Looking for a Food Stamp Application Form Templates? Download it for free!

YOUR RIGHTS AND RESPONSIBILITIES

READ BEFORE SIGNING:

I understand that it is important to give true information and if I do not, I am breaking the law.

I understand that I can be fined, imprisoned or have my benefits reduced for making false statements or for

pretending to be another person.

I know I can be punished for not reporting changes that may affect my eligibility or benefit amount.

I understand that if I get more Food Supplement benefits than I should, all adult members of my household are

liable for repaying the debt.

I know the Department can use the application against me in a court of law for fraud prosecution.

I know that failing to report or verify shelter, medical, or dependent care expenses or child support payments is

the same as saying I do not want a deduction for the expenses I did not verify or report.

I understand that the Department may check the information on this form to see if it is correct and may select my

case for a spot check, such as for a Quality Control Review.

I agree to allow someone from the Department to visit me at home. I will help them get all needed proofs from

any source.

I understand by signing this application:

• I accept cash assistance and/or medical assistance.

• I agree that Medicare Part B will make payments directly to doctors and medical suppliers.

• I give the Department the right to seek payment from private or public health insurance and any liable third

party. I understand that I must cooperate with the department in securing such payments. The Department

may seek payment without legal action, as long as it does not keep more than the amount Medical Assistance

paid.

• I give the Department the right to inspect, review and copy all medical records for services received through

the Medical Assistance Program.

I understand that when a person is deceased who was at least 55 years old when receiving Medical Assistance

the state may take money from the estate to repay payments made on behalf of that person. The program may

take the money only if there is no surviving spouse, unmarried child younger than 21, or blind or disabled child

(married or unmarried) of any age.

SIGNATURE SECTION

I understand that, as required by Maryland law, certain law enforcement agencies that investigate fraud can

obtain information about my application, income, benefits and other documentation as part of their investigation.

While access to my application and benefit information is normally limited (under Md. Code Ann. Human

Resources Article § 1-201), these limits do not apply to these investigative agencies. Such agencies include the

Department of Human Resources’ Office of the Inspector General. I understand that I do not need to provide

consent to these agencies in order for them to investigate any allegations of fraud against me. Any information

found as a result of the investigation may be used against me if an allegation of fraud is prosecuted.

I have read or someone has read and explained the entire application to me. I swear or affirm under penalty of

perjury, that all the information I gave is true, correct, and complete to the best of my ability, belief and

knowledge. I received a copy of my rights and responsibilities. I authorize any person, partnership, corporation,

association, or governmental agency that knows the facts about my eligibility to give that information to the

Department. I also authorize the Department to contact any person, partnership, corporation, association, or

governmental agency that has given proof of my eligibility for benefits. I certify, under penalty of perjury, that by

signing my name below, all persons for whom I am applying are U.S. citizens, lawfully admitted immigrants or

individuals in satisfactory immigration status.

Date

Signature of Applicant I Recipient

Date

Signature of Witness (If you Signed an X)

Date

Signature of Spouse (If Applicable)

Signature of Authorized Representative

Date

(If Applicable)

Signature of Case Manager

Date

I withdraw my application for: □ Cash Assistance

□ Food Supplement Program □ Medical Assistance

Signature of Applicant, Recipient,

Date

Authorized Representative

DHR/FIA CARES 9701 Revised 9/09

Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 12

Related Articles

Related forms

Related Categories