Submit Date & Time:

Head of Household: Brandon Herrera

04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

Printable MyCOBenefits Application

Your tracking number is 143468105.

What benefits do you want to apply for?

SNAP

Basic Information

What is your name?

Suffix (for example: Jr.,

First Name Middle Name Last Name
Sr., III)
Brandon Austin Herrera No Response

SSN Date of Birth Gender

XXX-XX-4441 07/08/2002 Male
Does Brandon Herrera pay money to a Does Brandon Herrera pay money to a
household in exchange for a room/lodging? This household in exchange for a room/lodging and
is also known as being a roomer. meals? This is also known as being a boarder.

Are you a participant in the Address Confidentiality Program (ACP)?

No
Are you homeless?
Yes
Do you have an address to receive mail?
Yes
What Colorado county do you live in?
Denver

What is your mailing address?

Address / [Link] 1 Address / [Link] 2 City State

7401 E 26TH AVE UNIT 119 DENVER CO
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

Zip County This address is a PO Box

80238-2628 Denver No

How can we reach you?

I would like to use the

email address listed
Home Phone Cell Number Email Address
above to receive email
notifications.
720-473-3027 720-473-3027 bh700686@[Link] Yes

What is your preferred language?

Spoken Language Written Language

English English

Household Members

Are there household members who will be part of the benefit programs ?
No Response

Previous Benefits

Did anyone in your household get any SNAP or cash benefits in another state in the last 30 days?
No
If you are applying for Colorado Works, have you received benefits from any other state since
1996?
No Response

Citizenship

Is anyone in the household not a US citizen?

No
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

Pregnancy Details

Is anyone in the home pregnant?

No Response

Disability

Does anyone in your household have a disability?

No

Student

Does anyone in the household attend high school, vocational, trade school or college?
No

Prior Conviction

Have you or any member of your household been convicted of, or disqualified for, buying or
selling, or attempting to buy or sell, SNAP benefits for more than $500 after 9/22/1996?
No Response
Are you or any member of your household hiding or running from the law to avoid prosecution,
being taken into custody, or going to jail, for a felony crime or attempted felony crime, or violating
a condition of parole or probation?
No Response
Have you or any member of your household been convicted of a felony under federal or state law
for possession, use, or distribution of a controlled drug substance (felony drug conviction) or for a
crime while under the influence of a controlled drug substance?
No Response
Has anyone in your household been convicted of trading SNAP benefits for guns, ammunitions,
explosives, or drugs after 9/22/1996?
No Response
Have you or any member of your household applying for assistance ever been disqualified for an
Intentional Program Violation or been convicted of welfare fraud in a criminal case?
No Response
Have you or any member of your household been convicted of fraudulently receiving duplicate
SNAP benefits in any State after September 22, 1996?
No
Have you or any member of your household been convicted as an adult of aggravated sexual
abuse, murder, sexual exploitation and other abuse of children, a Federal or State offense
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

involving sexual assault, or an offense under State law determined by the Attorney General to be
substantially similar to such an offense, after February 7, 2014?
No Response
In compliance with felony conviction?
No Response

Ethnicity and Race

What is your ethnicity?

Hispanic/Latino
What is your race?
White/Caucasian

Expedited Issuance Information

Is anyone in your household a migrant or seasonal farm worker?

No
How much cash on hand and/or money is in your checking/savings account?
No Response
How much money does your household expect to get this month (before deductions)?
No Response
How much do you pay for rent or mortgage?
No Response
Which utilities do you pay for (check all that apply)

Has any member received LEAP (Low-Income Energy Assistance Program) benefits of more than
$20 this month or in the last 12 months?

Child Support Obligation

Income

Does anyone in your household have a job or is self employed?

No
Has anyone in your household quit a job, lost a job, or reduced their work hours in the past 60
days?
No
Does anyone in your household have other types of income that is not from a job or
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

self-employment?
No

Expenses

How much do you pay for rent or mortgage?

No Response
Which utilities do you pay for?

