DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
1
MARYLAND DEPARTMENT OF HUMAN RESOURCES
FAMILY INVESTMENT ADMINISTRATION
APPLICATION FOR ASSISTANCE
Your Name (Last, First, Middle)
Home Telephone
Work Telephone
Where do you live? (Number and Street)
Apt. #
City
State
Zip Code
Cell Telephone
What language do you speak? □ English □ Spanish □ Other ___________________________________
If you do not speak English and need free translation services, call your case manager or call 1-800-332-6347.
What type of assistance do you need now? (Check all that you need)
□ Cash Assistance □ Child Care Services □ Food Supplement Program (Food Stamps)
□ Medical Assistance - Do you have any unpaid medical bills from the past 3 months? □ Yes □ No
Do you have any of these problems?
□ Utility shut off □ Eviction or foreclosure □ No place to stay □ No heat □ No food □ Cannot afford child care □ other:_____________
Are you or anyone in your household pregnant? □ Yes □ No If yes, who?________________________ Due Date___________
Are you or anyone in your household disabled? □ Yes □ No If yes, who? ________________________ Disability?___________
What type of assistance do you or any household members receive now
or in the past? (Check Now if you are currently receiving this assistance)
Under what name?
Now
1.
1.
Now
2.
2.
Now
3.
3.
If you are applying for the Food Supplement Program (FSP) you can complete all of the form and give it to us now. You may also
fill in your name, address, sign this page and give the page to us. You can then finish the rest of the application at home and bring or
mail it back to the office.
Your Food Supplement benefit is based on the date you sign this application and give it to the department of social services.
You may get Food Supplement benefits right away if you meet one of the following conditions:
Your household’s monthly rent or mortgage and utilities are more than your household’s income and resources.
Your household’s gross monthly income is less than $150, and your resources, such as bank accounts, are $100 or less.
Your household is a migrant or seasonal farm worker household.
If you qualify to get Food Supplement benefits right away, you will receive them within 7 days from the date you sign the form;
however, you may not get expedited Food Supplement Program benefits, if eligible, until we get a completed application form and
interview you.
YOUR SIGNATURE
DATE
Go to page 2
FOR AGENCY USE ONLY
LDSS Office
Programs applied for or receiving
AU ID #s
Case Manager’s Name
Application/Redetermination Date
MA #s
EXPEDITED SERVICE FOR FSP BENEFITS (CUSTOMERS SHOULD NOT WRITE IN THIS AREA – FOR AGENCY USE ONLY)
Applicants who meet the standards below are eligible to receive Food Supplement benefits within 7 days. The customer must be
interviewed, either in person or by telephone, in order to determine eligibility for expedited service. The application must be complete,
signed, and identity verified before expedited benefits can be issued.
1. Is the total household income this month, before deductions, less than $150 AND household cash/savings $100 or less? □ Yes □ No
Estimated self-reported income for this month = $__________ Household’s monthly rent or mortgage amount = $___________
Household cash and savings for all members = $__________ Appropriate utility standard (SUA, LUA or actual) = $___________
A. Total income and liquid resources = $__________ B. Total shelter costs = $___________
2. Is the total amount for B. (Total shelter costs) greater than the total for A. (Total income and liquid resources)? □ Yes □ No
3. Are the household members destitute migrant or seasonal farm workers whose cash and savings are $100 or less? □ Yes □ No
If the answer to any of the above questions is yes, this household is potentially eligible for Expedited FSP.
4. If there is another reason why this household should NOT be expedited, list it here: _______________________________________
I certify that I screened this applicant for expedited Food Supplement Program benefits and determined that the household □ was □
was not eligible for expedited issuance at this time.
Signature of Case Manager
Date
Date Received
(Agency use only)
DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
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A. HOUSEHOLD MEMBERS
Fill in the blanks for everyone that lives with you. List your own name first. Social
Security number and Citizenship are optional for members not applying for benefits.
Use the codes below to complete the Citizenship, Race and Ethnicity columns. Enter
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.
