Application For Assistance (Snap Application Form) - Maryland Department Of Human Resources Family Investment Administration Page 6
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13K. SHELTER COSTS – Complete if you are applying for Food Supplement Program Benefits
Is anyone in your household paying for any of the following? Check all those paid and answer the questions.
Expenses
Amount
How
Who Pays?
Expenses
Amount
How
Who Pays?
√
Often?
√
Often?
Rent
Water
Mortgage
Sewer
Electric
Garbage
Gas
Wood/Coal
Oil
Property Tax
Coop/Condo
Homeowner’s
/ Assoc. fees
insurance
Telephone
Other
Do you live in: □ Public Housing
□ Section 8 Housing
□ FMHA 515 Housing
□ Private Housing
Is heat included in your rent? □ Yes □ No
Do you pay an electric bill for lights or cooking? □ Yes □ No
If heat is not included in the rent, what is your source of heat? __________________
Do you pay for air conditioning? □ Yes □ No
Does someone help you with your utility costs? □ Yes □ No If yes, who?_________________________
Are you sharing any of the shelter costs listed above? □ Yes □ No If yes, with whom? ___________________
Your share? ________
Have you received Energy Assistance at your current address within the past 12 months? □ Yes □ No
L. MEDICAL EXPENSES – Complete Appropriate Section if Applying for Medical Assistance or Food Supplement Benefits
Medical Assistance – Do you or any household members pay medical expenses? □ Yes □ No
If yes, check the
appropriate box
Food Supplement Benefits – Do you or any household members pay medical expenses for any person age 60 or over,
or any person receiving disability benefits? □ Yes □ No
If yes, check the appropriate box and list the monthly amount you
pay.
DISCUSS THESE EXPENSES WITH YOUR CASE MANAGER.
□ Health/Medicare Insurance
$_______________
□ Medical/Dental Insurance
$______________
Others ____________
□ Dentures/Glasses/Hearing Aids $_______________
□ Transportation Costs
$______________
____________
□ Hospital
$_______________
□ Nursing
$______________
____________
□ Attendant Care
$_______________
□ Pharmacy Expense
$______________
____________
M. HOUSEHOLD’S DECLARATION INQUIRY – Complete if you are applying for Temporary Cash Assistance or Food
Supplement Benefits
1. Has anyone in your household ever been convicted of a felony committed on or after August 22, 1996 that involved
drugs?
□ YES
□ NO
If yes, who? ___________________________________________________________________
2. Is anyone in your household currently violating parole or probation or fleeing from the police or the courts?
□ YES
□ NO
If yes, who? ___________________________________________________________________
3. Has anyone in your household been convicted since August 22, 1996 in a Federal or State Court for not telling the truth
about where they lived or their identity in order to receive Food Supplement benefits or cash assistance from more than
one place in the same month?
□ YES
□ NO
If yes, who? ___________________________________________________________________
4. Has a court convicted any member of your household for trafficking Food Supplement benefits of $500 or more?
□ YES
□ NO
If yes, who?____________________________________________________________________
5. Is anyone in your household receiving benefits under another identity or as a member of another household or in
another State?
□ YES
□ NO
If yes, who?___________________________________________________________________
DHR/FIA CARES 9701 Revised 9/09
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