Release 66: Effective July 1, 2012

SNAP Worker Guide #1 -
Forms Used in the SNAP Program
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Following are the forms and their uses, as related to the Supplemental Nutrition Assistance (SNAP) program. The forms with the most high-volume use are grouped by type (for example, applications). The remainder of forms are listed in numerical order.

  1. Applications

    Form # Title/Use Paper Forms Server
    PDF fill in
    		ACCESS Notice
    Writer
    MSC 415F Application for Services
    Used at initial application and at recertification at self-sufficiency branches for clients receiving SNAP, cash and/or medical benefits. This form also serves to work register all OFSET mandatory members of the filing group. For initial applications, the form is used with the DHS 6609 packet.    		 X X X    
    DHS 415X Additional space for other people living with you
    Used to supplement MSC 415F for large households applying for benefits.    		 X X      
    DHS 415Y Re-Application for Food Stamp Benefits (Part 1)
    Used at recertification at self-sufficiency branches to establish a filing date when the client picks up the DHS 6608 recertification packet.    		 X X      
    SDS 539A Application Form
    Used at initial application and redetermination at branches serving the aged/clients with disabilities when they are applying for multiple programs. The form also serves to work register all OFSET mandatory members of the filing group. Must be used with the SDS 539F    		   X   X  
    SDS 539F Food Benefit Filing Form
    Used at branches serving aged/clients with disabilities to establish the filing date and to gather information to screen for expedited service.    		   X   X  
    SDS 539M Medicaid/Food Stamp Application for SSI Individuals and Couples
    Used at initial application and redetermination at branches serving aged/clients with disabilities when all members of the SNAP group are receiving SSI. Must be used with the SDS 539F.    		       X paper
    only    		  
    DHS 6608

    Client Packet for food benefits redetermination only –NA w/OFSET
    Prepackaged application packet used for recertification of open SNAP cases and consists of the following forms:

    MSC 415F

    Application for Services
    DHS 415R Your Rights and Responsibilities
    DHS 223

    Proof for Eligibility
    DHS 3400 Information and Referrals for Low-Income Households
    DHS 6608A Supplemental Nutrition Assistance Program (SNAP) Recertification Interview Information
    DHS 7280F OFSET Rights and Responsibilities
    DHS 9001 Client Complaint Information
    MSC 9013 We Want to Serve You Well
    DHS 1005 Alternate Format Notification

    X

     

     

     

     

    		 X  

     

     

     

     

     
     

     
     

     
     
    X paper only (DHS 9013)
     

     

    		  
    DHS 6608A

    Supplemental Nutrition Assistance Program (SNAP) Recertification Interview Information
    To use with mailed out recertification packets and allows a client to identify their hardship for an in-office interview.

    		 X   X    
    DHS 6609 Department of Human Services (DHS) Application for Services Information and Referral Packet
    Prepackaged forms that apply to all applicants and is given the MSC 415F filing page is received.

    DHS 415R Your Rights and Responsibilities
    DHS 3400 Information and Referrals for Low-Income Households
    DHS 7254 Oregon Telephone Assistance Program
    DHS 9001 Client Complaint Information
    		X X      
    MSC 6623 Client TANF/Medical Packet – PA
    Used by SSP offices when a client is reapplying for TANF or medical along with SNAP.    		 X X      
    DHS 7476 Employment Related Day Care (ERDC) Re-Application and Food Stamp (FS) Application
    Used at redetermination at self-sufficiency branches for clients receiving ERDC and SNAP. The SNAP certification period and ERDC certification period should match.    		 X X      


  2. Pending forms

    Form # Title/Use Paper Forms Server
    PDF fill in
    		ACCESS Notice Writer
    DHS 210 Notice of Pending Status
    Used at application at self-sufficiency branches to notify the client of what further information is needed and by what date, in order to determine eligibility.    		 X X X   GS00210
    DHS 210A Notice of Information or Verification Needed
    Used to request information or verification on an open SNAP case. The notice notifies the client of the information needed for their continued eligibility and the due date.    		 X X X   GS0210A
    DHS 487 Notice of Incomplete Information
    Notice to the client when the DHS 852 or DHS 7476 is incomplete and cannot be processed, and gives the client the deadline for completing the report.    		 X X X   GS00487
    SDS 539H Notice of Pending Status
    Used at application at branches serving the aged/clients with disabilities to notify the client of what further information is needed and by what date, in order to determine eligibility.    		 X X   X  


