Priority	Type (1)	Description	Examples
1	`\|` or `OR`	Logical "or" (Vertical bar). Filter the column for content that matches text from either side of the bar (2).	`box\|bat` (matches a column cell with either "box" or "bat"); (Find text that contains either "Alex" or "Peter");
2	`&&` or `AND`	Logical "and". Filter the column for content that matches text from either side of the operator.	`box && bat` (matches a column cell that contains both "box" and "bat"), (Find text that contains both "br" and "c"), or (When "filter-match" is set, find content with the letter "a", but not the letter "o")
3	`/\d/`	Add any regex to the query to use in the query ("mig" flags can be included `/\w/mig`)	`/b[aeiou]g/i` (finds "bag", "beg", "BIG", "Bug", etc); (matches text that ends with an "r")
4	`< <= >= >`	Find alphabetical or numerical values less than or greater than or equal to the filtered query (1).	(find values greater than or equal to 10)
5	`!` or `!=`	Not operator, or not exactly match. Filter the column with content that do not match the query. Include an equal (`=`), single (`'`) or double quote (`"`) to exactly not match a filter (v2.17.1).	`!fe` (hide rows with "female" in that column, but shows rows with "male"); (find text that doesn't contain an "a"); (find content that does not exactly match "Bruce")
6	`"` or `=`	To exactly match the search query, add a quote, apostrophe or equal sign to the beginning and/or end of the query	`abc"` or `abc=` (exactly match "abc"); or (exactly match "John")
7	`-` or `to`	Find a range of values. Make sure there is a space before and after the dash (or the word "to") (3).	or (match values between 10 and 30)
8	`?`	Wildcard for a single, non-space character.	`J?n` (finds "Jan" and "Jun", but not "Joan"); (finds "Dumass" and "Evans", but not "McMasters")
8	`*`	Wildcard for zero or more non-space characters.	`B*k` (matches "Black" and "Book"); (matches "Dumass", "Evans" and "McMasters")
9	`~`	Perform a fuzzy search (matches sequential characters) by adding a tilde to the beginning of the query (v2.13.3)	(matches "Bruce Lee" and "Brenda Dexter"), or (matches "Philip Aaron Wong")
10	text	Any text entered in the filter will match text found within the column	`abc` (finds "abc", "abcd", "abcde", etc); (finds "Aaron" and "Philip Aaron Wong")

ORIGINAL APPLICATION

Application Basic Information

SSN:

Expedited Service:

Expedited Services Reason:

Alternate Format:

Filing Date:

Date Submitted:

Language Preferences:

Written:

Spoken:

Voter Registration:

Contact Preference:

Application Completed By:

Applicant Contact Information

Phone Numbers

Home:

Work:

Ext:

Message:

Ext:

Cell:

Preferred Phone:

Preferred Time:

Hearing Assistance:

Email Address:

Mailing Address

Address:

Apt/Unit/Space #:

City:

State:

Zip:

Residence Address

Address:

Apt/Unit/Space #:

City:

State:

Zip:

Homeless:

Authorized Representative

The person* named below is authorized to represent me in my application and reviews.

*This person can give information and proofs that may be needed to complete my application for benefits. I will give this person information that is true and correct to the best of my knowledge.

First Name:

Last Name:

Address:

Apt/Unit/Space #:

City:

State:

Zip:

Phone:

Ext:

Alternate Payee

The person named below is authorized to receive an oregon trail card on my behalf. This person will need to show identification at the local office to get the card.

First Name:

Last Name:

Address:

Apt/Unit/Space #:

City:

State:

Zip:

Phone:

Ext:

Information for Expedited Food Stamp Determination

$150/mo or more income:

$100 or more cash/checking/savings:

Rent/Utilities more than income/cash/checking/savings:

Migrant/seasonal farm worker:

$25 or more new source income in next 10 days:

All income stopped in the last 30 days:

Household Summary Information

Relationships

Child Caretaker Information

Child:

Caretaker:

Household Information

First Name:

MI:

Last Name:

Suffix:

Date of Birth:

Estimated Age:

Gender:

In Filing Group:

Lives in this household:

Possess SSN:

SSN:

Applied for SSN:

SNAP Benefit:

Medical Benefit:

No Benefit:

US Citizen:

Place of Birth:

Other:

Not Citizen, How Admitted:

LPR Date:

Oregon Resident:

Disability:

Outstanding Arrest Warrant:

Racial Heritage:

Ethnicity:

Current member/veteran of military service:

Requesting ODVA contact:

Student:

School Name:

Schedule:

Type of School:

Work Study:

WIA:

Displaced Worker:

Employer Requested:

Benefit from Other States:

What State:

Programs:

Food:

Cash:

Medical:

Child Care:

Other:

Tribal Benefits:

ABAWD with SNAP (since Jan. 1st 2016):

ABAWD State:

Individual Deductions

Income Information

Current Job

Employer Name:

Phone:

Ext:

Start Date:

How Paid:

Salaried Rate of Pay:

Hourly Rate of Pay:

Hours Per Week:

Other:

How Often Paid:

Other:

Income last month:

Income this month:

Does one get paid with goods and services instead of money?

