Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 4
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13C. AUTHORIZED REPRESENTATIVE:
You may choose a person to apply for you. You may also choose a person to get your benefits through your
Independence Card. This person can use your benefits the same way you do. If you choose someone to help you, give
us the following information about the person and check what you want this person to do.
Name (Last, First , Middle)
Relationship
Telephone Number
Number, Street
City
State
Zip Code
Check what you want the representative to do:
□ Complete interview for you
□ Use your Independence Card (cash)
□ Receive your notices
□ Sign your application
□ Use your Food Supplement benefits
□ Receive your Medical Assistance card
D. STUDENTS
Are any household members between ages 18-50 attending a school for higher education (college, vocational or technical
school)?
□ Yes □ No
Name of student _______________________________________________
School__________________________________
Is the student employed? □ Yes □ No
Is the student getting educational grants, scholarships, or loans? □ Yes □ No
Amount $__________________
Amount of tuition $_________________ Books $_______________ Fees $________________ Transportation
$______________
E. RESOURCES/ASSETS
Does anyone in your household have any resources or assets such as a checking or savings account, stocks, bonds, cash
on hand, property other than where you live, prepaid burial plan, trust fund, IRA or KEOGH account? □ Yes □ No If yes,
list below:
NAME OF OWNER
LOCATION
(Specify if self-employed)
TYPE OF RESOURCE/ASSET
BALANCE/VALUE
(Name of Bank, at home, etc.)
F. TRANSFER OF ASSETS
Has anyone in your household sold, traded or given away any property, stocks, bonds, cash or other assets in the past 36
months? (60 months if a trust is involved)
Former Owner
Transfer
Who Received the Asset?
Type of asset
Date
Fair Market Value
Amount Received
Reason for Transfer
$
$
G. EARNED INCOME
Dose anyone in your household receive any income from employment? □ Yes □ No If yes, list all gross income before
deductions (such as full or part-time employment, self-employment, baby-sitting, odd jobs, day work, roomer/boarder
payments, etc.)
NAME OF EMPLOYER
RATE OF PAY
NUMBER OF
AMOUNT
HOW
NAME
(INCLUDE ADDRESS AND PHONE
HOURS
PER PAY
OFTEN
NUMBER)
WORKED
PERIOD
RECEIVED
DHR/FIA CARES 9701 Revised 9/09
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