Form Hs-0169 - Family Assistance Application - Tennessee Department Of Human Services


Tennessee Department of Human Services
We will take your application with only your name, address, and signature. However, the more you tell us, the
faster we can see if you can get help. If you are approved, your benefits will start from the date you filed the
Family Assistance Application
application. In most cases you will need to talk with a DHS worker to complete the application process.
You may be able to get SNAP/Food Stamps in 7 days if:
Case #: ____________________________
Your household's monthly income is less than $150, and you now have resources of $100 or less.
Date received: ______________________
Your shelter cost (plus utilities) is higher than your monthly income plus savings.
You do seasonal farm or migrant work.
County: ___________________________
If you have a disability that makes it hard for you to fill out or understand this application, we can help. We can call or visit you if you cannot come to our office.
I am applying for:
TennCare Medicaid and
___SNAP/Food Stamps
___Families First
___help w/ Medicare costs (QMB/SLMB/QI)
____ TennCare Medicaid Nursing Home or HCBS
We may use your home or cell phone number to call and remind you of an appointment.
Home Address
We will leave a message if you do not answer.
Zip Code
Home Phone
Work Phone
Cell/Other Phone
We use Social Security Numbers to check that you are who you say you are. We use them to make
Mailing Address (if different)
sure you get the right amount of aid, to change the amount of aid you get, to check other computer
and government records, and to make sure you qualify. We check Social Security, IRS, and
Zip Code
employment records. We may check Immigration and Naturalization Records. If those records don’t
match what you say, it may affect whether you can get help and how much cash or food stamps you
get. If you lie on purpose to get help, you may go to jail.
Do you need an interpreter? ( ) Yes ( ) No
You do not have to say what race or ethnicity you are. But it helps show if the State is following civil rights laws.
Please use the following to indicate race: W = White/ Caucasian, B = Black/African-American, A = Asian, H = Native Hawaiian/Pacific Islander, I =
If yes, what language? ___________________
American Indian/Alaska Native
Marital Status: Use one of the following below for each adult member of the household: married, single, divorced, widowed, separated
List everyone in your household
(NOT needed if person does not want
(including self)
Is this
to receive benefits)
Check box
To add more people, please attach
For more information, see page 1 of
Check box
Marital Status
Date of
Check box
if person
another application or sheet of
the Statement of Understanding
(see above)
(see above)
if person is
Check box
Enter all that
Social Security Number
if U.S.
I swear under penalty of perjury (a crime for lying under oath) and all other applicable penalties that the statements made on this application, any attachments, and to whoever interviewed me are true and correct. All
persons applying for or receiving aid are U.S. citizens, legal aliens, or eligible immigrants. I understand and agree to the rules and information given to me. If asked, I will give information that proves my statement, or I give
DHS permission to get proof. I understand I must report any changes the way DHS tells me to.
Release: The State of Tennessee or people who work for it may need to prove the information I gave is true. By signing this paper, I am saying it is OK to get proof. This will let them decide if I can get Food Stamps, Families
First, or TennCare Medicaid. I am also saying that I have read and understand the Statement of Understanding.
Signature: ___________________________________________ Date: ____________
Witness (if signed with an X): ___________________________________________Date: ____________
Guardian or Auth. Representative: ___________________________________________ Date: ____________
HS-0169 revised 01/13


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