  3. Rights and responsibilities

    Form # Title/Use Paper Forms Server
    PDF fill in
    		ACCESS Notice Writer
    DHS 222 Facility as Authorized Representative
    Used to notify A&D treatment centers and Group Care Homes of their responsibilities when they are the authorized representative.    		 None X      
    DHS 415R Your Rights and Responsibilities
    Used at self-sufficiency branches with applications to explain client rights, responsibilities, and reporting requirements.    		 X X      
    SDS 539R Rights and Responsibilities
    Used at branches serving aged/clients with disabilities with applications to explain client rights, responsibilities, and reporting requirements.    		   X   X  
    DHS 7280F OFSET Rights and Responsibilities
    Used to notify OFSET clients of their rights in the OFSET program, the requirements, good cause criteria, and penalties.    		 X X     FS7832R


  4. Client report forms and related forms

    Form # Title/Use Paper Forms Server
    PDF fill in
    		ACCESS Notice Writer
    DHS 852 Interim Change Report for Supplemental Nutritional Assistance Program (SNAP) and Employment Related Day Care (ERDC)
    Used by clients in the SRS report system to report the required information in the sixth month of the certification period. No benefits will be issued for the seventh month of the certification period until this form is submitted to the department and determined to be complete.    		 X X      
    DHS 853 Simplified Change Report For Supplemental Nutrition Assistance Program (SNAP) and Employment Related Day Care (ERDC)
    Used by clients in SRS to report changes at times other than the Interim Change Report. Send a new DHS 853 to the client for future change reporting each time one is submitted to the department.    		 X X      
    DHS 943 Change Report
    Used by CRS clients to report all changes. Send a new DHS 943 to the client for future change reporting, each time one is submitted to the department.    		   X      
    DHS 487 Notice of Incomplete Information
    Notice to the client when the DHS 852 is incomplete and cannot be processed, and gives the client the deadline for completing the report.    		 X X X   GS00487
    DHS 854 Simplified Reporting System
    Pamphlet explaining the requirements of SRS, what information is needed and how it is used to calculate benefits for cases certified longer than six months.    		 X X      
    DHS 856 Transitional Benefit Alternative
    Pamphlet explaining the requirements of TBA, what information is needed and how it is used to calculate benefits.    		 X X      
    DHS 7294
    		Notice of Income and Benefit Calculation
    Notice to the client about how income was averaged or anticipated or counted.    		 X X X   FS07294
    CM07294
    DHS 7351 Educational Income Calculation for ERDC and Food Stamps
    Worksheet for calculating educational income.    		 X X X    


  5. Miscellaneous

    Form # Title/Use Paper Forms Server
    PDF fill in
    		ACCESS Notice Writer
    DHS 138A Affidavit Concerning Lost Check
    Client's application to have benefits replaced when their SNAP benefits are issued by check and have been lost.    		 X X      
    DHS 208 How to Use Your Oregon Trail Card
    (EBT Card Brochure).    		   X      
    AFS 215

    Authorization to Cancel Benefits Deposited to an Electronic Benefits Transfer (EBT) Account
    Worker request to cancel EBT benefits.

    		   X      
    DHS 221 SNAP Benefits Computation
    Worksheet for hand-calculating SNAP benefits when computer systems are not available.    		 None X      
    DHS 221F

    NC2 Two-Step Calculation
    Interactive step 1 and step 2 calculation worksheet for NC2 cases.

    		     X    
    AFS 222A

    Monthly List of Residents  Receiving Food Stamp Benefits
    Used by A&D treatment centers and Group Care Homes acting as authorized representative to report residents receiving SNAP each month.