Only Answer the questions
below for each person
who wants benefits
APPLYING
FOR
(Yes or No)
NAME
(Last, First, Middle)
How are they
related to you?
DATE
OF
BIRTH
S SEX
ETHNICITY
RACE
IN SCHOOL
(Yes or No)
LAST GRADE
COMPLETED
U.S.
CITIZEN
(Yes or No)
SOCIAL SECURITY NUMBER
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?
□ Yes □ No
Country of origin
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
□ Yes □ No
Country of origin
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
□ Yes □ No
Country of origin
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
□ Yes □ No
Country of origin
US Entry date:
INS Number:
Household member
INS Status
Sponsored Immigrant?
□ Yes □ No
Country of origin
US Entry date:
INS Number:
DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
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C. 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
(Specify if self-employed)
TYPE OF RESOURCE/ASSET
BALANCE/VALUE
LOCATION
(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
Date
Who Received the Asset?
Type of asset
Fair Market Value
$
Amount Received
$
Reason for Transfer
G. EARNED INCOME
Does 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
NAME OF EMPLOYER
(INCLUDE ADDRESS AND PHONE
NUMBER)
RATE OF PAY
NUMBER OF
HOURS
WORKED
AMOUNT
PER PAY
PERIOD
HOW
OFTEN
RECEIVED
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H. DEPENDENT CARE
If anyone in your household pays someone to care for a child or disabled adult, fill in this section:
Name of Care Provider
Telephone
Name of Care Provider
Telephone
Number Street
Number Street
City State Zip code
City State Zip code
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
Who Pays?
Cost
$
Who Pays?
Cost
$
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
Household Member Receiving Care
Under 2 years
old? □ Yes □ No
Who Pays?
Cost
$
Who Pays?
Cost
$
I. CHILD SUPPORT/ALIMONY EXPENSE
Does any household member pay court ordered child support to a NON-HOUSEHOLD member? □ Yes □ No If yes, who?
(Includes current payments, arrearages, health insurance)
DEPENDENT’S NAME, ADDRESS AND PHONE NUMBER
AMOUNT PAID
PERSON OR AGENCY
PAID
HOW OFTEN
PAID
J. OTHER INCOME AND BENEFITS
If anyone in your household receives, applied for or was denied any benefit listed below, place a check in the box next to
the benefit
□ Alimony □ Child Support □ Social Security □ SSI
□ Railroad Retirement □ Veteran’s Pension/Benefit □ Unemployment Benefits □ Education Grants or Loans
□ Worker’s Compensation □ Pension or Retirement □ Union Benefits □ Disability, Sick or Maternity Benefits
□ Military Allotment □ Money from Rental Income □ Black Lung Benefits □ Money from Friends or Relatives
□ Lump Sum Cash Amounts □ Civil Service Annuity □ Temporary Cash Assistance □ TDAP
□ Social Security Disability □ Interest Dividends from Stocks, Bonds, Savings or Other Investments
□ Other ______________________________________
Do you agree to apply for all benefits you may be entitled to receive? □ Yes □ No
If you checked yes to receiving, applying for or being denied any benefits, fill in below:
HOUSEHOLD MEMBER
TYPE OF BENEFIT
Applied
CLAIM NUMBER
Received
Amount
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
yes
no
DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
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K. 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
Often?
Who Pays?
√
Expenses
Amount
How
Often?
Who Pays?
Rent
Water
Mortgage
Sewer
Electric
Garbage
Gas
Wood/Coal
Oil
Property Tax
Coop/Condo
/ Assoc. fees
Homeowner’s
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?___________________________________________________________________
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N. MEDICAL INSURANCE – Complete if you are applying for Medical Assistance or Temporary Cash Assistance
1. Has anyone applying dropped health insurance coverage in the past six months? □ YES □ NO
2. Does anyone applying have any health insurance? □ YES □ NO If you answered yes to question 2, fill in the section
below.
