. I understand

and agree that the CDJFS may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits. I understand

that in some instances, I may be asked to give consent to the CDJFS to make whatever contacts are necessary to determine my eligibility.

Signature of Applicant or Authorized

If Authorized Representative,

Witness Signature (If applicant signed

Date

Representative

Relationship to Applicant

with X)

Signature of Applicant or Authorized

If Authorized Representative,

Witness Signature (If applicant signed

Date

Representative

Relationship to Applicant

with X)

In accordance with Federal law and the U.S. Department of Agriculture (USDA) and U.S. Department of Health and 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, contact USDA or HHS.

Write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW., Washington, D.C. 20250-9410 or call

(202) 720-5964 (voice and TDD).

Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or

(202) 619-3257 (TDD)

USDA and HHS are equal opportunity providers and employers.

OFFICE USE ONLY

DATE RECEIVED:

APPL NUMBER:

CASE NUMBER:

9 9 YES 9 9 NO