    		 None X      
    DHS 223 Proof for Eligibility
    Explains to the client what verifications may be required to determine eligibility.    		 X X      
    MSC 231 Designation of Authorized Representative or Alternate Payee
    Used to designate persons with the authority to apply for benefits on behalf of the SNAP group or to designate persons to get an EBT card and use the benefits. The MSC 231 only needs to be completed when a nonfiling group member is named as AP or AR.    		 None X   X  
    SDS 246 Assignment of Personal Identification Number (PIN)
    Used to designate a proxy should a housebound client be unable to come to the branch office to get a personal identification number (PIN) for their EBT card.    		 X        
    MSC 284
    (Word Doc)    		 Overpayment/Overissuance Report
    Form forwarded to the Overpayment Recovery Unit when an overpayment is written.    		 None X X    
    MSC 284A
    (Word Doc)    		 Overpayment/Overissuance Change Report
    Form forwarded to the Overpayment Recovery Unit when the amount of a previously written overpayment is adjusted.    		 None X X    
    MSC 284B
    (Word Doc)    		 Notice of Overpayment and Planned Action
    Notice to the client prior to collection beginning on an overpayment.    		 None   X    
    DHS 362 Notice of Restoration of Lost Benefits
    Notice to the client when benefits are issued to make up for an agency caused underissuance of benefits.    		   X X   FS00362
    MSC 371
    (Word Doc)

    Investigation Referral
    Used to refer a case to the Investigator when information has been received through a community complaint or other source indicating that eligibility is questionable.

    		     X    
    DHS 411
    		Missed Appointment Postcard
    Postcard sent to appicants when they miss their first intake appointment.    		 X X     FSMA411
    DHS 414 Notice of Transfer
    Notice of new branch office, sent to the client when the case in transferred to a different office or the client has moved to a new service area.    		   X X   GS00414
    DHS 415Z Enumeration Request
    Used to verify that a client has applied for a new or duplicate Social Security Number, in order to meet the enumeration requirement for eligibility.    		 X X      
    MSC 443 Administrative Hearing Request
    Form the client may use to put a request for a fair hearing into writing (must be completed by the department if it is a verbal request).    		 X X X    
    DHS 456 Notice of Decision and Action Taken
    Hand-initiated notice to the client when benefits are approved, denied, reduced, or closed and there is no appropriate computer-generated notice.    		 X X X   GSC1 F01
    (Close)
    GSD1 F01
    (Deny)
    GSR1 F01
    (Reduce)
    DHS 457D

    Voluntary Agreement to Reduce or Close Benefits or Withdraw Application and Notice of Action Taken
    Notice signed by the client giving the department permission to take action on benefits immediately, which waives the right to a timely notice. Also used to withdraw an application request. Also used to take benefits out of EBT account to avoid an overpayment.