HEALTH INSURANCE POLICY NUMBER 1
POLICY HOLDER NAME
POLICY NUMBER
GROUP NUMBER
HOUSEHOLD MEMBER(S)
COVERED BY POLICY
RELATIONSHIP OF MEMBER TO
POLICY HOLDER
HOUSEHOLD MEMBER(S)
COVERED BY POLICY
RELATIONSHIP OF MEMBER
TO POLICY HOLDER
POLICY HOLDER ADDRESS
Number Street City State Zip Code Telephone
INSURANCE COMPANY/UNION
Insurance Company Name
Number Street City State Zip Code Telephone
HEALTH INSURANCE POLICY NUMBER 2
POLICY HOLDER NAME
POLICY NUMBER
GROUP NUMBER
HOUSEHOLD MEMBER(S)
COVERED BY POLICY
RELATIONSHIP OF MEMBER TO
POLICY HOLDER
HOUSEHOLD MEMBER(S)
COVERED BY POLICY
RELATIONSHIP OF MEMBER
TO POLICY HOLDER
POLICY HOLDER ADDRESS
Number Street City State Zip Code Telephone
INSURANCE COMPANY/UNION
Insurance Company Name
Number Street City State Zip Code Telephone
O. LIFE INSURANCE, FUNERAL PLANS or BURIAL FUNDS – Complete if you are applying for Medical Assistance or
Temporary Cash Assistance
NAME OF PERSON
INSURED
NAME OF PERSON
WHO PAYS
FACE VALUE
OR VALUE OF
PLAN
CASH
VALUE
POLICY NUMBER
OR ACCOUNT
NUMBER
COMPANY, FUNERAL HOME OR
BANK NAME
PLEASE USE THIS SPACE IF YOU NEED TO GIVE US MORE INFORMATION ABOUT ANY APPLICATION QUESTION.
If you need more space, ask for the 9701- Application for Assistance Addendum.
DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
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P. CHILD SUPPORT INFORMATION – Complete this section if you want TEMPORARY CASH ASSISTANCE OR MEDICAL
ASSISTANCE for a child who has an absent or deceased parent. Fill in a separate section for each absent or deceased parent.
#1
ABSENT PARENT (AP) INFORMATION
Name of Absent Parent (First, Middle, Last)
Relationship of absent parent to you.
Check one:
□ Absent □ Deceased
CHILD’S NAME
MARITAL STATUS OF CHILD’S PARENTS AT BIRTH
□ Married □ Divorced □ Unknown □ Separated □ Never Married
□ Married □ Divorced □ Unknown □ Separated □ Never Married
□ Married □ Divorced □ Unknown □ Separated □ Never Married
□ Married □ Divorced □ Unknown □ Separated □ Never Married
Social Security Number
Other Name
Date of Birth
Age
Race
Sex
□ Male □ Female
AP’s Last
Known Address
Number Street City State Zip Code Telephone
AP’s Parent's
Address
Number Street City State Zip Code Telephone
Driver’s License State
Birth Place (City, State)
Current or Prior Military
Dates: From: To:
Paying Military Allotment? □ Yes □ No
If yes, To whom?
Military Branch
Incarcerated
□ Currently □ Previously □ Never
Institution Name
ABSENT PARENT INCOME INFORMATION
Last Known
Employer
Name, Address & Telephone
Second
Employer
Name, Address & Telephone
Other Income/Benefits: □ Social Security □ SSI □ Veteran’s Pension □ Unemployment
□ Worker’s Compensation □ Pension/Retirement □ Union Benefits □ Other, list__________________________________
ABSENT PARENT COURT ORDER INFORMATION
Paying Support?
□ YES □ NO
To Whom?
Last Date Paid
Payment Amount
Court Ordered?
□ YES □ NO
If yes, where was the court order issued?
Can you give us a copy?
□ YES □ NO
#2
ABSENT PARENT (AP) INFORMATION
Name of Absent Parent (First, Middle, Last)
Relationship of absent parent to you.
