Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 32
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38DHS-2 Rev. 10-14
Page 28
RESPONSIBILITIES
You have a RESPONSIBILITY to supply the Department with accurate information about your income, resources and living arrangements.
You have a RESPONSIBILITY to tell us immediately (within ten (10) days) of any changes in your income, resources, family composition,
or any other changes that affect your household. For RIW Cash and CCAP, you must tell us immediately (within five (5) days) when
a child leaves your household for any reason. For SNAP, if you are a simplified reporter, you must report changes in income which brings
the household's gross income in excess of the applicable SNAP Gross Income Eligibility Standard for your household size. If you are unsure
about your reporting requirements, contact you DHS worker.
You have a RESPONSIBILITY if you are applying for CCAP, to find a suitable child care provider for your child(ren) and to make
appropriate arrangements to have your child(ren) attend that provider. The Department of Human Services will pay only for those hours
when you are either at work or involved in a DHS approved education/training activity, and the cost of any child care in excess of those hours
is your sole responsibility. If found eligible, you may be responsible for a share of the child care cost (co-payment) and you are responsible
to make such payment directly to your child care provider. If you are not found eligible, you have 30 days from the written notice to request a
hearing in writing to appeal your ineligibility. If the decision of the hearing is not in your favor, DHS is not responsible for any of the child
care costs that you may have incurred with your child care provider. By signing this form, you are authorizing the Department of Human
Services to inform the child care provider(s) after you have been notified if your child care assistance has been approved, discontinued or
denied.
You have a RESPONSIBILITY to provide Social Security numbers (or proof that you have applied for one) for yourself and your
household, or to apply, if you are required to, for them as a condition of eligibility. The collection of information on the application, as well
as the Social Security numbers of all members of your household for whom you receive assistance, is authorized under the Food and
Nutrition Act of 2008 (formerly the Food Stamp Act), as amended, 7 U.S.C. 2011-2036. This information will be used to determine whether
your household is eligible or continues to be eligible to participate in SNAP, MA, RIW, GPA and/or CCAP. The Department will verify this
information through computer matching with the Department of Labor and Training, the Social Security Administration, the Internal Revenue
Service, the Food and Nutrition Service, and other governmental and non-governmental entities authorized by law, regulation or contract,
and they will be subject to verification by Federal, State, and local officials. The income and eligibility information obtained from these
agencies will be used to make sure your household is eligible for and receiving the correct amount of SNAP benefits, GPA, Child Care, RIW,
and/or Medicaid. This information will also be used to monitor compliance with program regulations and for program management.
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 a claim arises against your household, the information on this application,
including all SSNs, may be referred to Federal and State agencies as well as private claims collection agencies for claims collection action.
Providing the requested information is voluntary. However, failure to provide a SSN will result in the denial of benefits to each individual
failing to provide a SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members.
You have a RESPONSIBILITY to report and provide proof of your expenses shown in questions 29 through 38 in order to get the
maximum amount of SNAP benefits allowed. Failure to report or provide proof of your expenses will be regarded as your statement
that you do not want to receive a deduction for the unreported or unproven expense.
You have a RESPONSIBILITY to cooperate fully with State and Federal personnel conducting quality control reviews.
Only U.S. citizens and certain legal immigrants may be eligible for SNAP benefits. If there are non-citizens living with you who are
not eligible, you may still apply for and receive benefits for other eligible household members. You are not required to provide
immigration information for people not applying for benefits, but you may need to provide other information for those people, such as,
income and resources.
RIW Restrictions on Use of EBT Cash Benefits and Penalties: Pursuant to Section 4004 of Public Law 112-96, it is prohibited for
a TANF recipient to use their TANF cash assistance benefits received under RI Works, Rhode Island General Laws 40-5.2 et seq., in
any electronic benefit transfer transaction (EBT) in:
any liquor store; or
any casino, gambling casino, or gaming establishment; or
any retail establishment which provides adult-oriented entertainment in which performers disrobe or perform in an unclothed
state for entertainment.
Any person receiving cash assistance through the RI Works Program who uses an EBT card in violation of the above standards shall
be subject to the following penalties:
For the first violation, the household will be sent a warning that a prohibited transaction occurred;
For the second violation, the household will be charged a penalty in the amount of the EBT transaction that occurred at the
prohibited location;
For the third and all subsequent violations, the household will be charged a penalty in the amount of the EBT transaction that
occurred at the prohibited location AND for the month following the month of infraction, the amount of cash assistance to
which an otherwise eligible recipient family is entitled shall be reduced by the portion of the family's benefit attributable to
any parent who utilized the EBT card in a restricted location. For a family size of two (2), the benefit reduction due to
noncompliance with use of EBT at a restricted location shall be computed utilizing a family size of three (3), in which the
parent's portion equals one hundred five dollars ($105).
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