    		 X X X    
    DHS 475 Job Search Verification
    Form used by clients performing job search to verify employer contacts.    		 X X     GS00475
    DHS 491 Statement of Person Living in the Household
    Form used to verify the financial arrangements and how food is shared when the client lives with others.    		 X X   X GS00491
    SDS 540 Notification of Planned Action
    Hand-initiated notice to the client when benefits are approved, denied, reduced, or closed, and there is no appropriate computer-generated notice.    		 X X   X  
    SDS 540A Agreement to Take Action
    Notice signed by the client giving the department permission to take action on benefits immediately, which waives the right to a timely notice. Also used to withdraw an application request.    		 X X   X  
    SDS 541 Notice of Eligibility and Responsibility
    Notice tells the clients they are eligible, and their first and second month's benefit amount.    		 None X      
    DHS 824F OFSET Appointment Letter
    Form letter used to advise OFSET participants of a scheduled appointment.    		   X X   FS0824F
    MSC 851 Verification of Earnings
    Form sent to employers to verify earned income for a specified period. This is generally used to determine if there is an overissuance.    		   X X    
    DHS 857 Notice for Free Meals or Free Milk at School or Child Care
    Give to clients after they are determined eligible for SNAP so their children can get free school meals or WIC.    		 X X      
    DHS 859B Self-Employed Income
    Worksheet used to determine whether a self-employed client has allowable costs related to their self-employment.    		 X X     GS0859B
    DHS 859C Paycheck Tracking Calendar
    Tool for ensuring that clients report all of their earned income.    		 None X      
    SDS 905 Notification of Case Transfer
    Notice of new branch office, sent to the client when they have moved to an area served by a different branch.    		 X X   X  
    DHS 1005 Alternate Format Notification
    Notice given to all applicants that forms and notices may be received under an alternate format.    		 X X      
    DHS 1058 Declaration of Indigency
    Statement of indigence by a sponsored noncitizen, used to exempt the noncitizen from deeming their sponsor's assets.    		 X X      
    DHS 1219SA Verification of School Attendance X X X   GS121SA
    MSC 1295 SNAP Claim Data Sheet
    Used to collect and organize case record information to be used in calculating an overpayment.    		 None X      
    MSC 2099 Authorization for Use and Disclosure of Information
    Used in instances where the client is unable to provide necessary verification. The form gives the department permission to contact a specific person or organization and share information about the client in order to verify eligibility.    		 X X X    
    DHS 3400

    Information and Referrals for Low-Income Households
    Given to all SNAP households at each certification and recertification when they have income below 185% FPL.

    		 X X      
    DHS 7253 Link-Up America
    Application for financial help to connect with a telephone service.    		 X X      
    DHS 7254 Oregon Telephone Assistance Program
    Notice and application to the client that because they are eligible for benefits, they can apply for a discount on their monthly telephone bill.    		 X X      
    AFS 7262 Direct Deposit - A Safer, Easier Way to Put Your Benefits in Your Account
    Used for clients in Cash-out counties using direct deposit.    		   X      
    DHS 7832D Oregon Food Stamp Employment & Transition (OFSET) Program Disqualification Referral
    Contractor to complete and send to SNAP office when recommending disqualification.    		   X X    
    DHS 7832F OFSET Program Case Plan
    Contractor completed case plan with OFSET mandatory clients.    		 X X      
    DHS 7832R OFSET Program-Client Agreement
    Use to refer OFSET mandatory clients to contractor or for independent work search.    		 X X     FS7832R
    DHS 9001

    Client Complaint Information
    Form explains client complaint procedures, should they perceive that they are being treated with discrimination. It is mandatory for use with all applications.

    		 X X   X  
    MSC 9013 We Want to Serve You Well (Contained in client application packets DHS 6608 & MSC 6623 only)
    An information only pamphlet that tells clients how to file a grievance.    		 X X      


  6. Outreach publications

    Form # Title/Use Paper Forms Server
    PDF fill in
    		ACCESS Notice Writer
    AFS 9206 Student Food Stamp Flyer
    Flier on SNAP rules for college students.    		 X paper
    only    		        
    DHS 9207 Oregon Helps: Now Showing at a Computer Near You
    Bookmark (4" x 9") on using www.oregonhelps.org to find out if you might be eligible for SNAP benefits.    		 X X      
    DHS 9208

    More Reasons to Sign Up for SNAP
    Explains how SNAP benefits make families eligible for free school meals and two phone assistance programs.

    		 X        
    AFS 9211

    Food Stamp Expedited Issuance
    Flier on expedited SNAP benefits.

    		 X paper
    only    		        
    DHS 9213

    Eating Right When Money’s Tight – A Guide for Seniors and People with Disabilities
    Client brochure for seniors and people with disabilities and the SNAP Program. Includes eligibility guidelines.

    		 X X      
    DHS 9216

    Know Your Rights, Client Bill of Rights
    Poster - lists rights of SNAP recipients.

    		 X paper
    only    		        
    DHS 9217 Know Your Rights
    Flier - lists rights of SNAP recipients.    		 X X      
    DHS 9221 Putting healthy food within reach
    Introduces the new name – SNAP – and gives general information about the program.    		 X        
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