Check one:
□ Absent □ Deceased
CHILD’S NAME
MARITAL STATUS OF CHILD’S PARENTS AT BIRTH
□ Married □ Divorced □ Unknown □ Separated □ Never Married
□ Married □ Divorced □ Unknown □ Separated □ Never Married
□ Married □ Divorced □ Unknown □ Separated □ Never Married
□ Married □ Divorced □ Unknown □ Separated □ Never Married
Social Security Number
Other Name
Date of Birth
Age
Race
Sex
□ Male □ Female
AP’s Last
Known Address
Number Street City State Zip Code Telephone
AP’s Parent's
Address
Number Street City State Zip Code Telephone
Driver’s License State
Birth Place (City, State)
Current or Prior Military
Dates: From: To:
Paying Military Allotment? □ Yes □ No
If yes, To whom?
Military Branch
Incarcerated
□ Currently □ Previously □ Never
Institution Name
ABSENT PARENT INCOME INFORMATION
Last Known
Employer
Name & Address: Number Street City State Zip Code Telephone
Second
Employer
Name & Address: Number Street City State Zip Code Telephone
Other Income/Benefits: □ Social Security □ SSI □ Veteran’s Pension □ Unemployment
□ Worker’s Compensation □ Pension/Retirement □ Union Benefit □ Other, list___________________________________
ABSENT PARENT COURT ORDER INFORMATION
Paying Support?
□ YES □ NO
To Whom?
Last Date Paid
Payment Amount
Court Ordered?
□ YES □ NO
If yes, where was the court order issued?
Can you give us a copy?
□ YES □ NO
DHR/FIA CARES 9701 Revised 09/2014 other versions obsolete
ASSIGNMENT OF SUPPORT RIGHTS FOR TEMPORARY CASH ASSISTANCE
I assign to the State of Maryland all rights, titles, and interest in support that I may have for
myself or for any person receiving TCA.
This includes any overdue support that has not been collected for the time that I or any person
received TCA assistance.
I agree to have the child support agency collect any support owed to me and to keep up to the
amount of TCA paid to me.
I agree to send to the State of Maryland any support l receive. If l do not turn over this support,
I will have to repay this amount to the State of Maryland. I may also be prosecuted for fraud.
When I am eligible for Medical Assistance:
I assign all rights, title, and interest in medical support and health insurance payments I may
have for myself or any person receiving Medical Assistance. This includes overdue medical
support or health insurance payments that have not been collected.
I agree to have the child support agency collect medical support payments owed to me and to
keep up to the amount of Medical Assistance payments that were made for me.
I agree to give the State of Maryland any medical support or health insurance payments I
receive.
I will cooperate to the best of my ability and knowledge with the child support agency while I
am receiving TCA and Medical Assistance
If I do not cooperate with the child support agency, I may lose all my benefits and my case may
be closed
I HAVE READ THESE STATEMENTS OR SOMEONE READ THEM TO ME. I UNDERSTAND WHAT
THEY MEAN. BY SIGNING MY NAME BELOW, I AGREE TO FOLLOW WHAT THEY SAY.
Signature
Date
DHR/FIA CARES 9701 Revised 09/2014 other versions obsolete
Your Rights and Responsibilities
FACTS YOU SHOULD KNOW ABOUT APPLYING FOR TEMPORARY CASH ASSISTANCE,
FOOD SUPPLEMENT PROGRAM (FORMERLY FOOD STAMPS) AND MEDICAL ASSISTANCE
Social Security Numbers
You must give us a social security number for each family member who wants benefits.
If a person who wants benefits does not have a social security number, that person must apply for
a number. We can help applicants get their numbers.
If a family member has applied for a social security number, we will not delay your application
while you wait for the number.
We use social security numbers to prove income. We do not give numbers to other agencies like
Immigration and Customs Enforcement.
Citizenship and Immigration Status
You must tell us about the citizenship and immigration status for each family member who wants
benefits.
Maryland uses the Systematic Alien Verification and Eligibility or SAVE system through the United
States Citizenship and Immigration Service (USCIS) formerly known as Immigration and
Naturalization Service (INS) to verify the alien status of all applicant and recipient non-citizen
households. Information received from USCIS may affect your household’s eligibility and benefit
amount.
