`DPHHS-HCS-252 (Rev.09/2010) STATE OF MONTANA Department of Public Health and Human Services SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM ublic Assistance (OPA) staff member.COMPLETION INSTRUCTIONSThe Montana Department of Public Health and Human Services (DPHHS) offers several programs to help you.
This application is to be used if yo
If you wish to apply for programs other than SNAP, please request a multiple program application.If you dont have time to complete the full application application: Fill in your name and address on page one; Sign your name on page one (or an authorized representative may sign for you); and may take the rest of thw, or you may mail or fax it to 2.
If you have completed the application process and are determined eligible for SNAP benefits, your benefits will
You may be entitled to receive SNAP rvice).
See the back of page one
Complete the entire application to the best of your ability.
If more space is needed to answer a question(s), use the space provided on page eight, or attach an additional
sheet with appropriate information about each additional person.
A household member, or an authorized representative members should fill out the a Social Security number oris voluntary.
However, if this information is not provided for a household member, he/she will not be eligib Social Security number and
DPHHS-HCS-252 (Rev.09/2010) STATE OF MONTANA Department of Public Health and Human Services SUPPLEMENTAL NUTRITION ASSISTANCE AGENCY USE Date Application Received
Date of Interview
Regular SNAP Middle
Initial Street Address Zip Mailing Address Zip Phone Number
Message Phone Number ress, describe how to get to your home:
Fill in all required blanks for everyone who lives with you either permanently or temporarily.
You must list under age 22 must list parents.
Also, you must include all persons who live with you and purchase and prepare food with you.
Name (List yourself first) Relationship To You Social Security Date of Birth
Sex (Optional) U.S.Citizen Yes EXPEDITED SERVICE QUESTIONS AGENCY USE Yes If the dollar amount is none, enter zero.Income less than $150, and cash and savings of no more than $100?
What is the total income (before deductions) your household has received or expects to monthCombined income and resources less than rent/mortgage and appropriate utility allowance? How much do the members of your household have in cash and savings? (give your best estimate)
Migrant/seasonal farm worker with liquid
How much is your monthly rent/mortgage?
If yes to any of the above questions
EXPEDITEScreened for expedited services? Yes How much are your monthly utilities?
Eligible for expedited services?Is anyone in your household a migrant or seasonal farm worker?
Yes OPA Employee:
I HEREBY SWEAR AND/OR AFFIRM THAT THE STATEMENTS MADE ON THIS APPLICATION ARE TRUE AND CORRECT.
(or Legal Guardian/Authorized Representative)
X Date Witness to Mark (If applicant cannot sign full name) X Date Page 1 INTERVIE 1. After your application is filed, you will be notified of the date and time of your interview.
Complete as much of the application as you can. A worker will help you with any unanswered questions at the interview.
If you do not have all the necessary information, this could delay a decision on your application.
An interview is required as part of the application process. 2. If you are not able to appear for an interview, or you are unable to find someone to represent you, call your local Office of Public Assistance to schedule a home visit or a phone interview. 3. If you cannot keep your appointment, you must schedule another appointment within 30 days of the application date.
If you do not schedule another appointment, your application will be denied.TO GET SNAP BENEFITS WITHIN SEVEN DAYS (EXPEDITED SERVICE)You may be entitled to expedited services if your income and resources are not enough to cover your monthly rent/mortgage and utilities, you have very little income or resources, or your household includes a migrant or seasonal farm worker.Complete the application and provide proof of identity of the person listed as number one on page one.
If you do not have time to complete this application now, complete the front page and turn it in today.This will ensure your benefits will start from today if you complete the application process and are determined eligible for SNAP benefits.If you are eligible for expedited service, you can receive SNAP benefits for this month even if you cannot give us all of the verification we need.
If you feel you are eligible for expedited services but your worker says you are not, you may ask for an administrative review, or you may request a Fair Hearing either orally or in writing.If you are not eligible for expedited service, your application will be processed within 30 days following the date the signed application was received.You have the right to file an application on the same day you contact us.
You may either leave the entire application or the completed front page at the office, or you may mail or fax it.
You do not have to be interviewed or have a scheduled appointment before submitting the aYour application will be processed within 30 days.Applicants soon to be released from an institution may make application for SNAP benefits prior to their release.
The application filing date for pre-release applicants is the date of release from the institution. 5. It is illegal to: Use SNAP benefits to get ineligible items such as alcoholic drinks and tobacco, pay on credit accounts; or Use someone elses S
USDA is an equal opportunity provider and employer.Revised March 2011
FROM FOOD STAMPS TO SNAP: STATE NAME CHANGE TRACKING CHART Name
Effective Name of State EBT Card MA SNAP 11/01/08 Bay State Access
VT 3SquaresVT 1/2/09 Vermont CA CalFresh
Hawaii EBT USDA is an equal opportunity provider and employer
.Revised March 2011 Name
Effective Name of State EBT Card
NV SNAP 10/1/2008 Nevada Quest
OR SNAP 1/1/2010 Oregon Trail
WA Basic Food Program Already in place QUEST Card
GU SNAP 1/1/2009 Guam Quest SERO AL Food Assistance Already in place Alabama EBT
FL Food Assistance Program
Already in Place
GA SNAP 07/01/2010 Georgia Peach KY
SNAP 2010 Benefit Security
MS SNAP 10/01/08 MDHS EBT
NC Food & Nutrition Services Already in place (US flag image only)
SC SNAP 10/01/08 Think Healthy, Eat Healthy!
