Submit Date & Time:

Head of Household: Jeanetta Piermore

08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

Printable MyCOBenefits Application

Your tracking number is 4208653041.

What benefits do you want to apply for?

SNAP
Adult Financial

Basic Information

What is your name?

Suffix (for example: Jr.,

First Name Middle Name Last Name
Sr., III)
Jeanetta No Response Piermore No Response

SSN Date of Birth Gender

XXX-XX-8228 March 14, 1964 Female
Marital Status Marital Status Date

Does Jeanetta Piermore pay money to a Does Jeanetta Piermore 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?
No
Do you have an address to receive mail?
Yes
What Colorado county do you live in?
Montrose

What is your mailing address?

 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

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

1608 ASH WAY MONTROSE CO
Zip County This address is a PO Box
81401-5747 Montrose No

Home Address

Address 1 Address 2 City State

1608 ASH WAY MONTROSE CO
Is your home address
Zip County the same as your
mailing address?
81401-5747 Montrose Yes

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.
435-580-0148 No Response No Response No

What is your preferred language?

Spoken Language Written Language Font Size Preference

No Response No Response

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 Response
If you are applying for Colorado Works, have you received benefits from any other state since
1996?
No Response
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

Citizenship

Is anyone in the household not a US citizen?

No Response

Pregnancy Details

Is anyone in the home pregnant?

No Response

Disability

Does anyone in your household have a disability?

No Response

Student

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

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
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 Response
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: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 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 07, 2014?
No Response
In compliance with felony conviction?
No Response

Ethnicity and Race

What is your ethnicity?

No Response
What is your race?
Black/African American

Expedited Issuance Information

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

No
Is the total money your household expects to get this month (before deductions) less than $150?
Yes
Does your household currently have less than $100 total? This includes cash on hand and in bank
accounts.
Yes
Are your housing expenses more than the total money your household expects to get this month
(including cash on hand and in bank accounts)? Housing expenses include rent, mortgage,
heating and cooling, electricity, water, phone, trash and sewer.
Yes
Expedited Processing
Yes

Child support obligation

Income

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

No Response
Has anyone in your household quit a job, lost a job, or reduced their work hours in the past 60
days?
No Response
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

Does anyone in your household have other types of income that is not from a job or
self-employment?
No Response

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 Response

Authorized Representative

Would you like to add an authorized representative?

No Response

Would you like to add an authorized representative?

Do any of the following

How is the Authorized
Who is the trusted apply to your trusted
Type of Representative Representative related
representative? representative?
to you?
Choose all that apply.
Conservator
Emergency
representative
Legal guardian
Financial power of
Someone not on my
Person Cousin attorney
application
Trustee
Medical durable power
of attorney
Group living
representative
Organization Name Name In care of Email
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

No Response Sydney Miller No Response No Response

County Address / [Link] Phone number For which programs?
1609 ash way,
Montrose Montorse, Colorado - 657-410-1999 SNAP;Adult Financial
81401
For my Colorado For my health
For my Adult Financial For my SNAP benefits,
Works benefits, my coverage benefits, my
benefits, my trusted my trusted
trusted representative trusted representative
representative can... representative can...
can... can…
Help me complete an
application, renewal,
Receive information
report changes, or
about my case.
interview.
Complete my interview
Help me get my EBT
or provide information
No Response card with benefits. No Response
for my case.
Use my EBT card to
Access my Adult
buy food for people in
Financial payment with
my household.
me.
Help with my case in
an emergency.
When did this person
Trusted
stop being your
Applicants signature representatives
Trusted
signature
Representative?
Jeanetta Piermore Sydney miller No Response

SNAP Outreach Partner

SNAP Outreach Partner Name Support Method

No Response No Response

Your Interview

Preferred method of
interview
No Response
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 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.

