Set up your Account

To apply for benefits online you will need to set up an account with a User ID and Password. This account will help keep your information private and secure. It will also let you save your application to work on later. If you don't wish to set up an Account at this time, the Home button of this page will return you to the Welcome page.

Already have an account set up?

Step 1: Your Name and Email Address

Please fill in your First and Last Name. You do not have to provide a Middle Initial or an Email Address.

First Name: (Required)

Middle Initial:

Last Name: (Required)

E-Mail Address:

Step 2: Your User Id and Password

To log in to your Account, you will need to create a User ID and password. You will need these when you want to logon to your Account. A user ID should be easy for you to remember and difficult for others to guess.

User ID: (Required)

About your User ID

User ID's must be 8-25 characters long
User ID's may contain numbers 0123456789
User ID's must not contain spaces
Special characters may not be used:
- !@#$%^&*(){}|":?><.,/
User ID's are not CaSeSeNsItIvE

Password: (Required)

Retype Password: (Required)

About your Password

Passwords must be 6-20 characters long
Passwords must contain at least 1 number
Passwords must contain at least 1 letter
Passwords must not contain the User ID
Passwords must not contain spaces
Passwords must be letters and numbers only
Passwords are CaSeSeNsItIvE

Step 3: Your Secret Questions and Answers

The Secret Questions are used if ever you need to recover your Account information. Click on the boxes to choose your questions and then fill in your answers in the spaces provided.

Secret Question #1: (Required)

Secret Answer #1: (Required)

Secret Question #2: (Required)

Secret Answer #2: (Required)

About your Secret Answers

Answer must be 3-25 characters long
Answers may not begin with a space
Answers may contain numbers 0123456789
Answers are CaSe SeNsItIvE

HOME

Your User ID and Password

Please fill in your User ID and Password

If you are new to this website and don't have a User ID or Password already set up, please click on "New User?" to create a User ID and Password.

User ID: (Required)

Password: (Required)

About your Password

Passwords are CaSeSeNsItIvE

New User?

Forgot your Password?

Forgot your User ID?

HOME

Have you forgotten your Password?

In order to access your Account, you must:

Provide your User ID
Answer your Secret Questions correctly
Create a new Password

If you have remembered your Password, the Home button at the bottom of this page will return you to the Welcome page

Your User Id

Please fill in your User ID

User ID: (Required)

Forgot your User ID?

HOME

Have you forgotten your Password?

In order to access your Account, you must:

Provide your User ID
Answer your Secret Questions correctly
Create a new Password

If you have remembered your Password, the Home button at the bottom of this page will return you to the Welcome page

Your Secret Questions and Answers

Next, please provide us with the answers to the two Secret Questions you chose when you set up your Account.

Secret Question #1:

Secret Answer #1: (Required)

Secret Question #2:

Secret Answer #2: (Required)

Your New Password

Finally, please provide us with a New Password so that you can access your Account.

Password: (Required)

Retype Password: (Required)

About your Password

Passwords must be 6-20 characters long
Passwords must contain at least 1 number
Passwords must contain at least 1 letter
Passwords must not contain the User ID
Passwords must not contain spaces
Passwords must be letters and numbers only
Passwords are CaSeSeNsItIvE

HOME

Have you forgotten your User ID?

You may recover your User ID if you:

Please fill in your Tracking Number. A Tracking Number is given to each application that is saved or submitted. It is located on the My Account Page next to every application.
Answer your Secret Questions correctly.

You may retrieve your User ID after you create a new Password. If you remember your User ID, the Home button at the bottom of this page will return you to the Welcome page.

Your Tracking Number

Please fill in your Tracking Number. A Tracking Number is given to each application that is saved or submitted. It is located on the My Account Page next to every application.

Tracking Number: (Required)

Forgot Tracking Number?

Don't have a Tracking Number?

HOME

Have you forgotten your User ID?

You may recover your User ID if you:

Answer your Secret Questions correctly

You may retrieve your User ID after you create a new Password. If you remember your User ID, the Home button at the bottom of this page will return you to the Welcome page.

Your Secret Questions and Answers

Next, please provide us with the answers to the two Secret Questions you chose when you set up your Account.

Secret Question #1:

Secret Answer #1: (Required)

Secret Question #2:

Secret Answer #2: (Required)

HOME

Have you Forgotten your Tracking Number Or Don't Have a Tracking Number?

A Tracking Number is given to each application that is saved or submitted. It can be used to gain access to your Account if you forget your User Id.

If you think you have a tracking number, you can try again by clicking the Have a Tracking Number? button below. If you have remembered your user ID, the Home button at the bottom of the page will return you to the welcome page where you can logon to your account. The Create New Account button will allow you to create a brand new Account.

HOME

HAVE A TRACKING NUMBER?

CREATE ACCOUNT

CHANGE PASSWORD CHANGE SECRET QUESTIONS

PRINT SCREEN LOGOUT

What is a Tracking Number?

A tracking number is given to each application that is saved or submitted. You can see this number on your Account page. Please write this Tracking Number down as it can be used to gain access to your account if you forgot your User ID.

Tracking Number	Applicant Name	Benefits Applied For	Date Last Saved	Filing Status	Last Section Completed	Date Submitted	Action	Action

You currently have no applications associated with this account. Click the button below to create a new application.

Your applications are loading. It may take a few minutes to complete. Please wait.

Once you delete an application it is gone. You will not be able to get it back. The application AND the tracking Number will no longer exist!

START NEW APPLICATION

Your password has been successfully changed.

To change your password

You may change your Password if you:

Give us your current Password.
Answer your Secret Questions correctly.

If you don't wish to change your password, the Cancel button at the bottom of the page will return your to your Account page. Your Password will remain the same.

Your Current Password

Please fill in your Password.

Current Password: (Required)

Your Secret Questions and Answers

Next, please provide us with the answers to the two Secret Questions you chose when you set up your Account.

Secret Question #1:

Secret Answer #1: (Required)

Secret Question #2:

Secret Answer #2: (Required)

Your New Password

Finally, please provide us with a New Password so that you can access your Account.

Password: (Required)

Retype Password: (Required)

About your Password

Passwords must be 6-20 characters long
Passwords must contain at least 1 number
Passwords must contain at least 1 letter
Passwords must not contain the User ID
Passwords must not contain spaces
Passwords must be letters and numbers only
Passwords are CaSeSeNsItIvE

CANCEL

Your secret questions have been successfully changed.

To change your Secret Questions

You may change your Secret Questions if you give us your Password. Please select different Secret Questions and give the Answers. If you don't wish to change your Secret Questions, the Cancel button at the bottom of this page will return you to your Account page. Your Secret Questions will remain the same.

Your Current Password

Please fill in your Password.

Current Password: (Required)

Your new Secret Questions and Answers

Please select two different Secret Questions and Answers

Secret Question #1: (Required)

Secret Answer #1: (Required)

Secret Question #2: (Required)

Secret Answer #2: (Required)

About your Secret Answers

Answer must be 3-25 characters long
Answers may not begin with a space
Answers may contain numbers 0123456789
Answers are CaSe SeNsItIvE

CANCEL

This application session will time out after 30 minutes of no activity. If this happens all information will be lost. You will need to start over.

All information will be lost if the internet window is closed before you click the submit button.

This application supports Internet Explorer 10 and greater, Firefox, Chrome, Safari, and Opera.

Oregon's online application is a quick and easy way to apply for benefits.

Filing an application online is the same as filing it in your local office. All answers you give must be true and correct. The application goes to the correct local office when you click the submit button. You can move backward BACK and forward NEXT by clicking the arrow buttons on the bottom of each page. All answers are private. We keep your answers in a safe and secure area. We do not share your answers with anyone without your permission.

This application is for customers who want to submit a new application or a recertification for SNAP benefits. It should not be used to report changes or to be used instead of an Interim Change Report. Right click here to complete an Interim Change Report form in a new window. This report will need to be submitted to your branch office and can't be attached to this online application.

It can take 20-45 minutes to fill out this application. When you submit the application, an electronic signature is created. It is as valid as a handwritten signature. Your application will then be sent to a local office for processing.

START NEW APPLICATION

Not everyone wants to file an application online, your other choices are:

Print, fill out and mail the application to a local office.
Fax the application to a local office.
Take the application to a local office.
- To locate a local office for:
- Children, Adults and Families
- Seniors and persons with disabilities

You may also call a local office to mail you an application Click here to learn more about the process Call 211info, 1-800-723-3638, for more on how and where to apply for benefits.

You can file part of the application for Food benefits. This tells us you want to apply for Food benefits. To do this you only need to give us your name, address and sign the form. Click here to submit an incomplete Food benefits application. You will need to begin the application again and fill it out entirely before your interview. DHS cannot decide if you are eligible for Food benefits until you fill out the entire application.

ARE YOU SURE?

You have chosen that you wish to submit an incomplete application for SNAP food benefits. If you decide to do this, you will still be required to complete the entire application. You will need to start a new application over again because you cannot come back to this one once it is submitted. The official application date is the date you submit the application. If our offices are closed, your official application date is the next business day. This is also the effective start date for your SNAP food assistance.

This action only tells DHS that you want to apply for SNAP food benefits. Once you submit this incomplete application, you will still need to fill out a new application in order to complete the process. You will not be able to come back into this application and finish it.

If you decide not to continue with an incomplete application, and would rather submit a completed application, click "No" then click the "Next" button to continue.