Does anyone in the household pay child or adult Dependent Care, legally-obligated child support,
medical expenses, and/or alimony?
No Response

Resources

Does anyone in the household have any resources, including those that are jointly owned with
someone else?
No

Authorized Representative

Would you like to add an authorized representative?

No

SNAP Outreach Partner

SNAP Outreach Partner Name Support Method

No Response No Response

Your Interview

Preferred Method of
Interview
Phone/ Virtual
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

Electronic Signature

By signing this form, I certify that I have reviewed this application; I understand and agree to the
Rights, Responsibilities and Penalties and under penalty of perjury, I certify the information I have
given is true including the information concerning citizenship and alien status. I have received
information on how to apply, what information is available, and what I may need to give the county
to help me with getting benefits.

I understand that an electronic signature has the same legal effect and can be enforced in the
same way as a written signature.

By checking this box and typing my name below, I am electronically signing my application.

Brandon Herrera

04/10/2023 2:01 PM

By completing and signing the State of Colorado Application for Public Assistance and other
documents required to determine whether I’m eligible for public assistance benefits AND by
accepting benefits that I am eligible to receive, I understand the following information and
agree to the following requirements:

I must tell the truth; it is a crime to lie on this application.

I may have to give papers that show what I’ve told you is true.
I may have to tell you of any changes to the information I gave you on my application. If I
think you made a mistake, I can ask for an appeal or fair hearing.
The department will not discriminate.
The department will confirm citizenship and immigration status for everyone applying for
benefits.
The department will tell you if your benefits change.
The department or relevant federal agency will take back any benefits you should not have
received.
I must report single game cash lottery or gambling winnings by any adult household member
equal to or greater than $3,500.00 before taxes or other amounts are withheld. I understand
that these winnings will disqualify the entire household.
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

1. The Department of Health Care Policy and Financing (HCPF) is the state agency
responsible for Medical Assistance Programs in Colorado. The Department of Human
Services is the state agency responsible for the other public assistance programs. The
County Departments of Human/Social Services and Medical Assistance Sites are the
agencies that receive and process applications for all public assistance programs. In this
statement, the term "department" is used to refer to all agencies.
2. I must give the department all needed proof and documents before qualifying for
benefits.
3. The information I give on the application and in the application interview is
confidential. However, the department can use or share the information with other
program(s) that any of my family and/or household members are getting or are
applying for. The information can only be used for purposes of treatment, payment,
determining eligibility, and other program and administrative operations, or other
purposes permitted by law for my family and/or household members or me.
Additionally, this information may be disclosed to other Federal and State agencies
for official examination and to law enforcement officials for the purpose of
apprehending persons fleeing to avoid the law. It will also be determined if the
information is factual. If any information is incorrect, SNAP may be denied and the
applicant may be subject to criminal prosecution for knowingly providing incorrect
information.
4. It is a crime to lie on the application or to take benefits that I know that my
family and I are not eligible to receive and I may be subject to criminal prosecution
for knowingly providing false information. Giving false information may be
punished by a fine of up to $250,000 or a jail term of up to 20 years, or both.
5. A person found to have intentionally given false information cannot get SNAP
and/or Cash Programs for 12 months for the first offense, 24 months for the
second offense, and permanently for the third offense. A court can also stop a
person from getting SNAP for another eighteen months. This crime is subject to
prosecution under other state and federal laws. Receiving duplicate benefits of
SNAP by lying about identity or residence will result in a ten (10) year
disqualification for the first offense, a ten (10) year disqualification for the second
offense and a permanent disqualification for the third offense. If I omit or provide
any information (other than lying about identity or residence) that leads to
duplicate benefits being issued, I can be disqualified for 12 months for the 1st
offense, 24 months for the 2nd offense and permanently for the 3rd offense. A
person convicted by a court or whose disqualification was obtained through an
Intentional Program Violation (IPV) waiver for misrepresenting their residence in
order to obtain assistance in two states at the same time will have their Colorado
Works assistance denied for ten (10) years.
6. If I am receiving SNAP, I must report if anyone in the household age 18 years or older
has been convicted on or after 2/7/2014 and is not in compliance with the terms of their
sentence of the following: aggravated sexual abuse, murder, sexual exploitation and or
abuse of a child (ren) or sexual assault.
7. The department will notify me in writing of how and when to tell the department
of any changes. If I am receiving Cash Programs, I know that I must tell the organization
providing the assistance if information I listed on this application changes by the 10th of
 Submit Date & Time:
7. Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