Income other than money:

Same amount next month:

Reason:

Weekly additional pay types:

Rental Expense

Full Monthly Rent:

Monthly Rent Applicant Pays:

Full Monthly Space Rent:

Monthly Space Rent Applicant Pays:

HUD or Section 8 Assistance:

Amount Applicant Pays:

Total Monthly Rental Housing Expenses Applicant Pays:

Home Ownership Expenses

Full Monthly Mortgage:

Monthly Mortgage Amount Applicant Pays:

Full Monthly 2nd Mortgage:

2nd Mortgage Amount Applicant Pays:

CondoHousing Assoc Fees:

How Often Paid:

Property Taxes:

How Often Paid:

Property Taxes Included in Mortgage:

Fire Hazard Ins:

How Often Paid:

Fire Hazard Ins Included in Mortgage:

Total Monthly Home Ownership Expenses Applicant Pays:

Housing Expenses Changes

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

What is the new amount?

How are you paying your expenses with no income?

Housing Assistance

Utility Expenses

Low Income Home Energy Assistance (LIHEAP) at this address during the last 12 months:

Utilities in addition to housing expenses:

Home is heated by:

Specify other:

How is heating expense paid:

Other Utilities Paid:

Utility Assistance

Things to Know

Legally, you may submit your applications 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 asked follow-up question 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 item with you, please continue with the application. The local office can get the things they need later.

Please click for examples of proof and costs

Please click for more about food benefits

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

SSN 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 you 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 SSN 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.

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 current 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.

Yes

No, please explain during my interview

Response:

Agreement Information

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 this 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.

Rights and Responsibilities

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 about your case.
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 also:

Help get child support unless:

You are in the JOBS Plus, State Family Pre-SSI/SSDI (SFPSS) or Port-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 yourself and 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 then 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 effect you.

If you get Medical benefits, you must also:

Tell medical providers if you have 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 your qualify for. This also applies to others you are getting help for.
Take a medical exam if needed. We may need to see if you can get benefits or services.
Pay a fee each month to keep getting Medical or Service benefits, if you have to. A bill mailed to you each month.
Allow DHS to be the beneficiary for me or my spouse's annuity.

Yes, I understand to these responsibilities

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

Response:

Assigning Rights and Support

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.

Assigning Rights and Support

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 states 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 states 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 childs 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.

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

Yes, I agree to report changes

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

Response:

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 second 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 and 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.

Yes, I understand these penalties

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

Response:

Information and Referrals (DHS3400)

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 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

DeclarationAndSignature

I agree to the following:

The Department of Human Services (DHS) may use computers to check all I said on this form. This includes matching with bank, income and unemployment-benefit records.

Response:

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

Response:

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.

Response:

I agree to report changes as required.

Response:

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.

Response:

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.

Response:

Adults under age 60 must register for the states'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.

Response:

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.

Response:

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.

Who needs to sign?

One person needs to sign for Food benefits. This person may be any of the following

Any person who is age 18 or older.
The primary person asking for benefits, if no adults are in the home.
The authorized representative if the person wanting benefits is not available.

More than one person may need to sign for Cash, Child Care or Medical benefits. Some people who may need to sign are:

All persons age 19 and older who want Medical benefits.
An 18 year old who is turning 19 in the next 30 days.
If you are completing this application for someone else, you can sign the application. We can ask for the other signatures later.

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:

Signature

Please type in your first name:

Middle initial:

Last name:

Caseworker Login

Work Queue

Output options

Output options

Branch Queue

Output options

My Account

Administration - Add New User

Administration User Search

CAPI Individual User Account

Branch Management

Zip Code - Branch Associations

Application Information

Appointment Details

Missed Appointment Details

Contact Preferences

Applicant Contact Information

Individual Information

Income and Expense Information

Housing and Utility Costs

Authorized Representative

Alternate Payee

Information for Expedited SNAP Determination

Narrative

Eligibility Determination

Approved

Denied

Pending

Withdrawn

Approved

Denied

Pending

Withdrawn

Application Events

ORIGINAL APPLICATION

Application Basic Information

Applicant Contact Information

Authorized Representative

Alternate Payee

Information for Expedited Food Stamp Determination

Household Summary Information

Relationships

Child Caretaker Information

Household Information

Individual Deductions

Income Information

Rental Expense

Home Ownership Expenses

Housing Expenses Changes

Housing Assistance

Utility Expenses

Utility Assistance

Things to Know

SSN Information

Agreement Information

Rights and Responsibilities

Your Responsibilities (Things you must do)

Assigning Rights and Support

Assigning Rights and Support

Reporting Changes

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

Information and Referrals (DHS3400)

DeclarationAndSignature

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