Are you sure you want to submit a partial Food benefits application now? (Required)

No, I want to continue with the application now.

Yes, I am sure. I want to submit an incomplete application (filing date only). I understand I will need to fill out a new application to finish the process.

About Yourself

Please enter the name of the person who is applying for benefits:

First Name: (Required)

Middle Initial:

Last Name: (Required)

Email Address:

By providing your email address, you are authorizing DHS to communicate with you via email.

Contact Information

Contact Telephone Number:

Please give us the address where you get your mail.

Street or PO Box: (Required)

Apt/Unit/Space #:

City: (Required)

State: (Required)

Zip Code: (Required)

This action only holds a possible start date for Food benefits. I know I have not given DHS enough information to decide if I qualify for Food benefits. DHS also cannot tell if I qualify for fast Food benefits. I know I need to start the application again. I know I need to finish it before the interview.

This action only states your intent to apply for Food benefits. It protects your start date if you are found eligible for Food benefits in the next 30 days. The official application date is the date your submit the application. If our offices are closed, your official application date is the next business day. This is also the effective start date for you SNAP food assitance.

You did not complete the full application for benefits. Department of Human Services(DHS) cannot decide if you qualify for fast service. DHS cannot determine if you qualify for Food benefits. You will need to complete the entire application. You may file a paper application or start this electronic application over again.

Not everyone wants to file an application online, your other choices are:

Print, fill out and mail the application to a local office.
Fax the application to a local office.
Take the application to a local office.
- To locate a local office for:
- Children, Adults and Families
- Seniors and persons with disabilities

To tell DHS of your plan to apply for Food benefits, you must sign this form. You can do this by typing your name below. Your types name will serve as your signature for this application.

Voter Registration

If you are not registered to vote where you live now, would you like to apply to vote today? Applying to register to vote or declining to register will not affect the amount of assistance you will be provided by this agency.

Voter Registration:

Yes

No

Signature

Please type in your First name (Required)

Middle Initial:

Last Name: (Required)

BACK

You did not complete the full application for Food benefits. This action told Department of Human Services (DHS) you intend to apply for Food benefits. It holds today as your date submitted. It can also protect your start date for Food benefits. You have not given enough information for DHS to decide if you qualify for Food benefits. You may file a paper application or start this electronic application over again. If you plan to file a paper application, please print the receipt. The printed statement is proof of your intent to apply. The official application date is the date you submit the application. If our offices are closed, your official application date is the next business day. This is also the effective start date for your SNAP food assistance.

PRINT RECEIPT

RETURN TO YOUR ACCOUNT

Discrimination:

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) You can file a complaint if you think DHS discriminated against you because of any of these reasons.

If you wish to file a Civil Rights program complaint of discrimination, please read the Client Discrimination Complaint Information form (DHS 9001), found online at: (right click to open in a new window).

In addition, you may file a complaint at any USDA office, or call (866) 632-9992 to request the USDA Program Discrimination Complaint Form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov

BACK

Legally, you may submit your application as long as it contains your name, address and electronic signature. However if you want benefits faster, complete as much of the application as possible. If you do choose to submit your application with only a name, address and electronic signature, you will still need to complete the rest of the application.

The official application date is the date you submit the application. If our offices are closed, your official application date is the next business day. This is also the effective start date for your SNAP food assistance.

Before you get started, there are a few things you should know. In this application, we will ask you questions about the people in your home, money and bills. To answer these questions, it's easier to have some items with you.

Information about your income and assets. This includes pay stubs, and any other income information for the last 30 days.
Full name and date of birth for household members.
Social security numbers for persons who want benefits.
Information about the bills you pay each month for housing, utilities, medical and child care.
Information about the citizenship/alien status of the people you are applying for.

In addition to this application, you may need an interview. You will be asked follow-up questions in the interview. The interview may be in person or over the phone.

Before you can get benefits, the local office may need to get proof of some of the answers you have given. They will call you or send a letter about this.

Even if you don't have these items with you, please continue with the application. The local office can get the things they need later.

Please right click to open examples of proofs and costs in a new window.

Please click for more about Food Benefits

You will get an answer about your application within 30 days of your filing date. Your filing date is the day you sign and submit this form using this website.

You may get your Food Benefits within 7 days. We ask questions in your application that will help us determine whether you qualify for these fast benefits.

Some adults who get Food Benefits will need to sign up for the Oregon Employment and Transition Program. The local office will let you know if you need to do this when they process your application.

If you need assistance filling out the Online Application, please call 1-855-626-2050. You can access support between the hours of 8:00 AM to 5:00 PM (Pacific Time).

Before you complete your application, you must read the Rights and Responsibilities section and sign the application form.

BACK

I am applying for myself or for someone in my household or both

I am applying for another individual not in my household

Please tell us who you are:

First Name: (Required)

Middle Initial:

Last Name: (Required)

If you are filling out this applicant for someone else, please answer all of the questions based on the applicant's situation.

You will be asked the questions as if you are the person applying for benefits. For example "How much do you make per month?".

BACK

About Yourself

Tell us about the person you are completing the application for.

First Name: (Required)

Middle Initial:

Last Name: (Required)

Suffix:

Gender: (Required)

Date Of Birth: (Required)

(mm/dd/yyyy)

Email Address:

By providing your email address, you are authorizing DHS to communicate with you via email.

Select each of the programs you are applying for: (Required)

Food Benefits

None

Please note: At least one person in the household must apply for benefits.

Contact Information

Please tell us how we can get in touch with you. For the phone numbers, please be sure to include area codes. If you do not have one of the items we ask for, just leave it blank.

Home Phone:

Cell Phone:

Message Phone:

Extension:

Work Phone:

Extension:

Please give us the address where you get your mail.

Street or PO Box: (Required)

Apt/Unit/Space #:

City: (Required)

State: (Required)

Zip Code: (Required)

Do you live at the above address? (Required)

Yes

No

I am homeless right now

Please tell us where you are staying. This can be a shelter or someone else's address.

Street: (Required)

Apt/Unit/Space #:

City: (Required)

State: (Required)

Zip Code: (Required)

Languages and Materials

After you apply for benefits, you will get notices from your worker.

What language do you prefer for written materials?

What language do you prefer to speak?

Do you need materials sent to you in a different format? (Required)

Yes

No

Alternate Format: (Required)

BACK

If you live in a shelter or another situation click the "More Info" box MORE INFO

What do we mean by live in your home?

Please include everyone who lives in your home. Tell us about everyone who lives with you, even if they are not applying for benefits.

If you do not have a home right now, tell us about the people you share food with.

If you are in a homeless shelter, domestic violence shelter, a treatment facility or group living situation, please tell us about your family that is with you. Do not include the other people who are not in your family but live in the facility or shelter.

If you need assistance filling out the Online Application, please call 1-855-626-2050. You can access support between the hours of 8:00 AM to 5:00 PM (Pacific Time).

Does anyone else live in your home? (Required)

Yes

No

Please tell us about the other person:

First Name: (Required)

Middle Initial:

Last Name: (Required)

Suffix:

Gender: (Required)

Date Of Birth:

(mm/dd/yyyy)

I do not know their date of birth.

Enter the person's age: (Required)

Select each of the programs you are applying for: (Required)

Food Benefits

None

Please note: At least one person in the household must apply for benefits.

This application shows that no one is applying for any benefits!

You must mark someone as applying for benefits to continue.

Use the edit buttons to change the benefit choices.

You are trying to apply for medical benefits only.

If this was a mistake you can apply for other benefits by using the edit buttons on this page. You can add another person to this application using the add button.

If you still want to apply for medical benefits only, click here.

Are you sure you want to exit this application and apply for medical benefits only?

Click Yes to save your work and go to medical only applications.

Click No to return to the last page that you were on so that you can edit the benefit choices.

Please note, the information you have entered so far will not move over to the medical only application. You will have to start again.

Please review what you have told us. To change your answers, click the edit button.

Please review what you have told us. To change your answers click the edit button on the right hand side of the screen in each section. If you click the "Delete" button the information will go away. Once it is deleted, you cannot get it back and you will need to re-enter the information.

Are you sure you want to delete this person?

Personal information

Applicants:

Click on the ADD button if you want to add another person.

SAVE & EXIT

Please select a summary page to edit a previously completed section:

Please review what you have told us. To change your answers, click the edit button.

Additional Case Information

Authorized Representative

What is an authorized representative?

A representative is a person who can apply for benefits for you. They need to know your situation. They can report changes for you.

Please remember that a person who is disqualified from receiving SNAP benefits cannot be chosen as an Authorized Representative or an Alternate Payee.

Alternate Payee

What is an alternate payee?

An alternate payee is a person who can use your food or cash benefits. They will get a card that lets them use your benefits for you.

Please remember that a person who is disqualified from receiving SNAP benefits cannot be chosen as an Authorized Representative or an Alternate Payee.

SAVE & EXIT

Why we need your Social Security Number (SSN):

When you apply for benefits, the Department of Human Services (DHS) will need the Social Security Number (SSN) for you and the other people who want benefits.

If you are applying for someone else, and not for yourself, we do not need your SSN or citizenship status. We will not contact immigration services for anyone not seeking benefits. If you do not have a SSN yourself, other family members who do have SSNs may still qualify.