the month following the change. I am aware I have 10 calendar days to report any
changes if I am enrolled in Health First Colorado or Child Health Plan Plus (CHP+).
Changes are to be reported to my local county office for Health First Colorado or to
CHP+. I am responsible for paying fees, premiums and co-payments for myself and my
family if they are required for Medical Assistance benefits. I know I have 30 calendar days
to report any change to Connect for Health Colorado if I am receiving Advance Premium
Tax Credits, Reduced Co-Pays or Deductibles, or I am enrolled in a Qualified Health
Plan. If my family is enrolled in multiple insurance affordability programs, I must report
changes to each organization in the appropriate time frame. I understand that a change in
information could affect my eligibility and eligibility of member(s) of my household.
8. If I do not tell the truth on my application or if information is left off of the application, or
if I do not report changes to the department, as required, I may lose my assistance, and I
may have to pay back the department for the assistance received when I was not eligible.
If I have to pay back money to the department, I understand that state or federal salaries,
rebates, or tax refunds that would be received by me or another person on this
application may be taken.
9. The law says the department must check the immigration status and citizenship for
anyone who is applying. They will not check immigration status of family members who
are not applying for benefits. I may be requested to give proof of non-citizen registration
documentation received from the United States Citizen and Immigration Service (USCIS)
for every non-citizen member in my house who is applying for benefits. The department
will confirm information with USCIS and any information received from USCIS may affect
my eligibility and benefits. Federal law (Public Law 97-98) requires me to give the
department the Social Security number and/or alien registration number of all persons
who are applying for public assistance. I must also provide the Social Security number
and/or alien registration number for all sponsors. For Adult Financial and Colorado
Works programs, sponsor information will be confirmed with USCIS and the
information received from USCIS may affect sponsor repayment for my eligibility
and benefits. My sponsor and I may be responsible for reimbursing the state for
benefits that I receive.
10. The following applies to all qualified non-citizens applying for Cash Programs:
As a condition of my eligibility for financial assistance programs I agree that, during the
time I am receiving such assistance, I will not sign an Affidavit of Support to sponsor a
non-citizen who is seeking permission to enter or remain in the United States. I
understand that any Affidavit of Support signed prior to July 1, 1997 does not affect my
eligibility for assistance. If I do not agree, I will no longer be eligible for financial
assistance from the State of Colorado.
11. I do not have to be a U.S. citizen to apply for assistance. Please do not let the fear
about immigration status stop you from seeking benefits for your family.
12. If I am a resident of an institution and jointly applying for SSI and SNAP prior to
leaving the institution, the filing date of the application is my date of release from the
institution. Processing time will begin from the date the application is received in the
SNAP office.
13. Privacy Act Information: The department is authorized to collect information on the
application, including Social Security numbers and will confirm information that may affect
initial or ongoing eligibility and payments for all persons listed on my application. I am
allowing the department to use Social Security numbers (SSN) and other
information from my application to request and receive information or records to
confirm the information in my application. SNAP will be denied to individuals that do
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

