Application for TANF, Food Stamps or Medical Assistance

PURPOSE: The Food Stamp Application

Simplified Reporting Requirements

PURPOSE: Given to SRR AUs at application to notify the AU of reporting requirements.

Notice of Privacy Practices

PURPOSE: Form 5460 is used for the purpose of informing a client regarding the uses and disclosures of protected health information, the client’s rights with respect to the client’s protected health information and to filing a compliant if the client believes his/her privacy rights have been violated.

(no number assigned), Eligibility Determination Document

PURPOSE: The Eligibility Determination Document is used during the interview to gather information and document the A/R’s responses to questions pertaining to program eligibility.

Rights and Responsibilities

PURPOSE: Form 297A is Part II of the generic application form. (Form 297 is Part I). TANF Medicaid and the Food Stamp Program use it. It provided the AU with a list of the AU’s rights and responsibilities.

Expense Statement

PURPOSE: The Expense Statement is completed at initial application, review or as needed. The completed form is used to interview the AU regarding income and expenses. The completed form is placed in the case file.

Change Report Form

PURPOSE: Change Report Form is used to report changes in an AU’s circumstances. A blank copy of the form is provided to the AU at initial application, review or when the AU reports a change.

Food Stamp Program Employment and Training Facts

PURPOSE: Food Stamp Employment and Training (E&T) Program Facts must be given to the applicants/recipients to explain the AU’s rights and responsibilities in the E&T program.

Voter Declaration Statement

PURPOSE: Food Stamp applicants are provided the opportunity to register to vote at the local DFCS office. The Voter Declaration Statement is used to document either the acceptance or declination of the service.