Jeanetta Piermore

08/12/2025 7:04 AM

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: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 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. I understand that any household member
who breaks any of the rules on purpose can also be:

a. Barred from SNAP for one year to permanently, fined up to $250,000, imprisoned for
up to 20 years, or both.
b. Barred from SNAP for an additional 18 months if court-ordered.
c. Subject to prosecution under other applicable Federal and State 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.
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

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 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. 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.
11. 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.
12. 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 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
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

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.
13. 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.
14. 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.
15. I can name someone or an organization to be my representative. For SNAP, Cash, and
Medical Assistance programs I must do this in writing, online through my PEAK account, or
through the mail. For Medical Assistance I can also do this over the Phone. 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.
16. 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
17. 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.
18. 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
19. 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. If I think
that cooperating will harm me or my children, I can tell Child Support Services and I may not
have to cooperate. Reasons for not cooperating with Child Support include but are not limited
to: potential physical or emotional harm to a child(ren), parent or caretaker relative;
pregnancy or birth of a child related to incest or forcible rape; legal adoption before the 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
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

complete additional documentation concerning the child(ren), the parentage of the child(ren),
and provide all court documents that concern the child(ren).
20. If I am adult between the ages of 18 and 54, 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.
21. 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.
22. 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.
23. 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.
24. 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,
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
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

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.
25. 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.
26. 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.
27. 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.
28. 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.
29. 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.
30. 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 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.
31. I understand that if I get cash assistance under Colorado Works, I must assign the
rights to any current and past-due child support due under an existing order to the
State, along with any medical support, to reimburse Medicaid for costs paid out for my
 31. Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

family. If I receive any current child support, medical support, or spousal support
directly while receiving cash assistance, I will give this to the child support unit (CSU).
For Health First Colorado, I know I’ll be asked to cooperate with the agency that
collects medical support from an absent parent. If I think that cooperating to collect
medical support will harm me or my children, I can tell child support and I may not
have to cooperate. If current child support is collected by the CSU, while I am receiving
Colorado Works, I may receive this money through the Pass-Through program. Once I
have discontinued Colorado Works, the CSU will continue to collect and send to me
any current child support, medical support, and spousal support until I tell the CSU in
writing to close my case.

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]
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

This institution is an equal opportunity provider.

Do Not Send Applications Here

Medical Assistance Nondiscrimination Policy

The Colorado Department of Health Care Policy and Financing (HCPF) does not discriminate
based on race, color, national origin (including limited English proficiency and primary language),
ancestry, age, sex (including pregnancy and sex characteristics), sexual orientation, gender
identity, gender expression, religion, creed, marital status, or disability in any of its programs,
services and activities.

For further information about our policies, to request language assistance services, auxiliary aids
and services, a reasonable modification, or to file a grievance, please contact:

Civil Rights Officer

303 E. 17th Avenue
Denver, CO 80203
Phone: 303-866-6010 (State Relay 711)
Fax: 303-866-2828
Email: hcpf504ada@[Link]
Complaints can also be filed with the U.S. Department of Health and Human Services, Office for
Civil Rights at [Link]/ocr/portal/[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.
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

Send in Required Documents

We Need Documents to Complete Your Application

When you apply for Supplemental Nutrition Assistance Program (SNAP) and/or cash benefits, you
need to give us certain documents to show that what you provided in your application is correct.

What do you need to do?

Please look at the list below. See what documents you have.
Give us copies of your documents by September 11, 2025 to ensure we have all the
information that we need to make a decision on your application.
We will need information for you and anyone in your household applying for SNAP benefits.
Your household is anyone who lives with you and purchases and prepares food with you.
You need to give only ONE document for each type of information. Sometimes one document
can serve more than one purpose. (For example, a driver’s license can show your identity
and your address.)
Please only give copies because we cannot return any original documents to you.

Program: SNAP

Type of information What are some examples of documents you can give us?

Driver’s license or State identification card

School or work identification card
Medical insurance identification card
Identity
Voter’s registration card
Birth certificate
Passport

Driver’s license
Utility bills (such as electric, gas, or water)
Residency Lease or mortgage receipts showing address
(where you live) Mail sent to you at the stated address
Library card showing address
Voter’s registration card

Social Security number (not the card) or proof that you have
applied for one.
Social Security number
Not required for household members who are not
applying for SNAP.
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

Type of information What are some examples of documents you can give us?

Immigration and naturalization documents

Immigration status
Not required if you are a U.S. citizen or if you are not
applying for SNAP.

