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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.

THIS BOX DHS USE ONLY

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

Name

___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.

City

State

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

City

State

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)

(Optional)

Check box

To add more people, please attach

person

For more information, see page 1 of

Check box

Race

Sex

Marital Status

Date of

Check box

if person

another application or sheet of

applying

the Statement of Understanding

(see above)

(M/F)

(see above)

Birth

if person is

paper

for

Check box

Hispanic/

Enter all that

pregnant

disabled

benefits?

Social Security Number

if U.S.

Latino

apply

(Yes/No)

citizen

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