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YOU CAN APPLY TO REGISTER TO VOTE HERE

YOU MAY BE ELIGIBLE FOR REDUCED TELEPHONE RATES

Check YES if you would like to apply to register to vote or update your

Check YES if you would like DCF to release your Name, SSN, Phone

voter registration information. If you check the NO box or do not check a

Number, and the fact that you receive food stamps or Temporary Cash

box, you will be considered to have decided not to apply to register to

Assistance to the local telephone company so you may receive a reduced

vote or update your voter registration information. Checking YES, NO, or

telephone rate through the Lifeline Program. YES

leaving this question blank will not affect your receipt of benefits.

YES

OPTIONAL INFORMATION

EXPEDITED FOOD STAMPS

ETHNICITY

This program helps low-income households buy food needed for good health.

To Be Entered on Front

Eligible households receive food stamp benefits within 7 days if:

Choose A or B: A. Hispanic or Latino B Not Hispanic or Latino

Your household's countable gross income is less than $150 and your total liquid

RACE

assets (such as cash, bank accounts, etc.) do not exceed $100 in the month

To Be Entered on Front. You may choose one or more numbers:

you apply for benefits;

American Indian or Alaskan Native

Your household's countable assets and gross monthly income are less than

Asian

your most recent monthly rent or mortgage and utility expenses; or

Black or African American

Native Hawaiian or Other Pacific Islander

Your household includes destitute migrant or seasonal farm workers.

White

IMPORTANT INFORMATION FOR IMMIGRANTS

SSNs will be used to check the identity of those applying for benefits. The non-citizen status of any person applying for benefits will be verified with the

Bureau of Citizenship and Immigration Services (BCIS). Under no circumstances will individuals who are not applying for benefits, be reported as not

lawfully residing in the United States. If you wish, you can apply for food stamps or medical assistance, without applying for temporary cash assistance.

Eligibility for food stamps or medical assistance is not connected to an application for temporary cash assistance, or to the temporary cash assistance time

limits. If you or members of your family use Medicaid, KidCare (Children’s Health Insurance Program-CHIP), or food stamps, the receipt of such benefits

will not affect your or your family members’ immigration status. Also, receipt of such benefits will not affect your or your family members’ ability to get a

green card, unless you receive long-term institutional care, such as a nursing home. Use of Cash Assistance or Supplemental Security Income (SSI)

might create problems with getting a green card, especially if the benefits are your family’s only income. Talk to an agency that helps immigrants with legal

questions before you apply.

NOTICE OF PENALTIES

You may be subject to prosecution for knowingly providing incorrect information to receive public assistance benefits.

Food Stamps If you are found guilty (by a state or federal court, or an administrative disqualification hearing, or sign a hearing waiver) of intentionally

making a false or misleading statement, concealing or withholding facts in order to receive or in an attempt to receive food stamps; or committing any act

that violates the Food Stamp Act, food stamp regulations, or any state statute for purposes of using, presenting, transferring, acquiring, receiving, or

possessing food stamp benefits, you will be disqualified. You will be ineligible for food stamps for 12 months for the first violation, 24 months for the

second violation and permanently for the third violation. If you are convicted of trafficking in food stamp benefits, you will be disqualified permanently. If

you are convicted of these acts, depending on the severity, you may be fined up to $250,000, imprisoned for up to 20 years, or both.

If you are convicted by a state or federal court of making a fraudulent statement with respect to identity or residency in order to receive food stamps in

more than one state at the same time, you will be ineligible to participate in the Food Stamp Program for a period of 10 years.

If you are fleeing to avoid prosecution, custody, or confinement, after conviction for a crime or an attempt to commit a crime which is a felony, or are in

violation of probation or parole imposed under a federal or state law, you are ineligible for food stamps. This information 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.

If you are found guilty of a drug-trafficking felony, or convicted by a federal, state, or local court of trading firearms, ammunition, or explosives for food

stamps, you are ineligible for food stamps.

Temporary Cash Assistance If you intentionally give false information or hide information to receive or continue to receive temporary cash assistance and

are convicted by a state or federal court or by an administrative disqualification hearing, or sign a hearing waiver, you may be disqualified for 12 months for

the first violation, 24 months for the second violation and permanently for the third violation.

If you are found guilty of a drug-trafficking felony, or fleeing to avoid prosecution, custody or confinement, after conviction for a crime or an attempt to

commit a crime which is a felony, or are in violation of probation or parole imposed under a federal or state law, you are ineligible for temporary cash

assistance. If you are convicted by a state or federal court of making a fraudulent statement with respect to identity or residency in order to receive

temporary cash assistance in more than one state at the same time, you will be ineligible to participate in the temporary cash assistance program for a

period of 10 years.

FLORIDA DEPARTMENT OF CHILDREN AND FAMILIES NON-DISCRIMINATION STATEMENT

No person shall, on the basis of race, color, religion, national origin, sex, age, or disability be excluded from participation in, be denied the benefits of, or be

subjected to unlawful discrimination under any program or activity receiving or benefiting from federal financial assistance and administered by the

Department.

To file a complaint, alleging violations of this policy, contact the Office of Civil Rights, Florida Department of Children and Families, 1317

Winewood Boulevard, Building 6, Room 124, Tallahassee, Florida 32399-0700 or call 1-850-487-1901, Suncom 277-1901, or TDD 1-850-922-9220.

USDA-HHS NON-DISCRIMINATION STATEMENT

In accordance with Federal Law and 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, S. W., Washington, D. C. 20250-9410 or call (202) 720-5964 (voice or TDD). Write Regional Manager, DHHS Office of Civil

Rights, Region IV, Sam Nunn Atlanta Federal Center, 61 Forsyth Street, SW, Suite 3B70, Atlanta, GA 30303-8909 or call 1-800-368-1019 or TDD 1-

800-537-7697.

SUBMITTING THE REQUEST FOR A ASSISTANCE

A Request for Assistance (RFA) may be submitted to any Department of Children and Families Economic Self-Sufficiency Services office in the State of

Florida by you, or by someone acting for you in person, by mail, or by Facsimile (FAX) during normal business hours (8:00 AM to 5:00 PM, Monday

through Friday). The Facsimile will be date stamped on the day it is received during normal business hours. When a Facsimile is received after normal

business hours it will be date stamped on the first business day following its receipt.

Back of CF-ES 2066, Sep 2003

Form Cf-Es 2066 - Request For Assistance - Florida Department Of Children And Family - 2003 Page 2

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