Form Dss-2435i - Fns Notice Of Expiration And Interview Recertification Form Page 4
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4Does anyone in your household fit a situation below? IF YES Who?
**14. Do you know of anything that has changed in your household such as anyone stopping or starting work or
school within the last 6 months? Yes No If yes, please list the changes
If someone stopped working who?
Total hours worked in past 30 days?
15. Is anyone in your household age 16 or older and attending school at least half time? Yes No If yes, list
persons name and school they attend
.
16. Does anyone in your household have a felony drug conviction or controlled substance after August 22, 1996?
Yes No If yes, please tell us his/her name, date, type, and place of conviction:
17. Is anyone in your household in violation of probation or parole or running from the law to avoid felony
prosecution? Yes No If yes, please tell us his/her name and the date and type of violation
18. Have you or any member of your household been convicted of trading benefits for drugs after August 22,
1996? Yes No If yes, please tell us his/her name, date, type, and place of conviction
19. Have you or any member of your household been convicted of buying or selling benefits $500 or more after
August 22, 1996? Yes No If yes, please tell us his/her name, and date
20. Have you or any member of your household been convicted of fraudulently receiving duplicate benefits in any
State after August 22, 1996? Yes No If yes, please tell us his/her name, date, type, and place of
conviction
21. Have you or any member of your household been convicted of trading benefits for guns, ammunitions, or
explosives after August 22, 1996? Yes No If yes, please tell us his/her name, date, type, and place of
conviction
? IF YES
**22. Is anyone in your household physically or mentally unfit for employment? Yes No
**23. Does anyone operate a Home School at least 30 hours a week? Yes No
**24. Does anyone care for an incapacitated person (does not have to live in the home)? Yes No
**25. Does anyone participate in an official Refugee Employment Program? Yes No
**26. Is anyone in the household unable to work due to alcohol and/or drug addiction? Yes No
**27. Is anyone in the household pregnant? Yes No
Do you need someone to help you get and/or use your Food and Nutrition Services benefits? Yes No If yes,
please list that person’s name
. If you checked
Yes above we will give or mail you a form. You and the person you want to help can complete the form and return it
to our office. This person will receive an EBT card and will have access to your Food and Nutrition Services benefits.
If there is an authorized representative listed on page 1 do you want them to continue? Yes No
How to Get A Fair Hearing
You have the right to ask for a hearing if you think your case is wrong. You have 90 calendar days to ask for a
hearing. Unless you ask for a hearing by then, you cannot have one. A household member or someone else such as
a lawyer, friend, or relative can represent you at a fair hearing.
Your Signature and Statement of Understanding
I understand that my signature authorizes federal, state, and local officials to contact other persons or
organizations to verify the information I have provided. Do not lie or hide information to get benefits that
your household should not get. I have given correct information on the citizenship/immigration status of all
individuals applied for. If a law enforcement officer requests the address, social security numbers, or
photographs in your file to assist in locating fugitive felons or probation/parole violators, the Department of
Social Services must provide this information. Any member who intentionally breaks any of the rules, may
not be able to get Food and Nutrition Services for one year for first offense, two years for second offense,
and permanently for third offense. If a court of law finds you guilty of using or receiving benefits in a
transaction involving the sale of a controlled substance, you will be not be eligible for benefits for two years
for the first offense, and permanently for the second offense. You may also be fined up to $250,000 and/or
jailed up to 20 years. If court ordered you may also be ineligible from the Food and Nutrition Services
program for an additional 18 months. If a court finds you guilty of having trafficked benefits for $500 or
more, or trading benefits for firearms, ammunition or explosives you will be permanently ineligible for Food
If you use your
and Nutrition Services.
food assistance benefits to buy nonfood items, trade, or sell your
benefits, pay on credit accounts, take someone’s EBT card without authorization or let someone use yours
you will lose your benefits.
I acknowledge that I have received an explanation of my right to an income deduction for Food and Nutrition
Services benefits for any of the following items: Child/adult care expenses, medical expenses, shelter expenses,
utility expenses, and operational expenses for self-employment. I understand that if I fail to report or verify any of
the above listed expenses, I may give up my right to receive a deduction for these expense(s).
Your Signature:
Date Signed:
Authorized Representative or Witness Signature (if applicable)
Date Signed:
Check which applies Home Cell Phone Work Message Number
Your Telephone Number:
***AGENCY USE ONLY***
Telephone
Office Visit
Date of Interview ____________________________
For information regarding the Teen Pregnancy Prevention Initiative contact your local Health Department or call the DHHS Customer Services Center
at 1- 800-662-7030. For information regarding services provided for Healthy Marriages contact your local County Department of Social Services.
DSS-2435I (Rev. 2-16)
Economic and Family Services
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