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THIS BOX For Families First only: Permission to release school attendance records

Your Food Stamps benefits may end if you:

I (client) give permission for the school attendance records of children on this application to be released to the Tennessee Department of Human

*Lie or hide facts to get Food Stamp benefits;

Services by the Tennessee Department of Education or my child’s school. The Department of Human Services will use these records, including

*Use someone else’s Benefit Security Card without their permission;

social security numbers, to help me meet my Families First responsibilities. The records will be destroyed when they are no longer needed.

*Buy things with Food Stamp benefits like beer, cigarettes, or soap.

If you break these rules, you will not get Food Stamp benefits for:

1 year the first time, 2 years the second time, and forever the third time.

Signature: ___________________________________________ Date: ____________

If you trade Food Stamp benefits for drugs. You can be cut off for:

2 years the first time and forever the second time.

I understand I may have one or two authorized representatives:

You’ll be cut off the Food Stamp Program forever if you’re found guilty of:

may apply for these benefits for me: Food Stamps( ); Families First ( ); TennCare Medicaid ( )

*Trading Food Stamp benefits for guns, ammunition, or explosives;

___________________________ may use my Food Stamp benefits for me ( ); may use my Families First benefits for me ( )

*Selling Food Stamp benefits worth $500 or more.

may apply for these benefits for me: Food Stamps( ); Families First ( ); TennCare Medicaid ( )

Don’t lie about who you are or where you live to get Food Stamps. Lying

___________________________ may use my Food Stamp benefits for me ( ); may use my Families First benefits for me ( )

can keep you from getting Food Stamps for 10 years.

List two people we can contact who can tell us about your situation:

These members of my household have been convicted of a felony for having, using, or selling illegal drugs:

_______________________________________________________________________________________________________

Name:________________________________ Phone: _____________________

Are you currently age 18-24, AND were you in state custody as a child? (check one) ( )Yes

( )No

Name: _______________________________ Phone: _____________________

List any household RESOURCES (cash, checking, savings, or other bank accounts, certificates of deposit, stocks, bonds,

Enter information about your household’s INCOME in the boxes below.

mutual funds, retirement accounts, trust funds, annuities, or other liquid assets)

Income includes but is not limited to employment, self-employment,

alimony, child support, disability benefits, Social Security/SSI, Worker’s

Type:_________________________ Value: $____________

Type:_________________________ Value: $________________

Compensation, Unemployment benefits, pensions, stipends, and interest

income

Type:_________________________ Value: $____________

Type:_________________________ Value: $________________

ANSWER QUESTIONS IN THIS BOX IF YOU ARE APPLYING FOR TENNCARE/MEDICAID

Person with Income

Source of income (such as job,

Monthly

Do you or your spouse have an annuity that was purchased on or after February 8, 2006? ( )Yes ( )No MUST check yes or no

Social Security, child support)

amount before

(Annuities are periodic payments made from funds deposited by an individual in order to establish a source of income for future use)

taxes/expenses

Did you receive a $100,000 lump sum payment from the Settlement Law Group in 1998? ( )Yes

( )No

If you’re currently receiving a Social Security check, were you also receiving a Social Security check in 1972? ( )Yes

( )No

Did you lose Medicare because you returned to work and your earnings were more than the Social Security income limit? ( )Yes

( )No

Have you been diagnosed with breast or cervical cancer? ( )Yes

( )No

Does anyone applying for Medicaid have other health insurance? ( )Yes

( )No

Child Care Expenses

Shelter Costs

Medical Expenses

Child Support Paid

List recurring medical expenses like prescriptions

If you pay child support to a child or children

Rent / Mortgage (circle one)

Amount paid per week: $ _________________

or insurance premiums. These can help you get

who don’t live with you, enter it here:

Monthly amount: $ ___________________

more Food Stamps if you’re elderly or disabled.

Child care provider name:

Type: _______________ $__________per month

Child: ______________ $________per month

Gas/Electric $_________________ per month

______________________________________

Type: _______________ $__________per month

Child: ______________ $________per month

Phone $ _____________________ per month

In accordance with federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this

Voter Registration

institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA

Are you registered to vote where you live now? ( )Yes ( )No

policy, discrimination is prohibited also on the basis of religion or political beliefs.

Would you like to register to vote? ( )Yes ( )No

Do you want DHS to mail a voter registration form to you? ( )Yes ( )No

To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W.,

Washington, DC 20250-9410 or call (800) 795-3272(voice) or (202) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200

The benefits you may receive from DHS will not change whether you

Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (Voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity

providers and employers.

You may also write Tennessee, DHS, Office of General Counsel, Citizens Plaza Building, 400 Deaderick Street, Nashville, TN 37243, (615) 313-4700.

Form Hs-0169 - Family Assistance Application - Tennessee Department Of Human Services Page 2

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