TN SNAP 2010 Benefit Security MARO DE Food Supplement Program 10/01/08 starts) Food First EBT
DC SNAP 3/1/09 starts) Capital Card
MD Food Supplement Program 10/1/08 Independence
NJ NJ SNAP 3/10/11 Families First
PA SNAP 3/1/09 starts)
VA SNAP 10/1/09 Virginia EBT USDA is an equal opportunity provider and employer.Revised March 2011 Name
Effective Name of State EBT Card
08/30/09 Nebraska EBT
ND SNAP 10/01/08 North Dakota
SD SNAP 07/01/09 South Dakota UT FSP
WY SNAP 04/01/09 Wyoming EBT TOTALS
Changed to SNAP 29
Changing to Alternate Name 8
Still Using FSP 7
Keeping Current Alternate Name 9
Demonstration projects and in those jurisdictions that have elected to exercise the program options allowed.
Funding is overwhelmingly Federal, although the States and other jurisdictions have financial responsibility for significant administrative costs, as well as liability for erroneous benefit determinations (as assessed under the food stamp quality control system, discussed below).
At the Federal level, the program is administered by the Agriculture Department's Food and Nutrition Service (FNS).The FNS gives direction to welfare agencies through Federal regulations that define eligibility requirements, benefit levels, and administrative rules.It also is responsible for overseeing State programs for the electronic issuance of food stamp benefits, and for approving and overseeing participation by retail food stores and other outlets that may accept food stamps.Other Federal agencies that have administrative roles to play include: the Federal Reserve System (through which food stamp benefits are redeemed for cash, and which has some jurisdiction over electronic benefit transfer (EBT) methods for issuing food stamp benefits), the Social Security Administration (responsible for the Social Security numbers recipients must have, for providing limited application intake services, and for providing information to verify recipients income), the Internal Revenue Service (providing assistance in verifying recipients income and mmigration Services of the Department of Homeland Security (helping welfare offices confirm alien applicants status), and the Agriculture Department's Inspector General (responsible for trafficking
States, the District of Columbia, Guam, and the Virgin Islands, through their local welfare offices, have primary responsibility for the day-to-day administration of the Food Stamp Program.They determine eligibility, calculate benefits, and issue food stamp allotments (using coupons or, in most cases, electronic benefit transfer cards) following Federal rules.They also have a significant voice in carrying
out employment and training programs and in determining some administrative features of the program (e.g., the extent to which verification of household circumstances is pursued, the length of eligibility certification periods,
the structure of EBT systems).Most often, the Food Stamp Program is operated through the same welfare agency and staff that runs the State's TANF Program.
In addition to the regular Food Stamp Program, the Food Stamp Act directs funding for a Nutrition Assistance Program in the Commonwealth of Puerto Rico and another in American Samoa.Separate legislation authorizes a variant of the Food Stamp Program in the Commonwealth of the Northern Mariana Islands.have a significant cost to the Food Stamp Program, and (3) implementation of provisions for State flexibility included in the 1996 Welfare Reform Law (Public Law 104-193) and the 2002 Farm Security and Rural Investment Act (Public Law 107-171), no major demonstration projects are operational.
Instead, a few small demonstrations are operating in some States (these deal with joint application processing and standardized food stamp benefits for SSI recipients, cash benefits for the elderly and SSI recipients, and privatizing program administration), and extensive waivers of administrative rules are routinely granted.
States also are allowed a number of significant options in how they implement the Food Stamp Program.
States may establish their own administrative standards in areas such as application processing, ongoing recertification of recipient households, reporting of changes in household circumstances (and adjusting benefits to take these changes into account), counting child support payments, and standardizing the treatment of utility expenses in benefit calculations.
In addition, States can use most of the rules they have established for TANF and Medicaid programs when deciding what income and resources (assets) to exclude in food stamp eligibility and benefit determinations, and may grant 5-month transitional food stamp benefits to those leaving the TANF program (without requiring them to reapply for food stamps).
The states may issue benefits (at their own cost) to ineligible noncitizens and those ineligible under the work rule for able-bodied adults without dependents (ABAWDs; discussed below).
With 50 percent Federal cost-sharing, they can operate outreach programs to inform low-income persons about food stamps and support nutrition education efforts.
They may choose to operate a simplified program under which they can use many of their TANF rules and procedures when determining food stamp benefits for TANF recipients.
States may sanction food stamp recipients failing to meet other public assistance program rules or failing to cooperate in child support enforcement efforts.
They may, to a certain extent, waive the application of the work rule for ABAWDs; and they may choose to disqualify an entire household if the head of the household fails to fulfill work-related requirements.
In some instances, they may include the cash value of food stamp benefits when using welfare to subsidize recipients wages.
States and localities may opt to run workfare programs for food stamp recipients.
Finally, States determine the content of employment and training programs for food stamp recipients (and, in many cases, who must
The Food Stamp Act provides 100 percent Federal funding of food stamp benefits, except when States choose to buy into the program and pay for issuing food stamp benefits to ineligible noncitizens or those made ineligible by the work rule for ABAWDs.The Federal Government also is responsible for its own administrative costs: overseeing program operations (including oversight of participating food establishments), redeeming food stamp benefits through the ecurit