not provide a Social Security number, and Social Security numbers will be used and
disclosed in the same manner for both eligible and ineligible members. I release the
department from all liability for sharing this information with other agencies for this
purpose. For example, the department may get and share information with any of the
following agencies: Social Security Administration; Internal Revenue Service; United
States Customs and Immigration Services; Colorado Department of Labor and
Employment; financial institutions (banks, savings and loans, credit unions, insurance
companies, landlords, leasing agents, etc.); child support services; employers; courts;
and other federal or state agencies; and for SNAP, law enforcement officials for the
purposes of apprehending persons fleeing to avoid the law.
14. If a SNAP, Colorado Works, and/or Adult Financial over-payment occurs against my
household, the information on this application, including all Social Security numbers, may
be referred to Federal and State agencies, as well as private claims collection agencies
for claims collection action.
15. The EBT (or Quest) card is used to pay me most of my public assistance benefits. I
cannot trade or sell EBT cards. The only people allowed to use my household’s EBT card
are members of my household, my authorized representative(s), and individuals outside
my household that have my permission to use my EBT card to access benefits for the
people in my household. I cannot use my EBT card to access my cash benefits at
locations identified as prohibited locations including licensed gaming establishments,
in-state simulcast facilities, tracks for racing, commercial bingo facilities, stores or
establishments in which the principal business is the sale of firearms, retail establishment
licensed to sell malt, vinous, or spirituous liquors, establishments licensed to sell medical
marijuana or medical marijuana-infused products, or retail marijuana or retail marijuana
products, establishments that provide adult-oriented entertainment in which performers
disrobe or perform in an unclothed state for entertainment. Continued misuse of my
EBT card at prohibited locations will cause my cash benefits to be suspended on
my EBT card and/or my cash benefits to be terminated for a period of 30 days
requiring a new application.
16. I can name someone or an organization to be my representative. I must do this in
writing. The person and/or organization I designate to be my authorized representative
may help me apply for assistance, get my benefits, and use my benefits to buy food for
me. I may name one person to help me with each separate task or I may name one
person to help me with all of these tasks.
17. If I think the department made a mistake, I can ask for a Fair Hearing. The
department will tell me in writing how to make an appeal. I can ask for a Fair Hearing
either verbally or in writing. My case may be presented by a member of my household or
my representative, such as legal counsel, friend, or relative. I may request an appeal for
any action on any program except for the CHP+ program
18. If I think the CHP+ program made a mistake, I can ask for an appeal. CHP+ tells me
about how to make an appeal in writing.
19. Colorado Works is not an entitlement program and benefits are not guaranteed. To
remain eligible, I may be required to complete an assessment and develop a plan. Unless
exempted, I will be required to participate in work readiness activities
20. As an applicant for Colorado Works, if I refuse to cooperate with Child Support
Services at the time I apply or while receiving cash assistance through Colorado Works,
without good cause, I will not receive assistance or a basic cash assistance grant for my
family. Good cause for not working with Child Support can be, but is not limited to;
potential physical or emotional harm to a child(ren), parent or caretaker relative;
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

pregnancy or birth of a child related to incest or forcible rape; legal adoption before court
or a parent receiving pre-adoption services; or other reasons determined to be in the best
interest of the child. In order to cooperate with Child Support Services, I will be required
to complete additional documentation concerning the child(ren), parentage of the
child(ren) and provide all court documents that concern the child(ren).
21. If I am an adult between the ages of 18 and 49, with no children under the age of 18
in my SNAP house, I will only be eligible to receive SNAP benefits for three months,
unless one of the following applies: I work in a job 80 hours each month and report my
hours worked to my local Employment First office, or I meet the Workfare program
requirements or work program requirements set by the Employment First office.
Additionally, I may continue to receive my SNAP benefits if I am determined to be
physically or mentally unable to work or if the SNAP office identifies other applicable
exemptions. If I meet any of these criteria, I will be able to continue receiving SNAP as
long as I remain eligible.
22. I understand and agree that to receive SNAP, certain members of the household
need to register for work. This means that certain members of the household must: A)
Report to the Employment First (work program) when the SNAP office schedules an
appointment. B) Comply with the instructions the Employment First (work program) gives
including reporting for all scheduled appointments and following through on the written
agreements signed. C) Provide information to the SNAP office or the Employment First
(work program) about any jobs me or my household member(s) get while on SNAP. D)
Tell the SNAP office or the Employment First (work program) if me or my household
member(s) are not able to work – I will be asked to provide verification; work any
workfare hours assigned; go to job interviews arranged for me or my household
member(s). Anyone who does not follow the work requirements may be disqualified from
receiving SNAP.
23. I must cooperate fully with state and federal staff if my case is reviewed. My
information on this application may be reviewed and confirmed by the department, or its
representatives. My household will not be eligible for SNAP if I refuse to cooperate with
any review of my case, including a quality control review.
24. I cannot use SNAP benefits to buy nonfood items, such as alcohol or cigarettes. I
can be disqualified for using SNAP to pay for items purchased on credit. If a court of law
finds a person guilty of using SNAP benefits to illegally purchase or receive
controlled substances that individual shall be disqualified for two years for a first
offense and permanently for a second offense. Individuals found by a Federal,
State, or local court to have used or received benefits in a transaction involving the
sale of firearms, ammunition, or explosives shall be permanently ineligible to
receive SNAP upon the first occasion of such violation. If a court of law finds a
person guilty of having trafficked benefits for an aggregate amount of $500 or
more, that individual will be permanently ineligible to receive SNAP upon the first
occasion of such violation.
25. The trafficking of benefits means:
a. The buying, selling, stealing, or otherwise effecting an exchange of SNAP
benefits issued and accessed via Electronic Benefit Transfer (EBT) cards, card
numbers and personal identification numbers (PINs), or by manual voucher and
signature, for cash or consideration other than eligible food, either directly,
indirectly, in complicity or collusion with others, or acting alone ; or,
b. The exchange of SNAP benefits or EBT cards for firearms, ammunition,
explosives, or controlled substances; or,
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