Information
If a family member will not tell us about citizenship, immigration status or social security number,
that person will not get benefits.
They must still give us proof of income, expenses and other things.
The other family members who give us their information will get benefits if they meet the rules.
Emergency Medical Assistance
Immigrants who are not eligible for other kinds of medical assistance and apply only for
emergency medical assistance do not have to tell us their social security number, immigration or
citizenship status.
Time Limits
Temporary Cash Assistance has time limits.
The Food Supplement Program (formerly Food Stamps) and Medical Assistance do not have a
time limit.
When Temporary Cash Assistance ends because of time limits, earnings or other reasons, you
may still get Food Supplement benefits and Medical Assistance.
Interviews
You, a responsible family member or someone you choose to represent you must be interviewed.
In most cases, we can interview you by telephone.
You must give or send us the proof we ask for at your interview.
If you need help applying for benefits, or have questions about information you must give us, want to
know what will happen to your benefits, do not speak English and need free translation services. Call
your case manager or call 1-800-332-6347. Si necesita ayuda para llenar el formulario favor de
llamar al 1-800-332-6347.
YOUR RIGHTS AND RESPONSIBILITIES
DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
The Family Investment Administration is committed to providing access, and reasonable
accommodation in its services, programs, activities, education and employment for
individuals with disabilities. If you need assistance or need to request a reasonable
accommodation, please contact your case manager or call 1-800-332-6347 or fill out the form
on the next page.
Requesting a reasonable accommodation:
If you are an individual with a disability, you may be entitled to reasonable accommodation to
help you access
DHR's activities, programs and services. This applies even if you are working
with a local department of social services or a vendor
who provides services for DHR's
customers.
A reasonable accommodation is a modification or adjustment to an activity, program or
service
which helps a qualified individual with a disability have meaningful access to DHR's
activities, programs and
services.
Examples of reasonable accommodations:
Hearing Impairment: sign language interpreter; providing an assistive listening device
Visual Impairment: having a qualified reader read to a customer
Mobility Impairments: mailing forms to a customer; meeting a customer at a more accessible
location
Developmental Disabilities: Having things written down; taking breaks; scheduling appointments
around
a customer's medical needs
You may request a reasonable accommodation from the local department of social services or
a vendor at any time. Your request
may be oral or written. A request for a reasonable
accommodation may be
made in person, in writing or over the telephone. There are no
particular words that you need to use to request an accommodation. A
request may be
made by you or someone helping you. If you need to request a reasonable accommodation
because
of your disability, you should speak with the case manager or the supervisor or the
Customer Access Coordinator (CAC) at your local department of social services. You may
ask the case manager for the name of the Customer Access Coordinator at your local
department of social services. You may use the form on the reverse side of this notice. You
may also ask for more information at the front desk.
1. Dial 7-1-1 or 800-735-2258 to initiate a TTY call through Maryland Relay.
2. The Maryland Relay Operator’s typed greeting, including the Operator’s identification number,
will display on your TTY or VCO phone.
3. When the Operator is finished typing, you will see the letters “GA.” This means “Go Ahead.”.
4. Type the number of the person you want to call, along with any special calling instructions. Then
type “GA”...
YOUR RIGHTS AND RESPONSIBILITIES
DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
Request for Reasonable Accommodation
Name of Person Needing an Accommodation
Name of Person Requesting the
Accommodation
Address:
Street Address/City/State/Zip Code:
Telephone number:
Nature of Disability or Impairment (specify):
Local Department of Social Services Location:
Accommodation Request (Type of accommodation requested.)
Please print or type. Be as
specific as possible. If required, attach additional comments.
Note: If requesting sign language services, specify type: American Sign Language Interpreter
(ASL), Certified Deaf Interpreter (CDI) or Communication Access Real Time Translation
(CART).
Please provide any additional information that may assist us in providing a reasonable
accommodation (specify):
YOUR RIGHTS AND RESPONSIBILITIES
DHR/FIA CARES 9701 Revised 11-2016 other versions obsolete
EQUAL RIGHTS
–
This institution is prohibited from discriminating on the basis of race, color,
national origin, disability, age, sex and in some cases religion or political beliefs.
