Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 3
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13A. HOUSEHOLD MEMBERS
Fill in the blanks for everyone that lives with you. List your own name first. Social
Only Answer the questions
Security number and Citizenship are optional for members not applying for benefits.
below for each person
Use the codes below to complete the Citizenship, Race and Ethnicity columns. Enter
who
wants benefits
each code that applies, using at least one code for each person.
Ethnicity Codes: 1= Hispanic or Latino, 2=Not Hispanic/Latino
Race Codes: you can choose one or more race code - 1=American Indian/Alaskan Native,
2=Asian, 3=Black/African American, 4=Native Hawaiian/Pacific Islander, 5=White
Citizenship/Immigration Code: 1=United States Citizen, 2=Permanent Resident, 3=Asylee,
4=Alien granted conditional entry, 5=Parolee 1 year or more, 6=Alien whose deportation is
withheld, 7=Refugee, 8=Battered alien spouse, child, or parent of child(ren)
Note: You do not have to give information about your race or ethnicity. If you do, it will
help show how we obey the Federal Civil Rights Law. We will not use this information to
decide if you are eligible. If you do not give us your race, it will not affect your
application. The case manager will enter a race code for statistical purposes only. Title
VI of the Civil Rights Act of 1964 allows us to ask for this information.
NAME
DATE
SOCIAL SECURITY NUMBER
(Last, First, Middle)
OF
BIRTH
Self
Are any of the household members a roomer or boarder? □ Yes □ No
If yes, who?_____________________________________
B. CITIZENSHIP/ IMMIGRATION STATUS
If anyone for whom you are applying is not a United States citizen, fill in this section. ONLY ANSWER THESE
QUESTIONS FOR EACH PERSON WHO WANTS BENEFITS. If you are not eligible for other kinds of Medical
Assistance and you are applying only for Emergency Medicaid, you do not have to fill-in this section.
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
Country of origin
□ Yes □ No
US Entry date:
INS Number:
DHR/FIA CARES 9701 Revised 9/09
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