DHS will use your SSN to help decide if you are eligible for benefits. Your SSN will be used to verify your income, other assets, and to match with other state and federal records such as IRS, Medicaid, child support, Social Security and Unemployment benefits.
DHS may use your SSN to prepare aggregate information or reports requested by funding sources for the program you apply for or receive benefits.
DHS may use or disclose your SSN:

If it is needed to operate the program you apply for or receive benefits from.
To conduct quality assessment and improvement activities.
To verify the correct amount of payments and recover overpaid benefits.
To make sure you get the correct benefits.

Federal laws (42 USC 1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920 and 42 CFR 457.340(b)) and DHS rule (OAR 461-120-0210) requires anyone applying for cash, food or medical benefits to give DHS their SSN.

I understand DHS may use or disclose my SSN and the SSN of each person I apply for, for the purposes listed on this screen. (Required)

Yes

No, please explain in the interview

BACK

Please select a summary page to edit a previously completed section:

Please review what you have told us. To change your answers, click the edit button.

SSN Information

SAVE & EXIT

Please select all of the job situations that apply. (Required)

Has a job right now (Not self-employed)

Is self-employed

Job ended in last 30 days

Is starting a new job in 30 days

Is on strike from a job

None of the above

Self-employment Information:

When self-employed you get income directly from your own business, trade or profession. You do not receive the funds, be earning a salary or wages from an employer. Clients are considered self-employed if they meet certain criteria.

Examples of types of self-employment are:

Newspaper carrier
Cosmetic sales
Plasma sales
Picking up bottles and cans
Real estate agents
Child care providers paid by the State of Oregon

There are other types of self-employment. The local office can help you determine if you are self-employed.

If you need assistance filing out the Online Application, please call 1-855-626-2050. You can access support between the hours of 8:00 Am to 5:00 PM (Pacific Time).

Self-employed can be many different things. Click the more info box to see a list of examples of self-employment.

Did have another job that ended in the last 30 days? Are you sure you want to enter this past job income information? (Required)

Yes

No

You said had a job that ended in the last 30 days. Please give more information about that job.

You have told us that has another job that ended in the last 30 days. Please tell us more about the job here.

Name of Employer? (Required)

Employer phone number, if available (include extension):

Extension:

Last day worked: (Required)

(mm/dd/yyyy)

Date of the final paycheck: (Required)

(mm/dd/yyyy)

Amount of the final pay (before taxes):

How much did get in gross income this month?

Why did the job end?

Please specify:

Will begin to work in another job in the next 30 days? Are you sure you want to enter this future job income information? (Required)

Yes

No

You stated will start a job in the next 30 days. Please give more information about that job.

You have told us that has another job that will begin in the next 30 days. Please tell us more about the other job here.

Name of Employer? (Required)

Start date for this job:

(mm/dd/yyyy)

Employer phone number, if available (include extension):

Extension:

What is the expected monthly income (before taxes and payroll deductions)?

How often will get paid?

Please explain how often you will get paid:

How are you paid?

Please tell us about the total gross amount that gets paid each pay period before taxes or anything else is taken out of the paycheck. By pay period, we mean the time between each paycheck.

Salary amount:

Please tell us the amount that is paid each hour.

Hourly rate of pay

Please tell us how many hours works each week at this rate. If the hours are not regular, try to estimate the number of hours he or she usually works at this hourly rate.

Hours per week

Please explain how you are paid:

Is on strike from another job? Are you sure you want to enter this strike income information? (Required)

Yes

No

You said is on strike. Please tell us more.

You have told us that is on strike from another job. Please tell us more about the other job here.

Name of Employer? (Required)

Employer phone number, if available (include extension):

Extension:

Before the strike, what was the monthly income (before taxes and payroll deduction)? (Required)

When did the strike begin? (Required)

(mm/dd/yyyy)

Does receive strike benefits? (Required)

Yes

No

Monthly amount:

Next, please tell us about any money received from any sources other than a job or self-employment. This could be money received monthly, like child support or social security, or it can be money received quarterly or yearly like tribal benefits or dividends.

You told us that has a disability but did not report disability income. If is receiving disability income please add this income to specific source of money group found below.

Please check each source of money receives. (Required)

Other - Please Specify

None of the above

Will receive any other ? (Required)

Yes

No

You told us that has Please tell us more.

What is the total monthly amount of before any deductions will receive this month? (Required)

How often does get this money? (Required)

How often:

Will the money from this source be the same amount next month? (Required)

Yes

No

Why will it be different?

Does have an overpayment or other deductions being taken out of this money? (Required)

Yes

No

Please select a summary page to edit a previously completed section:

Are you sure you want to delete this job?

Are you sure you want to delete this unearned income?

Please review what you have told us. To add more income, click on the link for the type of income you need to add. To change your answers, select the type of income that you want to change and click the edit button. To remove one of your answers, select the type of income you want to remove and click the delete button. To change your answers, select the type of income that you want to change and click the edit button.

SAVE & EXIT

Let's start with your housing costs.

Are your monthly rent and utility payments more than your monthly income and money in your bank accounts? (Required)

Yes

No

Does anyone in your household pay for housing? (This includes rent, space rent, mortgage, second mortgage, condominium fees, and association fees.) (Required)

Yes

No

Please enter all of the housing costs that apply.

Rent

Full monthly amount:

Amount you pay:

Space Rent

Full monthly amount:

Amount you pay:

Mortgage

Full monthly amount:

Amount you pay:

2nd Mortgage

Full monthly amount:

Amount you pay:

Property Taxes

Full monthly amount:

How often paid:

Condominium & Housing association fees

Full monthly amount:

How often paid:

Fire or Hazard insurance (not renters)

Full monthly amount:

How often paid:

BACK

Do you get help to pay housing from HUD or Section 8?

Yes

No

What do you pay?

Do you expect to pay the same amount for housing next month?

Yes

No

What is the new amount?

If you have reported that you have no income, how are you paying for your expenses?

BACK

Does anyone help pay for part of your housing? Does anyone else help pay for part of your housing? (Required)

Yes

No

Who pays?

First Name: (Required)

Middle Initial:

Last Name: (Required)

Phone Number:

Extension:

Amount they pay? (Required)

Does anyone help pay for part of your utility costs? Does anyone else help pay for part of your utility costs? (Required)

Yes

No

Who pays?

First Name: (Required)

Middle Initial:

Last Name: (Required)

Phone Number:

Extension:

Amount they pay? (Required)

Please answer the following question about medical expenses. We need to know the amount you must pay for each of these bills after the insurance or someone else pays. Do not include medical costs for other persons.

You will be asked to provide a copy of medical bills as proof of the costs.

Does this person pay for Medicare? (Required)

Yes

No

Please check all that apply.

Medicare Premium:

Monthly amount: (Required)

Medicare Part D Premium:

Monthly amount: (Required)

Please answer the following about health insurance costs. We need to know the amount you must pay for each of these bills after someone else pays. Do not include health insurance costs for other persons.

You will be asked to provide a copy of health insurance bills as proof of the costs.

Does this person have any out of pocket health insurance costs? Does this person have any other out of pocket health insurance costs? (Required)

Yes

No

Name of insurance company: (Required)

Monthly amount: (Required)

Dependent care costs may occur when a person is working, looking for work or going to school.

Are you, or is anyone in your household paying for dependent care? (Required)

Yes

No

Who is being cared for? (Required)

Please check all that apply.

Tell us about the dependent care costs for If more than one person in the household pays for the care, tell us about the total amount paid:

Who pays for Care? (Required)

Monthly amount: (Required)

Does the state pay for part of the cost? (Required)

Yes

No

Do you pay for care costs in additional to your copay? (Required)

Yes

No

Monthly amount: (Required)

Child Support payments include but are not limited to cash, insurance premiums or other court-ordered payments. For the deduction, the payment must be for a child not in your home.

Are you or anyone in your household paying child support? (Required)

Yes

No

Who pays child support payments? (Required)

Please check all that apply.

Child Support payments include but are not limited to cash, insurance premiums or other court-ordered payments. For the deduction, the payment must be for a child not in your home.

Does pay child support for a child that doesn't live with them? Does pay child support for another child that doesn't live with them? (Required)

Yes

No

First Name: (Required)

Middle Initial:

Last Name: (Required)

Total amount paid per month: (Required)

State the Court Order is from: (Required)

Please select a summary page to edit a previously completed section:

Are you sure you want to delete this person who helps pay for housing?

Are you sure you want to delete this person who helps pay for utilities?

Are you sure you want to delete this health insurance?

Are you sure you want to delete this dependent care cost?

Please review what you have told us. To change your answers, click the edit button. To add more household costs, click the add button. To remove one of you answers, click the delete button.

Shelter Costs

Other Shelter Information

Utility Costs

SAVE & EXIT

Congratulations! You are almost done! There are just a few additional questions that we need to ask.

You may need to have an interview as part of this application. We go over the application with you in the interview. It is important to make it to your interview.

Some people will need to come to the office for an interview.

If it's hard for you to get to the local office, you may be able to have a phone interview instead. Would you prefer to talk with a worker in person or by phone? (Required)

In person

By phone

Home Phone:

Cell Phone:

Message Phone:

Extension:

Work Phone:

Extension:

If you are hearing impaired, what phone method do you use?

What is the best way to reach you during the weekday? (Required)

What is the best time to call during the weekday? (Required)

When DHS contacts you for an interview, the number may appear blocked or unrecognized. If you indicate the best way to reach you is by phone, it is important that you answer during the designated time you have indicated to complete the interview process.

Within 7 days, DHS will send you information about scheduling an interview at a local office. If you need to reschedule, please let us know.