The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin,
sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity
in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information
(e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State
or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech
disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint
Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any
USDA office, or write a letter addressed to USDA and provide in the letter all of the information
requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) fax: (202) 690-7442; or
(3) email: [email protected].
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues,
persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in
Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by
State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
To file a complaint of discrimination regarding a program receiving Federal financial assistance
through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for
Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202)
619-0403 (voice) or (800) 537-7697 (TTY).
This institution is an equal opportunity provider.
RIGHT TO WRITTEN NOTICE
– We must always give you a written notice explaining your
benefits when we approve your case. We must always give you written notice when we change
your benefits, deny or close your case. You have 90 days from the notice date to ask for a
hearing. If you ask for a hearing within 10 days, you may be able to keep getting benefits while
you wait for the hearing.
RIGHT TO APPEAL
– Ask for a hearing if you disagree with the Department’s decision. Your
case manager can help you write your appeal. At the hearing, you can speak for yourself or
bring a lawyer, friend or relative to speak for you.
YOUR RIGHTS AND RESPONSIBILITIES
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RIGHT TO PRIVACY – You are giving personal information in the application. We use the
information to see if you are eligible for benefits. If you do not give the information, we may deny
your application. You have a right to review, change, or correct any information. We will not show
your information or give it to others unless you give us permission or federal and state law allows us
to do so.
RIGHT TO CLAIM GOOD CAUSE – If you want Temporary Cash Assistance (TCA), you must help
the Department get child support. You may not have to help if it puts you or your family in danger.
RIGHT TO REFUSE HELP – You do not have to accept help from a religious organization if it is
against your religious beliefs.
RIGHT TO TIMELY APPLICATION PROCESSING
–
If you are eligible for expedited
Food Supplement Program benefits we must give you your benefits within 7 days. For the regular
Food Supplement Program and other programs, except for certain Medical Assistance programs, we
must process your application within 30 days. There are times when there is a delay in processing.
If there is a delay, we will send you a letter to tell you why there is delay in processing your
application. If you are incarcerated or in another such institution and file an application for Food
Supplement benefits or cash assistance, you may not receive FSP or cash benefits until you are
released. The filing date of your application for assistance will be the date of your release from the
institution, if it is less than 30 days from the date your signed application was received in the Local
Department of Social Services (LDSS). FSP benefits are issued from the date of your release based
upon your application date.
Authorization to Receive Family Planning Information
If you want information, you can ask your case manager for a Family Planning Guide. You may
also contact:
1-800-546-8900 if you need help in finding a provider for birth control or arranging prenatal
care, or
The Center for Maternal and Child Health at 410-767-6713 www.fha.state.md.us/mch
YOU HAVE THE FOLLOWING RESPONSIBILITIES
PROVIDE INFORMATION – You must give true and complete information. You may need to give us
proof of this information. We will keep this information private. Any delay in providing proof may result
in your case being delayed or denied.
Collecting application information, including the social security number of each household member, is
authorized under the Food and Nutrition Act of 2008, U.S.C.2011-2036, Social Security Act §1137(f)
and 42 U.S.C. §1320b-7(d). We use the information to find out if your household is eligible. We check
this information by matching computer programs.
We also use the information to see if you meet program rules. We may contact your employer, bank or
other party. We may also contact local, state or federal agencies to make sure the information is
correct. We can give your information to other federal or State agencies for official use and to law
enforcement officers who need it to find persons fleeing to avoid the law.
If you get too much in benefits:
You may have to repay the money for the benefits, and
We may give the application information, including social security numbers, to federal or state
agencies, as well as private claims collections agencies, for action.
YOUR RIGHTS AND RESPONSIBILITIES
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Giving information is voluntary. If you do not give us information such as social security numbers for
everyone who wants help, we may deny benefits for each person who does not give a social security
number. If you do not have a social security number, we will help you get one.
