Looking for a Food Stamp Application Form Templates? Download it for free!

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Children enrolled in Medicaid are automatically enrolled in the Utah Statewide Immunization

Information System (USIIS). If you do not want your children enrolled in this system, you must

call the USIIS HelpLine at 801-538-6872 or the Immunization Hotline at 1-800-275-0659.

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If you receive benefits for which you are not eligible, you must pay them back.

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If you choose a license-exempt child care provider, the State of Utah does not regulate or monitor

the child care. We can give you more information about how to choose a quality child care provider.

VERIFICATION OF INFORMATION

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For all those applying for benefits, your Social Security number, as well as other information you give

us, will be subject to verification using the State Income and Eligibility Verification System. DWS will

ensure that your household is eligible for Food Stamps and other federal assistance programs through

electronic matches. Computer matching, program reviews and audits will be conducted with DWS,

Department of Homeland Security, Social Security Administration and Internal Revenue Service

records. It also includes inquiries to banking and loan institutions and any other organizations or

individuals who may have eligibility information regarding you and other household members. Your

application may be denied and you could be subject to criminal prosecution if you intentionally provide

false information. The submitted information received from USCIS may affect the household’s eligibility

and level of benefits.

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Computer matches will be completed when you apply and after you receive assistance. Your Food Stamp, Financial, Child Care

and Medical benefits may be reduced, denied or terminated because of information from these sources. Information provided on

your application will be verified using Federal, State, and Local resources. Your application for Food Stamps may be denied

and/or you could be subject to criminal prosecution if you intentionally provide false information.

OBEY PROGRAM RULES

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All the members of your household must obey the program rules and provide complete and accurate information. Do not provide

false information in order to receive benefits. Do not give Food Stamp benefits to anyone who has no right to use them or

purchase ineligible items. Do not use other individuals’ Food Stamp benefits unless you are the authorized representative.

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Do not trade or sell an EBT card. Do not use Food Stamp benefits to buy nonfood items, such as alcohol, cigarettes, or to pay

on credit accounts. Using Food Stamp benefits to purchase food on credit could result in a disqualification.

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If you break any of these rules, you may be disqualified from receiving Food Stamp benefits, Child Care or Financial

Assistance.

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The first time you violate a rule, you may not be eligible for these benefits for 12 months.

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The second rule violation may result in a 24 month disqualification.

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The third time, you may be ineligible permanently for Food Stamp, Child Care or Financial program benefits.

You may also be prosecuted under other laws.

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There may also be a fine up to $250,000 or a jail sentence up to 20 years.

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The court may also order an additional 18 months of Food Stamp ineligibility if convicted of a felony or

misdemeanor related to inappropriate use of Food Stamp benefits.

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If a court of law finds you guilty of using or receiving benefits in a transaction involving the sale of a controlled

substance, you will not be eligible for benefits for two years for the first offense, and permanently for the

second offense.

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If a court of law finds you guilty of having used or received benefits in a transaction involving the sale of

firearms, ammunition or explosives, you will be permanently ineligible to participate in the Program upon the

first occasion of such violation.

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If a court of law finds you guilty of having trafficked benefits for an aggregate amount of $500 or more, you will

be permanently ineligible to participate in the Program upon the first occasion of such violation.

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If you are found to have made a fraudulent statement or representation with respect to the identity or place of

residence in order to receive multiple Food Stamp benefits simultaneously, you will be ineligible to participate

in the Program for a period of 10 years.

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Knowingly providing false information or fraudulent participation in any program may result in criminal or civil action and/or

administrative claims.

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If you sell food you purchased with your Food Stamp benefits, you will be disqualified from the Food Stamp program for 12

months for the first offense, 24 months for the second offense, and permanently for any additional offenses.

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You will be disqualified for Food Stamps, Financial and Child Care programs for 10 years each for the first and second offenses

if you make a fraudulent statement regarding your identity and residence to get multiple benefits. The third offense will result in

permanent disqualification.

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An EBT card cannot be used to access cash benefits at a Point-of-Sale or ATM machine in an establishment that primarily sells

liquor, allows gambling or gaming, or provides adult-oriented entertainment where performers disrobe or perform unclothed.

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A customer who access FEP cash benefits at one of the above establishments may be disqualified from Family Employment

Programs for 12 months for an intentional program violation.

Equal Opportunity Employer/Program

Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals

with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.

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Dws-Esd 61app - Application For Food Stamps, Financial Assistance, Child Care, And Medical Assistance - 2014 Page 29

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