At the interview you may be asked to prove some of your statements. This will include identification, and proof of income.

Examples of the kinds of proof you may need.

BACK

Save Options

Are you ready to leave? Please click one of the buttons to tell us what you would like to do, then click the next button at the bottom of the page.

Save or Continue

Please select an option (Required)

Save the application and come back later

Keep working on this application

About Saving Your Application

Please note that saving your application is NOT the same as submitting it to DHS for processing.

The "Save" action stores your application so you can come back to it later to finish. You can locate it when you log in to your account. Department of Human Services is not able to process your application until it is submitted.

These pages have legal requirements for the programs you are applying for.

You will read about:

Your rights and responsibilities
Assignment requirements for medical
Reporting changes
Program penalties

At the end of this section we will ask you to tell us you understand what you have read. We will also ask you to tell us you have given true and correct information on the application. When you are finished, you can submit your application. Your typed name is your signature for this application. It is an electronic signature and is created when you submit your application. It is the same as writing your name on a paper application.

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You can ask Department of Human Services (DHS) staff to explain the Rights and Responsibilities if you do not understand.

DHS will treat you with respect in a fair and polite way.
DHS will give you information about its payments and services. DHS may also refer you to other services you need.
You have the right to ask about and apply for any program.
You can ask for a receipt for any form you turn in to the DHS office.
You can ask for a meeting with a worker. You can also ask to talk with a person in charge.
You can ask for an interpreter to help you apply, fill out forms or report changes.
DHS will give you information in a format or language you can understand.
DHS will do its best to meet your special needs if you have a disability. DHS follows the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.
You can ask to see what is written about you in your case file.
You may not get Senior Farm Direct checks if you are in a Senior Farmers Market Nutrition Program in another State.
You can ask not to work with child support if you have "good cause". This means that working with child support would be a danger to you or your children. DHS will give you forms that explain good cause. These forms tell you how the Oregon Child Support Program may be able to help you get child support and still keep you and your children safe. DHS will also answer your questions about good cause.
DHS will tell you if you qualify for benefits:
- Within 30 days of the date you file an application for Food benefits. If you qualify for faster benefits, you will find out within 7 days.
- Within 45 days of the date that you apply for Cash, Child Care or Medical benefits.
- Within 90 days of the date you ask for a medical decision about your disability.
You can ask for a hearing if you disagree with a DHS decision. For Cash, Child Care or Medical benefits, you must use the Administrative Hearing Request form, (DHS 0443). Someone at your DHS office can help you fill it out. If you get Food benefits, you can ask for a hearing on the DHS 0443, by phone, in writing or in person.
- For Cash, Child Care or Medical benefits, you must ask for a hearing within 45 days of the date on the notice about the decision.
- For Food benefits, you must ask for a hearing within 90 days of the date on the notice.

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You are agreeing to do certain things when you, your spouse or your partner get benefits from Department of Human Services (DHS). You may lose benefits if you do not do these things. You may also be asked to repay benefits if you get too many.

If you are in any DHS program, you must:

Give DHS true, correct and complete information.
Give proof of the things you report. If you cannot get proof, let DHS help you.
Take part in an employment program if you are required. This includes finding, accepting and keeping a job.
Help DHS if your case is chosen for a review. Cases are chosen at random.
Allow DHS staff to visit your home to get information about your case.
Let the Child Support Program share information with DHS.
Report changes to DHS within 10 days after they occur.

If you get Food Benefits, you must also:

Not quit a job or reduce your work time to less than 30 hours a week.

If you get Temporary Assistance to Needy Families (TANF), you must:

Help get child support unless:
- You are in the JOBS Plus, State Family Pre-SSI/SSDI (SFPSS) or Post-TANF Program.
- It would mean danger to you and your children. Be sure to tell DHS if it would be dangerous.
Take part in any training plan offered to you by DHS or its partner agencies, unless you have "good cause". You can talk to your worker about good cause.
Take any medical exam that is needed to see if you qualify for services.
Apply for and use any other benefits or money you qualify for. You must do this for yourself and any others you want help for.
Accept social Services that are ordered by the court or are related to training or employment.
Go to mental health and drug or alcohol programs, if DHS determines you need the help. You only have to do this if you can get into a program that is free to you.

Cash (TANF) time limits

Oregon has a five (5) year time limit. Please talk to your worker about how this could affect you.

If you get Medical benefits, you must also:

Tell medical providers if you have other health insurance. They should bill the other insurance before they bill DHS for your medical care.
Try to get health coverage and medical cash support from a parent who does not live with your child. This is to help pay for your child's medical expenses.
Apply for and use other benefits and money you qualify for. This also applies to others you are getting help for.
Take a medical exam if needed. We may need this to see if you can get benefits or services mailed to you each month.
Pay a fee each month to keep getting Medical or Service benefits, if you have to. A bill will be mailed to you each month.
Allow DHS to be the beneficiary for you or your spouse's annuity.

Please indicate if you agree or disagree with these responsibilities (Required)

Yes, I agree to these responsibilities

No, I don't understand. Please explain during my interview

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Assigning Rights and Support - Cash for families

Cash for families is also known as Temporary Assistance for Needy Families or TANF.

What you need to know about "assigning support"

"Support" means money you get for you or your children, like alimony or child support. When you get cash benefits, you are assigning the state the right to keep the support you or anyone in your family get from another person. The money goes to repay the state for the cash you get.

By signing this form, you agree to "assign" to DHS all rights to these payments for anyone who is covered by your public assistance. That means yourself and other family members (including any child born in the future).

By signing this form, you agree to help DHS find and obtain these payments. There is a limit on how much DHS can take in payments. It cannot take more than the amount it has paid in assistance for you and your family.

NOTE: This does not apply during any period of time that you receive cash benefits from JOBS Plus, State Family Pre-SSI/SSDI Program (SFPSS) or the Post-TANF Program.

This means that while you are getting cash benefits:

The state will keep part of the support payments (for both current and past-due payments) received for you and members of your family. The state will not keep all your child support. The state will send you $50 of current child support received per child per month up to $200 per family per month. The state will not count this money as income when figuring your eligibility and benefits.

NOTE: If you are an applicant for cash assistance or you are in SFPSS or JOBS Plus, the state will generally not keep any of your child support. When determining your eligibility and benefits, $50 (per child per month up to $200 per family per month) of current child support received will not be counted towards your monthly income.

When you leave the cash program:

Current support payments will go to you.
Any past-due payments for months you were on cash assistance will be kept by the state.
Any past-due payments for months you were not on cash assistance may go to you.

Working with Child Support

While you are getting cash benefits, you will need to work with the state's Child Support Program.

Important: You do not have to work with child support if you think it would mean danger for you or your children.

Working with child support can mean:

Helping to locate your child's other parent (unless you think it would mean danger for your or your children).
Legally naming the child's father (establishing paternity).
Getting a support order.

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When you get DHS medical benefits, DHS will pay your medical bills for covered services. During this time, you must let DHS have any money you get from private health insurance or from an injury. DHS will not take more than the amount paid in assistance for you and your family.

Working with Office of Private Health Partnerships

DHS works with the Office of Private Health Partnerships (OPHP) to provide Healthy KidsConnect medical coverage for your children. While your children are getting Healthy KidsConnect benefits, you may need to fill out and submit forms to OPHP. OPHP will let you know if you need to do anything further.

Helping get other medical coverage

You will need to work with DHS to try and get medical coverage or money for medical care from other sources. This means:

For yourself: You must try to get things such as:

Health insurance from your employer (DHS may be able to help you pay for this).
Insurance payments because of an injury.
Medical coverage from the Veteran's Administration.

For your children: If the other parent isn't living with you, you may need to work with the state's Child Support Program to get health care coverage and medical cash support for the children.

Working with child support

While you are getting medical benefits you will need to work with the state's Child Support Program.

NOTE: This does not apply if your children are receiving Childrens Health Insurance Program benefits or Healthy KidsConnect benefits.

Important: You do not have to work with child support if you think it would mean danger for you or your children.

Working with child support can mean:

Helping to locate your child's other parent.
Legally naming the child's father (establishing paternity).
Getting an order for health care coverage.
Getting an order for cash to help with your child's medical expenses.

If you are pregnant and you only want state medical coverage for yourself, you do not have to work with child support.

What you need to know about "assigning support"

"Support" means money you get for you or your children, like alimony or child support. It includes cash ordered to help you pay for your child's medical expenses. When you get DHS medical for your child, you are "assigning" the state the right to keep the medical cash support anyone in your family gets from another person. The money goes to repay the state for the medical benefits your child gets.

This means that while you are getting DHS medical benefits:

The state will keep all medical cash support payments received for you to help pay for your child's medical expenses. This includes current and past-due payments.

When your child leaves the medical program:

Current support payments will go to you.
Any past-due payments for months your child was on medical assistance will be kept by the state.
Any past-due payments for months your child was not on medical assistance may go to you.

If you have other insurance:

If you or a member of your family have other medical insurance, tell the provider (doctor, clinic or hospital) before you get care. They must bill the other insurance company before they bill DHS.

If DHS pays a medical bill that should have been paid by insurance, DHS will take action to get its money back. For example:

If DHS pays a bill that private insurance should have paid, DHS will try to get the money back from the insurance company.
If DHS pays a medical bill and the provider also gets paid by an insurance company, DHS will try to get its money back from the provider.
If DHS pays a medical bill and an insurance company sends you a check for it, DHS will try to get its money back from you.