c. A SNAP participant, including the participant’s designated authorized

representative, who knowingly transfers SNAP benefit to another who does not, or
does not intend to, use the SNAP benefits for the SNAP household for whom the
SNAP benefits were intended; or
d. The reselling of food that was purchased with SNAP benefits for cash; or
e. Obtaining a cash deposit when returning water or other containers that were
purchased with SNAP benefits. Purchasing water containers is an eligible food
item that can be paid for with SNAP benefits; however, when the container is
returned, the deposit should be returned to the client’s EBT card and not given to
the client in cash.
f. Attempting to buy, sell, steal, or otherwise affect an exchange of SNAP benefits
issued and accessed via Electronic Benefit Transfer (EBT) cards, card numbers
and personal identification numbers (PINs), or by manual voucher and signatures,
for cash or consideration other than eligible food, either directly, indirectly, in
complicity or collusion with others, or acting alone.
26. If I do not report and provide proof of mortgage, housing fees, property
insurance, property taxes, court ordered child support payments, child or adult
care, and medical expenses paid by people in my household who are elderly or
who have a disability, I am stating that I do not want that specific deduction used
to determine my SNAP benefit amount.
27. I can ask for SNAP apart from asking for benefits from other programs. My
eligibility for SNAP will be determined apart from any other programs. The SNAP
office shall process all SNAP applications in accordance with SNAP timeliness,
noticing, and fair hearing requirements, even if I am applying for other programs.
28. Colorado residents who have a qualifying disability, such as persons receiving
SSI or SSDI benefits, or residents who are at least 65 years of age (or a surviving
spouse age 58 or older) might also qualify for a Property Tax/Rent/Heat Rebate
from the Department of Revenue. Visit [Link] and click on the PTC
button at the top of the page or call 303-238-7378 for details.
29. IEVS refers to the Income Eligibility Verification System. IEVS reports
discrepancies between the information you provide and information in the
Department of Labor's system as well as Social Security Administration's various
systems. Information available through IEVS will be requested, used, and may be
verified through collateral contacts when discrepancies are found. This
information may affect your eligibility and benefit level.
30. I will immediately notify the State of any medical claim or lawsuit I have. I will
cooperate with the State in collecting the medical bills the State has paid. The state
may collect from any insurance company or court settlement for medical bills that
the State has paid. If I am on Medical Assistance and receive money for the same
medical bills that the State has paid, I will give the money to the State. I assign to
the State all rights to payment for medical expenses and treatment. I also assign
my right to appeal a denial of benefits by another party responsible for payment for
the benefits to the State.
31. Federal and Colorado state law require the Department of Health Care Policy
and Financing to recover all medical assistance benefits, including capitation
payments, paid on behalf of Health First Colorado clients from the estates of
deceased Health First Colorado clients who were permanently institutionalized. For
Health First Colorado clients who were over the age of 55 when benefits were
 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

provided, the Department recovers payments for nursing facility services, home
and community-based services, and related hospital and prescription drug
services. There are certain exemptions to estate recovery. For further information,
please contact your county and request the “Medical Assistance Estate Recovery
Program” brochure.

