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

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We will take your application with only your name, address, and signature if you are only applying for
Tennessee Department of Human Services
SNAP/Food Stamps. But 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 application. In most cases you will need to talk with a DHS worker to
Family Assistance Application
complete the application process.
THIS BOX DHS USE ONLY
You may be able to get SNAP/Food Stamps in 7 days if:
Case #: ____________________________
1.
Your household's monthly income is less than $150, and you now have resources of $100 or less.
Date received: ______________________
2.
Your shelter cost (plus utilities) is higher than your monthly income plus savings.
3.
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.
Name
I am applying for: ___Families First
___SNAP/Food Stamps
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.
Home Phone
Work Phone
Cell/Other Phone
City
State
Zip Code
Mailing Address (if different)
We use Social Security Numbers to check that you are who you say you are. We use them to make
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
employment records. We may check Immigration and Naturalization Records. If those records don’t
City
State
Zip Code
match what you say, it may affect whether you can get help and how much cash or food stamps you
get. If you give incorrect information 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)
(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
if
(see above)
(M/F)
(see above)
Birth
if person is
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 or Families
First. 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 12/13

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