BACK

You must report certain changes that affect you, your spouse or partner, or anyone you get benefits for. You must report changes within 10 days of them occurring. Your benefits could stop or be late if you do not report changes on time. Anyone in your home who is age 18 or older could be asked to repay benefits if they get too many.

If you get Food benefits and are in Simplified Reporting, you only need to report a change in:

Your income, if it goes over the limit for the program.

If you get Food benefits and are not in Simplified Reporting, you must report a change in:

Who lives with you.
A change in your address.
Housing and utility costs after you move.
If you must legally pay child support.
Where you get your money. This includes getting, losing or quitting a job.
Your income from work, if the change is more than $100 per month.
Your other income, if the change is more than $50 a month.
If you get money, items worth money, or sell property. This includes buying or changing vehicles.

NOTE: You may want to report changes in your living costs even if you don't have to. Increases in housing, medical or child care costs or in how much child support you pay, may help you get more Food benefits.

If you get Cash, Child Care or Medical benefits for families (not the Oregon Health Plan or Healthy KidsConnect), you must report a change in:

Who lives with you.
A change in your address.
Marital status.
If you get or change medical coverage.
If you are involved in an injury accident.
When someone who gets benefits becomes pregnant and when a pregnancy ends.
The birth of a child.
Where you get your money. This includes getting, losing or quitting a job.
Your income from work, if the change is more than $100 per month.
Your other income, if the change is more than $50 a month.
If you get money, items worth money, or sell or give away property. This includes buying or changing vehicles.

When you start getting cash benefits, the amount of your food benefits will go down.

If you get Oregon Health Plan or Healthy KidsConnect you must report a change in:

Name for anyone getting benefits.
If you get or change medical coverage.
When someone who gets benefits becomes pregnant and when a pregnancy ends.
The birth of a child.
When someone receiving Healthy KidsConnect moves out of the house.
A change in your address.

If you get child care benefits, you must report changes in:

Who lives with you.
Where you get your income. This includes getting, losing or quitting a job.
Your rate of pay.
Who provides your child care.

Your approval notice will tell you what your reporting requirements are. (Required)

Yes, I agree to report changes.

No, I don't understand. Please explain during my interview

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Penalties in the food Benefits Program (Supplemental Nutrition Assistance Program)

You, your spouse or partner could be disqualified from receiving food benefits if you do any of the following things.

If you do the following...

You will lose food benefits...

Hide information or make false statements
Use EBT cards that belong to someone else
Use food benefits to buy alcohol or tobacco
Trade or sell benefits or EBT cards
Dump containers only for the cash redemption value
Resell food bought with food benefits for cash

12 months for the first offense
24 months for the second time
Permanently for the third time

Trade food benefits for controlled substances such as drugs

24 months for the first offense
Permanently for the third time

Trade food benefits for firearms, ammunition or explosives

Permanently

Trade, buy or sell food benefits of $500 or more

Permanently

Give false information about who you are or where you live so you can get extra food benefits

10 years for each offense

You can also be fined up to $250,000 or put in prison for up to 20 years, or both, for doing these things. You may also be charged under other federal laws.

If you do the following...

You may be...

Use EBT cards which are not yours
Transfer your EBT cards to other people
Acquire or possess EBT cards which are not yours
Dump containers for the cash redemption value
Resell food bought with food benefits for cash

Guilty of a felony or misdemeanor
Fined
Put in prison
Ineligible for food benefits for a period of time

Penalties in the Cash (Temporary Assistance for Needy Families) Program

If you knowingly do the following...

You will lose Cash benefits...

Give false information about yourself or someone you are applying for
Hide information about yourself or someone you are applying for
Give false information about where you live

12 months for the first offense
24 months for the second time
Permanently for the third time

You will also have to pay back all the TANF you were not supposed to get. Your food benefits will not go up even though you get less in TANF if you told us something that was not true or did not tell us something that was true.

Do you understand these penalties? (Required)

Yes, I understand these penalties

No, I don't understand. Please explain during my interview

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Where to find help

It is not always easy to find out where to call when you need help. This list of services may be helpful to your family. It includes phone numbers and Web addresses for many of the services. You can find other local numbers in the government services section of your phone book. You can access the Internet at most public libraries. If you need help finding one of these services, ask your worker.

Prevention services

Boys and Girls Aid offers pregnancy information, counseling and referral.

Call 1-800-342-6688 or go to www.boysandgirlsaid.org.

The Family Planning Unit in the county health department helps with pregnancy prevention services.

Look in county government listings of your phone book or go to www.oregon.gov/DHS/ph/lhd/lhd.shtml.

Protection

The Oregon Department of Human Services (DHS) helps seniors and people with developmental and physical disabilities who are being abused or need protection.

Call 1-800-232-3020 or go to www.oregon.gov/DHS/spwpd/abuse/home.shtml.

DHS has a hotline for reporting child abuse or neglect.

Contact a law enforcement agency or go to the local DHS child welfare office. See a list of locations at www.oregon.gov/DHS/localoffices/locations.shtml.

Food services

The Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) puts healthy food within reach for low-income Oregonians.

Ask at a DHS or Area Agency on Aging (AAA) office.
Call 1-800-SAFENET (723-3638) or go to www.snap.oregon.gov.

Food banks provide food boxes to people in need.

See the social services section of the phone book.

Loaves and Fishes delivers meals to the elderly and homebound in the Portland area

See the social services section of the phone book or go to www.loavesandfishesonline.org.

Meals on Wheels delivers meals to the elderly and homebound.

See the social services section of the phone book.

School meal programs help pay or pay for meals at lunch and before or after school.

Call your local school.

Women, Infants and Children (WIC) gives nutrition information and extra food to pregnant women and children younger than age 5.

Call the county health department or go to www.oregon.gov/DHS/ph/lhd/lhd.shtml.

Child care

Ask DHS about child care programs that help with child care costs.

Get information at www.oregon.gov/DHS/children/childcare/.

Child care resource and referral agencies help families find child care providers.

Call 1-800-342-6712 or go to www.oregonchildcare.org.

Employment services

Many agencies help people gain the skills needed to find a job, get a job or keep a job.

Contact DHS or the Employment Department. Go to www.oregon.gov/DHS/jobs/ or www.oregon.gov/EMPLOY.

WorkSource Oregon programs refer displaced workers to services in their local area.

Call 1-800-282-6514 or go to www.worksourceoregon.org.

Housing

Community action agencies help families pay housing costs in an emergency.

For information, find your local office in the phone book or go to www.oregon.gov/OHCS.

Women's Crisis Line gives referrals to local shelters or safe homes.

Call 1-888-235-5333.

Each county housing authority has housing for low-income families or the elderly. They may also help pay rent for low-income families.

See the phone book for your local county housing authority office.

Shelters or safe homes offer short-term housing for the homeless or people leaving abuse.

Call the local DHS office or go to www.oregon.gov/DHS/localoffices/locations.shtml.

Utilities

Your utility or heating company may help with heating costs.

Call your utility or heating company.

Community action agencies help people pay heating costs.

See the phone book.

Oregon Telephone Assistance Program helps with basic telephone costs.

Call your phone company or go to www.oregon.gov/PUC/rspf/otap.shtml.

Medical services

County health departments offer health care for low-income families.

See the white pages or get a list of health departments at www.oregon.gov/DHS/ph/lhd/lhd.shtml.

The Family Health Insurance Assistance Program helps pay for insurance through your employer, if you have been uninsured for the last six months.

Call 1-800-542-3104 or go to www.oregon.gov/OPHP/FHIAP.

The Office of Private Health Partnerships administers low-cost health insurance plans for uninsured small businesses.

Call 1-800-542-3104 or go to www.oregon.gov/OPHP.

Medicare covers people who are age 65 and older or have a disability.

Call 1-800-772-1213 or 1-800-633-4227, or go to www.medicare.gov.

Counties offer mental-health services.

Look in county government listings of your phone book.

Oregon Health Plan provides health benefits.

Call 1-800-359-9517 to apply or 1-800-699-9075 for information.
Go to www.oregon.gov/DHS/healthplan/.

Healthy Kids Program provides health benefits to Oregon children.

Call 1-800-359-9517 to apply or 1-877-314-5678 for information.
Go to www.oregon.gov/DHS/healthplan/app_benefits/main.shtml for information or to apply online.

Oregon Medical Insurance Pool offers high-risk insurance if you have been turned down due to a preexisting condition.

For information, call 1-800-542-3104 or go to www.oregon.gov/DCBS/OMIP.

Oregon SafeNet is a health and social service hotline offering information.

Call 1-800-SAFENET (723-3638) or go to www.oregonsafenet.org.

Senior Health Insurance Benefits Assistance program provides free information about health insurance for seniors.

Call 1-800-722-4134 or go to www.oregon.gov/DCBS/SHIBA.

Oregon Department of Veterans' Affairs helps disabled veterans get medical services.

Call 1-800-692-9666 or go to www.oregon.gov/ODVA.

Other services

DHS Division of Seniors and People with Disabilities helps older adults and people with disabilities get services.

Call 1-800-282-8096 or go to www.oregon.gov/DHS.

This hotline for alcohol and drug services helps alcoholics, addicts and their families.

Call 1-800-282-7035 or go to www.orpartnership.org.

The Alcohol and Drug Referral Center helps you find a treatment center.

Call 1-800-923-4357 or go to www.orpartnership.org/web/services/crisislines.asp.

