Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 13
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13YOUR RIGHTS AND RESPONSIBILITIES
ASSIGNMENT OF SUPPORT RIGHTS FOR TEMPORARY CASH ASSISTANCE
I assign to the State of Maryland all rights, titles, and interest in support that I may have for
myself or for any person receiving TCA.
This includes any overdue support that has not been collected.
I agree to have the child support agency collect any support owed to me and to keep up to the
amount of TCA paid to me.
I agree to send to the State of Maryland any support l receive. If l do not turn over this support, I
will have to repay this amount to the State of Maryland. I may also be prosecuted for fraud.
When I am eligible for Medical Assistance:
I assign all rights, title, and interest in medical support and health insurance payments I may
have for myself or any person receiving Medical Assistance. This includes overdue medical
support or health insurance payments that have not been collected.
I agree to have the child support agency collect medical support payments owed to me and to
keep up to the amount of Medical Assistance payments that were made for me.
I agree to give the State of Maryland any medical support or health insurance payments I
receive.
I will cooperate to the best of my ability and knowledge with the child support agency while I am
•
receiving TCA and Medical Assistance
If I do not cooperate with the child support agency, I may lose all my benefits and my case may
•
be closed
I HAVE READ THESE STATEMENTS OR SOMEONE READ THEM TO ME. I UNDERSTAND WHAT
THEY MEAN. BY SIGNING MY NAME BELOW, I AGREE TO FOLLOW WHAT THEY SAY.
Signature
Date
DHR/FIA CARES 9701 Revised 9/09
12
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