REPORT CHANGES - You must report all changes within ten days unless you are part of the Food
Supplement Program simplified reporting group and are not receiving Cash Assistance or Medical
Assistance. If you want to know if you are part of this group, ask your case manager. You may tell us
about any changes in person, by telephone, or by mail to the Department.
Warning – We may deny, lower or stop your benefits if you give us wrong information or do not
report changes. A judge may fine and/or imprison you if you deliberately give wrong information
or do not report changes.
WORK REQUIREMENTS FOR THE FOOD SUPPLEMENT PROGRAM
Individuals applying for or receiving Food Supplement (FSP) benefits must know and understand the
following information about the Food Supplement Program work registration and work requirements.
Food Supplement work requirements are covered in federal law at 7 CFR 273.24.
Everyone over age 18 is required to be registered for work unless otherwise exempt, because they
are: over age 60, caring for a child under age 6 living in their home, applied for or receiving
unemployment benefits, self-employed- working a minimum of 30 hours or more per week at the
equivalent of federal minimum wage, attending a recognized school or institution of higher education at
least half time, or the individual is mentally or physically unfit for work. Work registration is not the same
as participation.
Beginning January 1, 2016 able bodied individuals without dependents (ABAWDS), ages 18-50, who are
not exempt for work registration under one of the above reasons or they reside in an area that is
designated as exempt, are required to be work registered and participate in a work program/activity or be
employed.
These individuals known as ABAWDS may only receive Food Supplement benefits for three
months in a fixed 36 month period unless the individual is employed or participating in an
approved work or educational activity a minimum of 80 hours per month. The individual may not
receive Food Supplement benefits again until he or she meets the work requirements. You will
receive additional information from the case manager and information is available on the DHR
website at http://www.dhr.state.md.us/blog/
AUTHORIZED REPRESENTATIVES – In most instances, if your authorized representative gives us
wrong information, you will have to pay back any amount you are overpaid.
If your authorized representative knowingly gives us the wrong information or does not use your benefits
properly, we may disqualify the person from being an authorized representative and prosecute them for
fraud under state and federal law.
If a drug and alcohol treatment center or a group living arrangement acts as your authorized
representative for your food benefits and they willfully give us wrong information about your situation, we
may prosecute the person under applicable State or federal law.
YOUR RIGHTS AND RESPONSIBILITIES
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TCA and FOOD SUPPLEMENT PROGRAM PENALTIES
Do not:
Give false information or withhold information to get or continue to get TCA and/or FSP benefits.
Trade or sell TCA or FSP benefits, or electronic benefit cards.
Use TCA and FSP or electronic benefit cards to buy items not allowed, such as alcohol and
tobacco or to pay on credit accounts.
Use someone else’s TCA or FSP benefits.
Use someone else’s Electronic Benefits Card without authorization.
Use your EBT card containing TCA benefits in a liquor store, adult entertainment venue such as a
strip club or in a gambling establishment such as a casino.
Your FSP benefits will not increase if your cash assistance is reduced or closed because you did not
follow the rules.
If a household member deliberately breaks the rules, we may bar the person from the TCA or FSP.
We may bar this person for one year after the first violation.
We may bar this person for two years:
* After the second violation, or
* After the first time a court finds this person guilty of buying illegal drugs with TCA or Food
Supplement Program benefits.
We may bar this person permanently:
* After the third violation, or
* After the second time a court finds a person guilty of buying illegal drugs with TCA or FSP
benefits, or
* After the first time a court finds this person guilty of buying guns, bullets, or explosives, with TCA
or FSP benefits.
* After a court finds this person guilty of trafficking TCA or FSP benefits of $500 or more.
We may bar this person for ten years if found guilty of making a false statement about the
person’s identity in order to receive multiple benefits at the same time.
A judge can also fine this person up to $250,000, imprison the person for up to 20 years, or both.
A judge can also bar this person for an additional 18 months. The person may also have to face
further prosecution under other federal laws.
Individuals who request four or more replacement Independence cards in one year may be
referred to the Office of the Inspector General for investigation of trafficking benefits.