The Division of Child Support (part of the Oregon Department of Justice) or the county district attorney can help you get child support.

See state or county listings in the phone book.
Call 503-986-6090 or go to www.dcs.state.or.us.

Gamblers Addiction Services are available.

Call 1-800-233-8479 or go to www.1877mylimit.org.

Legal Aid Service offers legal help. See the white pages.

For more information, go to www.oregonlawhelp.org/OR.

Oregon SafeNet is a social service hotline.

Call 1-800-SAFENET (723-3638) or go to www.oregonsafenet.org.

Social Security provides income to people who are retired or have disabilities.

Call 1-800-772-1213 or go to www.ssa.gov.

The Oregon State Police provides information about sex offenders.

Call 1-800-551-2934 for information.

VINE is a free service that provides information to victims about sex offenders.

Call 1-877-674-8463, or go to www.vinelink.com.

Unemployment benefits may help if you lose your job or your work hours have been cut. Call the local Employment Department office.

Go to www.oregon.gov/EMPLOY/UI for information.

Veterans' Affairs provides cash and medical help to disabled veterans.

Call 1-800-692-9666, 1-800-827-1000 (national hotline) or go to www.oregon.gov/ODVA/.

DHS provides training, benefits and help in finding work for people with disabilities.

See state listings in phone book or go to www.oregon.gov/DHS/employment.shtml.

Workers' compensation in Oregon

Call 1-800-452-0288 or go to http://egov.oregon.gov/DCBS/wcd_info.shtml.

This document can be provided upon request in alternative formats for individuals with disabilities. Other formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications and other electronic formats. E-mail dhs.forms@state.or.us, call 503-378-3486 (voice) or 503-378-3523 (TTY), or fax 503-373-7690 to arrange for the alternative format that will work best for you.

DHS 3400 Revision January 2010

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Congratulations!

You have successfully submitted an application for . The application was submitted on . You may print a receipt to keep for your records. You may print a copy of the summary pages to keep for your records.

For Food Benefits:

We will contact you within 7 days to set up a time for an interview.

Your household meets the criteria to get Food benefits faster than normal. We will contact you within 7 days to set up a time for an interview. You will need to provide proof of who you are at your interview.

If your application was submitted after working hours or on a day that DHS is closed, your filing date will be on the date DHS reopens.

If you have applied for Cash, Child Care or Medical benefits:

We will review your application and decide if you qualify for benefits. You may need to have an interview for these benefits. We will let you know if we need anything else.

Contact Method

You have told us that you prefer to talk to a worker

Hearing impaired phone method used:

Best contact method during the week:

Best time to call:

When DHS contacts you for an interview, the number may appear blocked or unrecognized. If you indicate the best way to reach you is by phone, it is important that you answer during the designated time you have indicated to complete the interview process.

PRINT SUMMARY

PRINT RECEIPT

RETURN TO YOUR ACCOUNT

PRINT SCREEN

BACK

Confirmation

Congratulations!

You have successfully submitted an application for . The application was submitted on . You may print a receipt to keep for your records. You may print a copy of the summary pages to keep for your records.

For Food Benefits:

We will contact you within 7 days to set up a time for an interview.

Your household meets the criteria to get Food benefits faster than normal. We will contact you within 7 days to set up a time for an interview. You will need to provide proof of who you are at your interview.

If your application was submitted after working hours or on a day that DHS is closed, your filing date will be on the date DHS reopens.

If you have applied for Cash, Child Care or Medical benefits:

We will review your application and decide if you qualify for benefits. You may need to have an interview for these benefits. We will let you know if we need anything else.

Contact Method

You have told us that you prefer to talk to a worker

Hearing impaired phone method used:

Best contact method during the week:

Best time to call:

When DHS contacts you for an interview, the number may appear blocked or unrecognized. If you indicate the best way to reach you is by phone, it is important that you answer during the designated time you have indicated to complete the interview process.

Basic Information

Personal information

Additional Case Information

Authorized Representative

Alternate Payee

SSN Information

Household Information

Income Information

Household Costs

Shelter Costs

Other Shelter Information

Utility Costs

Agreements

These pages have legal requirements for the programs you are applying for.

You will read about:

Your rights and responsibilities
Assignment requirements for medical
Reporting changes
Program penalties

At the end of this section we will ask you to tell us you understand what you have read. We will also ask you to tell us you have given true and correct information on the application. When you are finished, you can submit your application. Your typed name is your signature for this application. It is an electronic signature and is created when you submit your application. It is the same as writing your name on a paper application.

Your Rights (Things you can expect from DHS)

You can ask Department of Human Services (DHS) staff to explain the Rights and Responsibilities if you do not understand.

DHS will treat you with respect in a fair and polite way.
DHS will give you information about its payments and services. DHS may also refer you to other services you need.
You have the right to ask about and apply for any program.
You can ask for a receipt for any form you turn in to the DHS office.
You can ask for a meeting with a worker. You can also ask to talk with a person in charge.
You can ask for an interpreter to help you apply, fill out forms or report changes.
DHS will give you information in a format or language you can understand.
DHS will do its best to meet your special needs if you have a disability. DHS follows the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.
You can ask to see what is written about you in your case file.
You may not get Senior Farm Direct checks if you are in a Senior Farmers Market Nutrition Program in another State.
You can ask not to work with child support if you have "good cause". This means that working with child support would be a danger to you or your children. DHS will give you forms that explain good cause. These forms tell you how the Oregon Child Support Program may be able to help you get child support and still keep you and your children safe. DHS will also answer your questions about good cause.
DHS will tell you if you qualify for benefits:
- Within 30 days of the date you file an application for Food benefits. If you qualify for faster benefits, you will find out within 7 days.
- Within 45 days of the date that you apply for Cash, Child Care or Medical benefits.
- Within 90 days of the date you ask for a medical decision about your disability.
You can ask for a hearing if you disagree with a DHS decision. For Cash, Child Care or Medical benefits, you must use the Administrative Hearing Request form, (DHS 0443). Someone at your DHS office can help you fill it out. If you get Food benefits, you can ask for a hearing on the DHS 0443, by phone, in writing or in person.
- For Cash, Child Care or Medical benefits, you must ask for a hearing within 45 days of the date on the notice about the decision.
- For Food benefits, you must ask for a hearing within 90 days of the date on the notice.

Your Responsibilities (Things you must do)

You are agreeing to do certain things when you, your spouse or your partner get benefits from Department of Human Services (DHS). You may lose benefits if you do not do these things. You may also be asked to repay benefits if you get too many.

If you are in any DHS program, you must:

Give DHS true, correct and complete information.
Give proof of the things you report. If you cannot get proof, let DHS help you.
Take part in an employment program if you are required. This includes finding, accepting and keeping a job.
Help DHS if your case is chosen for a review. Cases are chosen at random.
Allow DHS staff to visit your home to get information about your case.
Let the Child Support Program share information with DHS.
Report changes to DHS within 10 days after they occur.

If you get Food Benefits, you must also:

Not quit a job or reduce your work time to less than 30 hours a week.

If you get Temporary Assistance to Needy Families (TANF), you must:

Help get child support unless:
- You are in the JOBS Plus, State Family Pre-SSI/SSDI (SFPSS) or Post-TANF Program.
- It would mean danger to you and your children. Be sure to tell DHS if it would be dangerous.
Take part in any training plan offered to you by DHS or its partner agencies, unless you have "good cause". You can talk to your worker about good cause.
Take any medical exam that is needed to see if you qualify for services.
Apply for and use any other benefits or money you qualify for. You must do this for yourself and any others you want help for.
Accept social Services that are ordered by the court or are related to training or employment.
Go to mental health and drug or alcohol programs, if DHS determines you need the help. You only have to do this if you can get into a program that is free to you.

Cash (TANF) time limits

Oregon has a five (5) year time limit. Please talk to your worker about how this could affect you.

If you get Medical benefits, you must also:

Tell medical providers if you have other health insurance. They should bill the other insurance before they bill DHS for your medical care.
Try to get health coverage and medical cash support from a parent who does not live with your child. This is to help pay for your child's medical expenses.
Apply for and use other benefits and money you qualify for. This also applies to others you are getting help for.
Take a medical exam if needed. We may need this to see if you can get benefits or services mailed to you each month.
Pay a fee each month to keep getting Medical or Service benefits, if you have to. A bill will be mailed to you each month.
Allow DHS to be the beneficiary for you or your spouse's annuity.

Do you understand these responsibilities?

Yes, I agree to these responsibilities

No, I don't understand. Please explain during my interview

Assigning Rights and Support - Cash for families

Cash for families is also known as Temporary Assistance for Needy Families or TANF.

What you need to know about "assigning support"

"Support" means money you get for you or your children, like alimony or child support. When you get cash benefits, you are assigning the state the right to keep the support you or anyone in your family get from another person. The money goes to repay the state for the cash you get.

By signing this form, you agree to "assign" to DHS all rights to these payments for anyone who is covered by your public assistance. That means yourself and other family members (including any child born in the future).

By signing this form, you agree to help DHS find and obtain these payments. There is a limit on how much DHS can take in payments. It cannot take more than the amount it has paid in assistance for you and your family.

NOTE: This does not apply during any period of time that you receive cash benefits from JOBS Plus, State Family Pre-SSI/SSDI Program (SFPSS) or the Post-TANF Program.

