FSD Uso oly -Date Race MISSOURI DEPARTMENT OF SOCIAL SERVICES FAMILY SUPPORT DIVISION APPLICATION FOR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) eodiaa ‘osm Yovhve tg apy or SHA ees a yi SET Beye ae en rth as Fed Serpe on () recs you apa wih en cx yor ie, Sais nd Spee marcas ane eh okra ean ee o tannin aroun comet show, al Sap then watt oa yoo oe penta tne |S ‘inl on he opizton arent Coes ay Sher par en pannel rome aaa Hs eae Soria ie clit ocetiins tami Stncte pis atnoacbce | 7 FE Rat vets Ga ocean mnt Me may yon esteiomseeeearmees | [uk] fog bo >) eer ue of aptcaon: approve er SMP beets re rnd om the date F0 ces eatin, TH {Ete yu aetna Se apy for Snr boner id speed ery coe ap ete ns Pe OO, g | teens | treet: lapeBalngy Sate Home J330 cRYso aaices [Pp al " Hot Butler wg freee Boe ei eT address, (diferent {Cay fate: E oan than above): phone 1: _ 5773-4) 3-g792 Mice Ctiome CJwork [other Phone 2: Ccet Come (Jwork [lather ematodses: cide clageon Yin 2 genilieom Lthebest way to contact you:L cai Fifemat C]eat []tex (not avaiable everywhere) JUNDER THE LAWS OF THE STATE OF MISSOURI, AND THE REGULATIONS OF THE UNITED STATES DEPARTMENT OF AGRICULTURE, || HEREBY APPLY FOR SNAP BENEFITS. Hourseutue: arn EERO Rouen I eligible, you will receive your benefits within 7 days of filing your application if you answer “yes” to any of the questions| below. Otherwise, you will receive your benefits within 30 days of filing your application. date: §/2 % Jes }1. Does your household expect to receive less than $150 in income this month and have $100 Yes No or less available in cash and/or in a bank account? wh Oo |2. Does your household have rent/mortgage and/or utility costs that are more than your total Nive: no income, available cash, and bank accounts for this month? |3. Does your household include a migrant or seasonal farm worker whose income has stepped Dives {No and whose available cash and bank accounts do not exceed $100? |Help FSD verify your identity for faster service. FSD will try to verify your identity electronically. Please (1) include a copy of | your identification with your application, or (2) bring someone such as a friend, family member, landlord, or employer to any FSD office, or (3) list a contact below in order to heip us verify your identity. FSD will call this person if needed. Tame of person Phone vetyyourkientty: cl, Sauter Number 5°73 719 a6 ‘MO 886-0460 (1-2025) Page 10f8 5-1 (2-205)ye [Write your information on line 1. Enter the information of all the people who live in your household, including your spouse, /any children under age 22 who are in your household at least half (50%) of the time, and anyone who eats the majority of |their meals in your household. Include all household members regantless of their citirenship or immigration status. Citizenship or immigration status does not automaticaly disqualify an applicant from receiving SNAP benefits. Racial and ethnic information is collected to ensure that program benefits are distributed without regard to race, color, or national origin. Providing this information fs optional and does not affect your eligibility or the amount of SNAP benefits you receive. Providing the Social Security Number (SSN) and immigration status of each household membes is voluntary. However, you will not receive SNAP benefits for individuals who do not provide a SSN and/or immigration status. Immigration status lof applicant househald members may be subject to verification by U.S. Citizenship and immigration Services (USCIS). Information provided by USCIS may affect your eligibility and benefit level. — wae tepirinnaoe | usitome [sex [eT mearnm | soe] NE | mace | OR, SSES b : Pacinon sf Krai m | s* | O/5/w| 54340me YO] | | ¥ A fe ls 5 le 1. ls 2. + Not Required for List ALL that apply: 4 Mark "Y"if you buy and cook Sarcignary —|-Wite T'dhektticasAmescan 3-Ameinnen/Asia abe |" nasnnciceamteree demninaion [action chateaus mae Twins If you do nat have enough space for all household members, attach an additional list with their information. 1. List anyone who is a boarder in your household: Rone 2. List anyone who is a foster child or foster adult in your household:__WOP.t_ 3. List anyone who is not a U.S. citizen in your household: Done l4. Do younced a new Missouri EBT card? Mves CINo 5. 1s English your preferred language? Mes Co fo, what is the language spoken most often in your home? MO 886-0460 (1-2025) Page 2088 FS-4 (1-2025)Section 4 - Household deci: i benefits for the person in which the “yes” answer applies. ‘$500 or more after 9-22-96? 1. Have you or any member of your household been convicted of buying or selling SNAP benefits of []ves__[U{No /Answer “yes” or “no” to each of the questions in this section. Please provide the name of the household member for whom [the answer is “yes”. A “yes” response to any of the questions in this section may result in a disqualification for SNAP tyes, win? [Fase [is custody, or jail for a crime (or attempted crime) that isa felony? 