YOUR RIGHTS AND RESPONSIBILITIES
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MEDICAID WARNING AND PENALTY - Only use Medical Assistance cards if you are eligible.
Every person convicted of “Medicaid Fraud” with a value of $500 or more in money, services, or goods is
guilty of a felony, and shall:
1. Pay back money, services or goods; or the value of those services or goods unlawfully received;
2. Be subject to a fine of no more than $10,000, imprisoned for no longer than five years, or both.
Every person convicted of “Medicaid Fraud” with a value of less than $500 in money, services or goods
is guilty of a misdemeanor, and shall:
1. Pay back money, services or goods; or the value of those services or goods unlawfully received;
2. Be fined no more than $1,000 and imprisoned for no longer than three years or both.
READ BEFORE SIGNING:
I understand that it is important to give true information and if I do not, I am breaking the law.
I understand that I can be fined, imprisoned or have my benefits reduced for making false statements or
for pretending to be another person.
I know I can be punished for not reporting changes that may affect my eligibility or benefit amount.
I understand that if I get more Food Supplement benefits than I should, all adult members of my
household are liable for repaying the debt.
I know the Department can use the application against me in a court of law for fraud prosecution.
I know that failing to report or verify shelter, medical or dependent care expenses or child support
payments is the same as saying I do not want a deduction for the expenses I did not verify or report.
I understand that the Department may check the information on this form to see if it is correct and may
select my case for a spot check, such as for a Quality Control Review.
I agree to allow someone from the Department to visit me at home. I will help them get all needed proofs
from any source.
I understand by signing this application:
I accept cash assistance and/or medical assistance.
I agree that Medicare Part B will make payments directly to doctors and medical suppliers.
I give the Department the right to seek payment from private or public health insurance and any
liable third party. I understand that I must cooperate with the department in securing such
payments. The Department may seek payment without legal action, as long as it does not keep
more than the amount Medical Assistance paid.
I give the Department the right to inspect, review and copy all medical records for services
received through the Medical Assistance Program.
I understand that when a person is deceased who was at least 55 years old when receiving Medical
Assistance the state may take money from the estate to repay payments made on behalf of that person.
The program may take the money only if there is no surviving spouse, unmarried child younger than 21,
or blind or disabled child (married or unmarried) of any age.
YOUR RIGHTS AND RESPONSIBILITIES
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SIGNATURE SECTION
I understand that, as required by Maryland law, certain law enforcement agencies that investigate fraud
can obtain information about my application, income, benefits and other documentation as part of their
investigation. While access to my application and benefit information is normally limited (under Md.
Code Ann. Human Resources Article § 1-201), these limits do not apply to these investigative agencies.
Such agencies include the Department of Human Resources’ Office of the Inspector General. I
understand that I do not need to provide consent to these agencies in order for them to investigate any
allegations of fraud against me. Any information found as a result of the investigation may be used
against me if an allegation of fraud is prosecuted.
I have read or someone has read and explained the entire application to me. I swear or affirm under
penalty of perjury, that all the information I gave is true, correct, and complete to the best of my ability,
belief and knowledge. I received a copy of my rights and responsibilities. I authorize any person,
partnership, corporation, association, or governmental agency that knows the facts about my eligibility to
give that information to the Department. I also authorize the Department to contact any person,
partnership, corporation, association, or governmental agency that has given proof of my eligibility for
benefits. I certify, under penalty of perjury, that by signing my name below, all persons for whom I am
applying are U.S. citizens, lawfully admitted immigrants or individuals in satisfactory immigration status.
Signature of Applicant/
Recipient
Date
Signature of Witness (If you
Signed an X)
Date
Signature of Spouse (If
Applicable)
Date
Signature of Authorized
Representative (If
Applicable)
Date
Signature of Case Manager
Date
I do not wish to apply for assistance at this time. I withdraw my application for:
Cash Assistance Food Supplement Program Medical Assistance
Emergency Assistance to Families and Children
Signature of Applicant/
Recipient
Date
Printed Name of
Applicant