This means that while you are getting cash benefits:

The state will keep part of the support payments (for both current and past-due payments) received for you and members of your family. The state will not keep all your child support. The state will send you $50 of current child support received per child per month up to $200 per family per month. The state will not count this money as income when figuring your eligibility and benefits.

NOTE: If you are an applicant for cash assistance or you are in SFPSS or JOBS Plus, the state will generally not keep any of your child support. When determining your eligibility and benefits, $50 (per child per month up to $200 per family per month) of current child support received will not be counted towards your monthly income.

When you leave the cash program:

Current support payments will go to you.
Any past-due payments for months you were on cash assistance will be kept by the state.
Any past-due payments for months you were not on cash assistance may go to you.

Working with Child Support

While you are getting cash benefits, you will need to work with the state's Child Support Program.

Important: You do not have to work with child support if you think it would mean danger for you or your children.

Working with child support can mean:

Helping to locate your child's other parent (unless you think it would mean danger for your or your children).
Legally naming the child's father (establishing paternity).
Getting a support order.

If you are applying for medical benefits:

When you get DHS medical benefits, DHS will pay your medical bills for covered services. During this time, you must let DHS have any money you get from private health insurance or from an injury. DHS will not take more than the amount paid in assistance for you and your family.

Working with Office of Private Health Partnerships

DHS works with the Office of Private Health Partnerships (OPHP) to provide Healthy KidsConnect medical coverage for your children. While your children are getting Healthy KidsConnect benefits, you may need to fill out and submit forms to OPHP. OPHP will let you know if you need to do anything further.

Helping get other medical coverage

You will need to work with DHS to try and get medical coverage or money for medical care from other sources. This means:

For yourself: You must try to get things such as:

Health insurance from your employer (DHS may be able to help you pay for this).
Insurance payments because of an injury.
Medical coverage from the Veteran's Administration.

For your children: If the other parent isn't living with you, you may need to work with the state's Child Support Program to get health care coverage and medical cash support for the children.

Working with child support

While you are getting medical benefits you will need to work with the state's Child Support Program.

NOTE: This does not apply if your children are receiving Childrens Health Insurance Program benefits or Healthy KidsConnect benefits.

Important: You do not have to work with child support if you think it would mean danger for you or your children.

Working with child support can mean:

Helping to locate your child's other parent.
Legally naming the child's father (establishing paternity).
Getting an order for health care coverage.
Getting an order for cash to help with your child's medical expenses.

If you are pregnant and you only want state medical coverage for yourself, you do not have to work with child support.

What you need to know about "assigning support"

"Support" means money you get for you or your children, like alimony or child support. It includes cash ordered to help you pay for your child's medical expenses. When you get DHS medical for your child, you are "assigning" the state the right to keep the medical cash support anyone in your family gets from another person. The money goes to repay the state for the medical benefits your child gets.

This means that while you are getting DHS medical benefits:

The state will keep all medical cash support payments received for you to help pay for your child's medical expenses. This includes current and past-due payments.

When your child leaves the medical program:

Current support payments will go to you.
Any past-due payments for months your child was on medical assistance will be kept by the state.
Any past-due payments for months your child was not on medical assistance may go to you.

If you have other insurance:

If you or a member of your family have other medical insurance, tell the provider (doctor, clinic or hospital) before you get care. They must bill the other insurance company before they bill DHS.

If DHS pays a medical bill that should have been paid by insurance, DHS will take action to get its money back. For example:

If DHS pays a bill that private insurance should have paid, DHS will try to get the money back from the insurance company.
If DHS pays a medical bill and the provider also gets paid by an insurance company, DHS will try to get its money back from the provider.
If DHS pays a medical bill and an insurance company sends you a check for it, DHS will try to get its money back from you.

Reporting Changes

You must report certain changes that affect you, your spouse or partner, or anyone you get benefits for. You must report changes within 10 days of them occurring. Your benefits could stop or be late if you do not report changes on time. Anyone in your home who is age 18 or older could be asked to repay benefits if they get too many.

If you get Food benefits and are in Simplified Reporting, you only need to report a change in:

Your income, if it goes over the limit for the program.

If you get Food benefits and are not in Simplified Reporting, you must report a change in:

Who lives with you.
A change in your address.
Housing and utility costs after you move.
If you must legally pay child support.
Where you get your money. This includes getting, losing or quitting a job.
Your income from work, if the change is more than $100 per month.
Your other income, if the change is more than $50 a month.
If you get money, items worth money, or sell property. This includes buying or changing vehicles.

NOTE: You may want to report changes in your living costs even if you don't have to. Increases in housing, medical or child care costs or in how much child support you pay, may help you get more Food benefits.

If you get Cash, Child Care or Medical benefits for families (not the Oregon Health Plan or Healthy KidsConnect), you must report a change in:

Who lives with you.
A change in your address.
Marital status.
If you get or change medical coverage.
If you are involved in an injury accident.
When someone who gets benefits becomes pregnant and when a pregnancy ends.
The birth of a child.
Where you get your money. This includes getting, losing or quitting a job.
Your income from work, if the change is more than $100 per month.
Your other income, if the change is more than $50 a month.
If you get money, items worth money, or sell or give away property. This includes buying or changing vehicles.

When you start getting cash benefits, the amount of your food benefits will go down.

If you get Oregon Health Plan or Healthy KidsConnect you must report a change in:

Name for anyone getting benefits.
If you get or change medical coverage.
When someone who gets benefits becomes pregnant and when a pregnancy ends.
The birth of a child.
When someone receiving Healthy KidsConnect moves out of the house.
A change in your address.

If you get child care benefits, you must report changes in:

Who lives with you.
Where you get your income. This includes getting, losing or quitting a job.
Your rate of pay.
Who provides your child care.

Do you agree to report changes?

Yes, I agree to report changes.

No, I don't understand. Please explain during my interview

Penalties in the food Benefits Program (Supplemental Nutrition Assistance Program)

You, your spouse or partner could be disqualified from receiving food benefits if you do any of the following things.

If you do the following...

You will lose food benefits...

Hide information or make false statements
Use EBT cards that belong to someone else
Use food benefits to buy alcohol or tobacco
Trade or sell benefits or EBT cards
Dump containers only for the cash redemption value
Resell food bought with food benefits for cash

12 months for the first offense
24 months for the second time
Permanently for the third time

Trade food benefits for controlled substances such as drugs

24 months for the first offense
Permanently for the third time

Trade food benefits for firearms, ammunition or explosives

Permanently

Trade, buy or sell food benefits of $500 or more

Permanently

Give false information about who you are or where you live so you can get extra food benefits

10 years for each offense

You can also be fined up to $250,000 or put in prison for up to 20 years, or both, for doing these things. You may also be charged under other federal laws.

If you do the following...

You may be...

Use EBT cards which are not yours
Transfer your EBT cards to other people
Acquire or possess EBT cards which are not yours
Dump containers for the cash redemption value
Resell food bought with food benefits for cash

Guilty of a felony or misdemeanor
Fined
Put in prison
Ineligible for food benefits for a period of time

Penalties in the Cash (Temporary Assistance for Needy Families) Program

If you knowingly do the following...

You will lose Cash benefits...

Give false information about yourself or someone you are applying for
Hide information about yourself or someone you are applying for
Give false information about where you live

12 months for the first offense
24 months for the second time
Permanently for the third time

You will also have to pay back all the TANF you were not supposed to get. Your food benefits will not go up even though you get less in TANF if you told us something that was not true or did not tell us something that was true.

Do you understand these penalties?

Yes, I understand these penalties

No, I don't understand. Please explain during my interview

Civil Rights

Discrimination:

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) You can file a complaint if you think DHS discriminated against you because of any of these reasons.

If you wish to file a Civil Rights program complaint of discrimination, please read the Client Discrimination Complaint Information form (DHS 9001), found online at: (right click to open in a new window).

In addition, you may file a complaint at any USDA office, or call (866) 632-9992 to request the USDA Program Discrimination Complaint Form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov

Social Security Information

Why we need your Social Security Number (SSN):

When you apply for benefits, the Department of Human Services (DHS) will need the Social Security Number (SSN) for you and the other people who want benefits.

If you are applying for someone else, and not for yourself, we do not need your SSN or citizenship status. We will not contact immigration services for anyone not seeking benefits. If you do not have a SSN yourself, other family members who do have SSNs may still qualify.

DHS will use your SSN to help decide if you are eligible for benefits. Your SSN will be used to verify your income, other assets, and to match with other state and federal records such as IRS, Medicaid, child support, Social Security and Unemployment benefits.
DHS may use your SSN to prepare aggregate information or reports requested by funding sources for the program you apply for or receive benefits.
DHS may use or disclose your SSN:

If it is needed to operate the program you apply for or receive benefits from.
To conduct quality assessment and improvement activities.
To verify the correct amount of payments and recover overpaid benefits.
To make sure you get the correct benefits.

Federal laws (42 USC 1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920 and 42 CFR 457.340(b)) and DHS rule (OAR 461-120-0210) requires anyone applying for cash, food or medical benefits to give DHS their SSN.

Information and referrals for low-income households

Where to find help

It is not always easy to find out where to call when you need help. This list of services may be helpful to your family. It includes phone numbers and Web addresses for many of the services. You can find other local numbers in the government services section of your phone book. You can access the Internet at most public libraries. If you need help finding one of these services, ask your worker.

Prevention services

Boys and Girls Aid offers pregnancy information, counseling and referral.

Call 1-800-342-6688 or go to www.boysandgirlsaid.org.

