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Date Received

MARYLAND DEPARTMENT OF HUMAN RESOURCES

(Agency use only)

FAMILY INVESTMENT ADMINISTRATION

APPLICATION FOR ASSISTANCE

Your Name (Last, First, Middle)

Home Telephone

Work Telephone

Where do you live? (Number and Street)

Apt. #

City

State

Zip Code

Mailing Address (If different from home)

Cell Telephone

What language do you speak? □ English □ Spanish

□ Other ___________________________________

If you do not speak English and need free translation services, call your case manager or call 1-800-332-6347.

What type of assistance do you need now? (Check all that you need)

□ Cash Assistance

□ Child Care Services

□ Food Supplement Program (Food Stamps)

□ Medical Assistance - Do you have any unpaid medical bills from the past 3 months? □ Yes

□ No

Do you have any of these problems?

□ Utility shut off □ Eviction or foreclosure □ No place to stay □ No heat □ No food □ Cannot afford child care □ other:_____________

Are you or anyone in your household pregnant? □ Yes □ No If yes, who?________________________ Due Date___________

Are you or anyone in your household disabled? □ Yes □ No If yes, who? ________________________ Disability?___________

What type of assistance do you or any household members receive now

or in the past? (Check Now if you are currently receiving this assistance)

Under what name?

Now

If you are applying for the Food Supplement Program (FSP) you can complete all of the form and give it to us now. You may also

fill in your name, address, sign this page and give the page to us. You can then finish the rest of the application at home and bring or

mail it back to the office. You will not get any benefits until we receive the entire form and interview you.

Your Food Supplement benefit is based on the date you sign this application and give it to the department of social services.

You may get Food Supplement benefits right away if you meet one of the following conditions:

Your household’s monthly rent or mortgage and utilities are more than your household’s income and resources.

Your household’s gross monthly income is less than $150, and your resources, such as bank accounts, are $100 or less.

Your household is a migrant or seasonal farm worker household.

If you qualify to get Food Supplement benefits right away, you will receive them within 7 days from the date you sign the form;

however, you will not get expedited Food Supplement benefits, if eligible, until we get a completed application form and interview you.

YOUR SIGNATURE

DATE

Go to page 2

FOR AGENCY USE ONLY

LDSS Office

Programs applied for or receiving

AU ID #s

Case Manager’s Name

Application/Redetermination Date

MA #s

EXPEDITED SERVICE FOR FSP BENEFITS (CUSTOMERS SHOULD NOT WRITE IN THIS AREA – FOR AGENCY USE ONLY)

Applicants who meet the standards below are eligible to receive Food Supplement benefits within 7 days. The customer must be

interviewed, either in person or by telephone, in order to determine eligibility for expedited service. The application must be complete,

signed, and identity verified before expedited benefits can be issued.

1. Is the total household income this month, before deductions, less than $150 AND household cash/savings $100 or less? □ Yes □ No

Estimated self-reported income for this month = $__________ Household’s monthly rent or mortgage amount = $___________

Household cash and savings for all members = $__________ Appropriate utility standard (SUA, LUA or actual) = $___________

A. Total income and liquid resources = $__________

B. Total shelter costs = $___________

2. Is the total amount for B. (Total shelter costs) greater than the total for A. (Total income and liquid resources)? □ Yes

□ No

3. Are the household members destitute migrant or seasonal farm workers whose cash and savings are $100 or less? □ Yes

□ No

If the answer to any of the above questions is yes, this household is potentially eligible for Expedited FSP.

4. If there is another reason why this household should NOT be expedited, list it here: _______________________________________

I certify that I screened this applicant for expedited Food Supplement benefits and determined that the household □ was □ was not

eligible for expedited issuance at this time.

Signature of Case Manager

Date

DHR/FIA CARES 9701 Revised 9/09

Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 2

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