USDA Nondiscrimination Policy

Do Not Send Applications Here

In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil
rights regulations and policies, this institution is prohibited from discriminating on the basis of
race, color, national origin, sex (including gender identity and sexual orientation), religious
creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.

Program information may be made available in languages other than English. Persons with
disabilities who require alternative means of communication to obtain program information
(e.g., Braille, large print, audiotape, American Sign Language), should contact the agency
(state or local) where they applied for benefits. Individuals who are deaf, hard of hearing or
have speech disabilities may contact USDA through the Federal Relay Service at (800)
877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027,

USDA Program Discrimination Complaint Form which can be obtained online at:

[Link]
[Link], from any USDA office, by calling (833) 620-1071, or by writing a
letter addressed to USDA. The letter must contain the complainant’s name, address, telephone
number, and a written description of the alleged discriminatory action in sufficient detail to
inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged
civil rights violation. The completed AD-3027 form or letter must be submitted to:

1. mail:
Food and Nutrition Service, USDA
1320 Braddock Place, Room 334
Alexandria, VA 22314; or
2. fax:
(833) 256-1665 or (202) 690-7442; or
3. email:
FNSCIVILRIGHTSCOMPLAINTS@[Link]

This institution is an equal opportunity provider.

Do Not Send Applications Here

 Submit Date & Time:
Head of Household: Brandon Herrera
04/10/2023 2:01 PM
Tracking Number: 143468105 Case Number:

Medical Assistance Nondiscrimination Policy

The Department of Health Care Policy and Financing and Connect for Health Colorado do not
discriminate on the basis of race, color, ethnic or national origin and expression, marital status,
religion, creed, political beliefs, or disability in any of its programs, services and activities. For
further information about the Department’s policy, to request free disability and/or language
aids and services, or to file a discriminating complain, contact: 504/ADA Coordinator, 1570
Grant St., Denver, CO 80203, Phone: 303-866-6010, Fax: 303-866-2828, State Relay: 711,
Email: hcpf504ada@[Link]. For information about Connect for Health Colorado’s policy,
aids and services or to file a discrimination complaint, contact: General Counsel, 3773 Cherry
Creek N. Dr., Suite 1005, Phone: 303-590-9640, Fax: 303-322-4217. Complaints can also be
filed with the U.S Department of Health and Human Services Office for Civil Rights at
[Link]

For Other Programs: For information about the Colorado Department of Human Services
policies, to request free disability and/or language aids and services, or to file a discrimination
complaint, contact: 504/ADA Coordinator, 1575 Sherman St Denver, CO 80203, Phone:
303-866-7129, Fax: 303-866-6080, State Relay: 711, Email: CDHSCR@[Link]. For
additional information please visit [Link]/cdhs.

Civil rights complaints can also be filed with the U.S. Department of Health and Human
Services Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal
available at [Link] or by mail, phone, or fax at:
1961 Stout Street Room 08-148 Denver, CO 80294, Telephone: 800-368-1019, Fax:
202-619-3818, TDD: 800-537-7697. Complaint forms are available at
[Link]
[Link].

Domestic violence information and services are available to me. If I ever feel I am in
immediate danger I should call 911. If I would like to receive information regarding safety and
services in Colorado, I will call the Colorado Coalition Against Domestic Violence at
303-831-9632 or toll free at 1-888-778-7091. I may also find the location of services near me
by going to [Link]/cdhs/[Link] National Domestic Violence Hotline at
1800799SAFE (7233) or TTY 18007873224 or [Link] can also provide
information. If I am a survivor of domestic violence, sexual assault, or stalking, the Address
Confidentiality Program (ACP) can provide me with a legal substitute address to use instead of
my physical address for use with state and local government agencies. I can find out more
about the ACP at [Link]. If I need or receive either of these services, I should tell my
department worker.