You may need to provide other documents depending on your situation.

We may need
Type of What are some examples of documents you can
additional
information give us?
documents if:

Paycheck stubs (for the past 30 days)

Employer statement (if you are paid in cash or
Someone in your What you earn
if you do not have your check stubs)
household is working (wages or pay)
Self-employment invoices or receipts (includes
rental income and freelance or contract work)

Someone in your Social Security payment documents

household has other What you receive Other retirement or pension benefits
income (including as unearned or Alimony
Social Security or other income Child support agreement
assistance payments) Unemployment benefits

Someone in your What you have as Statements for bank accounts, savings
household has savings other financial accounts, and/or CDs
or resources resources Stock shares or bonds

Supplemental Security Income (SSI) or Social

Someone in your What you receive Security Disability Insurance (SSDI) benefit
household is receiving for disability documents
disability payments payments Veterans Administration (VA) disability benefits
statement

Copy of your lease

Your household has What bills you
Mortgage documents
rent or a mortgage for have for rent or
Property taxes
where you live mortgage
Insurance on property
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

We may need
Type of What are some examples of documents you can
additional
information give us?
documents if:
What bills you
have for
Your household has Utility bills (gas, water, electricity, telephone
electricity, heat,
utility expenses etc.)
gas, water,
telephone etc.
Someone in your
What you pay for
household is
childcare or Bills or receipts for childcare or dependent
responsible for
dependent adult adult care
childcare or adult care
care costs
costs

Copy of court order showing your child support

Someone in your obligations
What you pay for
household pays child Income summary if child support is deducted
child support
support from wages or income
Proof of child support payments made

Proof of Financial aid statement from school

Someone in your
enrollment and Enrollment forms or transcripts to verify your
household is 18–49
what is paid for current status as a student
years old and a
educational Receipts for mandatory school fees, books, or
student
expenses supplies

Medical bills
Summary of provided services such as doctor
or hospital visits
An Explanation of Benefits (EOB) or other
detailed receipts showing unreimbursed
Bills of medical
medical expenses
expenses for this
Identification from the Medical Assistance
Someone in your person (Does not
Program for people 65 and older (Medicare)
household is age 60 or include expenses
that shows Plan “B” coverage
older or a person with paid by insurance
Prescription pill bottles showing cost on label
a disability or someone
or printout
outside of the
Medical payment agreement
household)
Invoices or receipts for medical equipment
such as wheelchairs, hospital beds, or walkers
(including any rental costs)
Receipts for transportation and lodging to
obtain medical treatment
 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

What time periods should your documents cover?

In general, the documents you provide to us should cover the last 30 days before you applied for
SNAP and cash benefits. Medical expenses can be averaged over 1 year.

How can you give us the documents we need?

If you have an interview in the office, please bring the documents or copies with you. If not,
follow the instructions below.
Please only give copies of your documents to your local office because we cannot return
any original documents to you.

Choose the option that is easiest for you to give your local office copies of your documents:

Electronically:

You will need to create a login and password the first time you use the website or mobile
application.

Website: You may upload your documents at [Link]/PEAK.

Mobile application: You may use your mobile device to take photos of your documents
and then upload them to the MyCOBenefits mobile application. You can also use a
computer to scan and upload copies of your documents to the MyCoBenefits mobile
application.

What will happen to your application?

The sooner you can provide these documents, the sooner we can tell you if you can get
SNAP or cash benefits.
If you do not give us the documents within 30 days of applying, we may have to deny your
application.

What if you need more help?

If you have trouble getting any of these documents or you have questions, we can help.

We may be able to suggest other ways to verify this information.

If you cooperate with us, they will do everything they can to help get the needed
documents.

For more information:

 Submit Date & Time:
Head of Household: Jeanetta Piermore
08/12/2025 7:04 AM
Tracking Number: 4208653041 Case Number:

You can find county contact information at

[Link]
services-department
You can visit the PEAK website at [Link]/PEAK

You can also get information from us about how to use an authorized representative if you
need one.

An authorized representative is a person you select who can talk to us about your case.