The Family Planning Unit in the county health department helps with pregnancy prevention services.

Look in county government listings of your phone book or go to www.oregon.gov/DHS/ph/lhd/lhd.shtml.

Protection

The Oregon Department of Human Services (DHS) helps seniors and people with developmental and physical disabilities who are being abused or need protection.

Call 1-800-232-3020 or go to www.oregon.gov/DHS/spwpd/abuse/home.shtml.

DHS has a hotline for reporting child abuse or neglect.

Contact a law enforcement agency or go to the local DHS child welfare office. See a list of locations at www.oregon.gov/DHS/localoffices/locations.shtml.

Food services

The Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) puts healthy food within reach for low-income Oregonians.

Ask at a DHS or Area Agency on Aging (AAA) office.
Call 1-800-SAFENET (723-3638) or go to www.snap.oregon.gov.

Food banks provide food boxes to people in need.

See the social services section of the phone book.

Loaves and Fishes delivers meals to the elderly and homebound in the Portland area

See the social services section of the phone book or go to www.loavesandfishesonline.org.

Meals on Wheels delivers meals to the elderly and homebound.

See the social services section of the phone book.

School meal programs help pay or pay for meals at lunch and before or after school.

Call your local school.

Women, Infants and Children (WIC) gives nutrition information and extra food to pregnant women and children younger than age 5.

Call the county health department or go to www.oregon.gov/DHS/ph/lhd/lhd.shtml.

Child care

Ask DHS about child care programs that help with child care costs.

Get information at www.oregon.gov/DHS/children/childcare/.

Child care resource and referral agencies help families find child care providers.

Call 1-800-342-6712 or go to www.oregonchildcare.org.

Employment services

Many agencies help people gain the skills needed to find a job, get a job or keep a job.

Contact DHS or the Employment Department. Go to www.oregon.gov/DHS/jobs/ or www.oregon.gov/EMPLOY.

WorkSource Oregon programs refer displaced workers to services in their local area.

Call 1-800-282-6514 or go to www.worksourceoregon.org.

Housing

Community action agencies help families pay housing costs in an emergency.

For information, find your local office in the phone book or go to www.oregon.gov/OHCS.

Women's Crisis Line gives referrals to local shelters or safe homes.

Call 1-888-235-5333.

Each county housing authority has housing for low-income families or the elderly. They may also help pay rent for low-income families.

See the phone book for your local county housing authority office.

Shelters or safe homes offer short-term housing for the homeless or people leaving abuse.

Call the local DHS office or go to www.oregon.gov/DHS/localoffices/locations.shtml.

Utilities

Your utility or heating company may help with heating costs.

Call your utility or heating company.

Community action agencies help people pay heating costs.

See the phone book.

Oregon Telephone Assistance Program helps with basic telephone costs.

Call your phone company or go to www.oregon.gov/PUC/rspf/otap.shtml.

Medical services

County health departments offer health care for low-income families.

See the white pages or get a list of health departments at www.oregon.gov/DHS/ph/lhd/lhd.shtml.

The Family Health Insurance Assistance Program helps pay for insurance through your employer, if you have been uninsured for the last six months.

Call 1-800-542-3104 or go to www.oregon.gov/OPHP/FHIAP.

The Office of Private Health Partnerships administers low-cost health insurance plans for uninsured small businesses.

Call 1-800-542-3104 or go to www.oregon.gov/OPHP.

Medicare covers people who are age 65 and older or have a disability.

Call 1-800-772-1213 or 1-800-633-4227, or go to www.medicare.gov.

Counties offer mental-health services.

Look in county government listings of your phone book.

Oregon Health Plan provides health benefits.

Call 1-800-359-9517 to apply or 1-800-699-9075 for information.
Go to www.oregon.gov/DHS/healthplan/.

Healthy Kids Program provides health benefits to Oregon children.

Call 1-800-359-9517 to apply or 1-877-314-5678 for information.
Go to www.oregon.gov/DHS/healthplan/app_benefits/main.shtml for information or to apply online.

Oregon Medical Insurance Pool offers high-risk insurance if you have been turned down due to a preexisting condition.

For information, call 1-800-542-3104 or go to www.oregon.gov/DCBS/OMIP.

Oregon SafeNet is a health and social service hotline offering information.

Call 1-800-SAFENET (723-3638) or go to www.oregonsafenet.org.

Senior Health Insurance Benefits Assistance program provides free information about health insurance for seniors.

Call 1-800-722-4134 or go to www.oregon.gov/DCBS/SHIBA.

Oregon Department of Veterans' Affairs helps disabled veterans get medical services.

Call 1-800-692-9666 or go to www.oregon.gov/ODVA.

Other services

DHS Division of Seniors and People with Disabilities helps older adults and people with disabilities get services.

Call 1-800-282-8096 or go to www.oregon.gov/DHS.

This hotline for alcohol and drug services helps alcoholics, addicts and their families.

Call 1-800-282-7035 or go to www.orpartnership.org.

The Alcohol and Drug Referral Center helps you find a treatment center.

Call 1-800-923-4357 or go to www.orpartnership.org/web/services/crisislines.asp.

The Division of Child Support (part of the Oregon Department of Justice) or the county district attorney can help you get child support.

See state or county listings in the phone book.
Call 503-986-6090 or go to www.dcs.state.or.us.

Gamblers Addiction Services are available.

Call 1-800-233-8479 or go to www.1877mylimit.org.

Legal Aid Service offers legal help. See the white pages.

For more information, go to www.oregonlawhelp.org/OR.

Oregon SafeNet is a social service hotline.

Call 1-800-SAFENET (723-3638) or go to www.oregonsafenet.org.

Social Security provides income to people who are retired or have disabilities.

Call 1-800-772-1213 or go to www.ssa.gov.

The Oregon State Police provides information about sex offenders.

Call 1-800-551-2934 for information.

VINE is a free service that provides information to victims about sex offenders.

Call 1-877-674-8463, or go to www.vinelink.com.

Unemployment benefits may help if you lose your job or your work hours have been cut. Call the local Employment Department office.

Go to www.oregon.gov/EMPLOY/UI for information.

Veterans' Affairs provides cash and medical help to disabled veterans.

Call 1-800-692-9666, 1-800-827-1000 (national hotline) or go to www.oregon.gov/ODVA/.

DHS provides training, benefits and help in finding work for people with disabilities.

See state listings in phone book or go to www.oregon.gov/DHS/employment.shtml.

Workers' compensation in Oregon

Call 1-800-452-0288 or go to http://egov.oregon.gov/DCBS/wcd_info.shtml.

This document can be provided upon request in alternative formats for individuals with disabilities. Other formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications and other electronic formats. E-mail dhs.forms@state.or.us, call 503-378-3486 (voice) or 503-378-3523 (TTY), or fax 503-373-7690 to arrange for the alternative format that will work best for you.

DHS 3400 Revision January 2010

Declaration and Signature

I agree to the following:

DHS will request and use the Income and Eligibility Verification System (IEVS) data and this information may affect eligibility and benefit levels. This includes verification through third party contacts when discrepancies in information are found. Third party contacts may include matching with bank, income and unemployment-benefit records.

The Department of Justice Division of Child Support may release the child support records for children in my application to DHS.

DHS may give the information on this application to:

Federal and state agencies who are doing reviews.
Law-enforcement officials. This is if it will help them arrest someone who is fleeing from the law.
Federal and state agencies and private collection agencies. This is if I have to repay benefits to DHS.

I agree to report changes as required.

I will not get Food benefits from the Tribal Food Distribution Program on Indian Reservations and the Supplemental Nutrition Assistance Program(Food benefits) at the same time. I also cannot get Tribal TANF from a tribe and TANF cash benefits from DHS at the same time.

I will give proof of the things I have told DHS. I will also let DHS contact other people and agencies to get proof. DHS can do this when the proof is needed to determine if my family is eligible for benefits.

Adults under age 60 must register for the state's employment program when they apply for Food benefits. They will be registered when I sign the form. The people I add to my Food benefits in the future will also be registered.

I have given DHS complete information. I affirm under penalty of perjury that statements made are true and correct. This is true for things I reported about persons in my home or about the people I am applying for. This includes how I reported citizenship, income, resources, property and anything else I have given DHS and their contractors.

You must sign this application before submitting it. You can do this by typing your name below. Your typed name below means you agree the information you gave is correct. Your typed name will serve as your signature for this application.

You have signed the application electronically.

Signature:

Voter Registration:

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Your Rights (Things you can expect from DHS)

Your Responsibilities (Things you must do)

If you are in any DHS program, you must:

If you get Food Benefits, you must also:

If you get Temporary Assistance to Needy Families (TANF), you must:

Cash (TANF) time limits

If you get Medical benefits, you must also:

Assigning Rights and Support - Cash for families

Cash for families is also known as Temporary Assistance for Needy Families or TANF.

What you need to know about "assigning support"

This means that while you are getting cash benefits:

When you leave the cash program:

Working with Child Support

Working with child support can mean:

If you are applying for medical benefits:

Working with Office of Private Health Partnerships

Helping get other medical coverage

Working with child support

Working with child support can mean:

What you need to know about "assigning support"

This means that while you are getting DHS medical benefits:

When your child leaves the medical program:

If you have other insurance:

When you start getting cash benefits, the amount of your food benefits will go down.

Penalties in the food Benefits Program (Supplemental Nutrition Assistance Program)

If you do the following...

You will lose food benefits...

If you do the following...

You may be...