2. Are you or any member of your household hiding or running from the law to avoid prosecution, [Jes [Z{No ifyes, who? [First Last 3. Are you or any member of your household violating a condition of probation or parole? Lives PfNo tyes, who? [First | last, receive SNAP benefits in 2 or more households at the same time? 4. Have you or anyone in your household made false statements about your fdentity oraddressto ‘L]Yes [Z{Wo tyes, who? [First Last duplicate SNAP benefits in any state after 9-22-96? 5. Have you or any member of your household been convicted in a federal or state court ofa Dives {no felony committed after 8-22-96 related to illegal possession, use, or distribution of a controlled substance? Ifyes, who? [First last_] [6. Have you or any member of your household ever been convicted of fraudulently receiving Lives Zino Fyes, who? [First last ‘ammunitions, or explosives after 9-22-96? 7. Have you or any member of your household been convicted of tra iding SNAP benefits for guns, [Jyes [No iyes, who? [First last }8. Have you or any member of your household ever been convicted of trading SNAP Genefitsfordrugs []Yes Z{No alter 8-22-96? IFyes, who? [First ast | ] }9. Has anyone in your household been convicted of one or mare of the following crimes since 27-142 [Yes [Y{No 1L Aggravated semual abuse 2. Murder 3, Seal exploitation and other abuse of children 4. Sexual Assault Ifyes, who? [First Last Which crime(s)? Yourself and all of the people who five with you (as listed in Section 3). if yes, please provide the frst and ast name ofthe household member. :L Has anyone received SNAP benefits in a state other than Missouri within the past 30 days? ves ano tyes, who? First last ‘State: 2. tsanyone disabled? Cites No Ifyes, who? | First Last 3. Isanyone age 18 or older and enrolled in school? [ves {No ifyes, who? | First bast ‘School: First last ‘School: First fast ‘School: MO 886-0460 (1-2025) Page 3 of8 FS-1 (1-2025){Resources [Resources are bank accounts and other types of money you own by yourself or with other people. i Does anyone have oF anyone’snam@ on any checking or savings accounts, debit ards, CDs, RAS Gr ves (Glo another type of retirement accounts, trusts, stacks, bonds, or digital cash accounts? If yes, please fist the information for the account(s} below: -- . ‘Who Owns? Account Type: _| Balance/Cash Value: ‘Bank Name: First Name last Name *|_ Ontong |S -ber.00 | Us nk Damon | Kael 2 s 3. $ 4 $ Ss. $ 6. $ |Income Income fs money that's paid to you, such as earnings froma job or payments from Socfal Security or child support.” 1. Does anyone earn income or money fram working? Des Zo yes, lst who gets it, their employer, and monthly gross income before taxes or deductions: \Who eams income fromworking? First Name ast Name Employer Amount How Often Received? s is $ 2. Does anyone eam income or money from the following sources? Lives Wino If yes, check the sourceand list who gets itand the monthly amount: i ____ Who gets it? 1 Source ~ First Name Last Name ‘Monthly amount [social Security income (Retirement, is Disability or Survivor's} (Cisupplemental Security income (S51) $ (Liveteran's Administration (VA) benefits $ (ichitd support $ [Unemployment benefits $ [Gifts or donations $s [student loans, grants, scholarships + $ TJother sources - list here: L $ L 2 2 $ 3. Has anyone's income stopped or been reduced in the last 30 days? Lives Wno Ityes, whose? [First Last Date of last paycheck Gross amount of last paycheck: $, ‘MO 886-0460 (1-2025) Page 40f8 FS (1-2025)[Expenses | Expenses are the bills you are responsible for paying. 1, Does anyone pay the following expenses for the home you live in? Cmanoropte | “Ne [patients | gen Rent: $_ oO [Etiouse Payment: [$3 Jonc ces | Pamclo Genatas | Sendork : |Lttectric: 30 ves [Eno $ 3 las: © Lives [Lino [lother Fuck: © ves _|CINo + Listthe Fuel: Phone: Cte Clwater: sewer: 2. Does anyone pay court-ordered child support and/or alimony? Dives ZiNo if yes, list the total monthly amount $. Who Pays? [Fist Name Lata | $ YSi05 Pamela Gardens Sondlers 3 2 $ $ 3. Does anyone who is either disabled or age 60 and older have medical expenses such as Lives {fio insurance or Medicare premiums, doctor visits, in-home care, transportation for medical care, or eyeglasses? If yes, list the total monthly amount: $ Who Pays? [First Name: | USDA NON-DISCRIMINATION STATEME 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 clit 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.¢., 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 disabities may contact USDA through the Federal Relay Service at (800) 877-8339, To file a program discrimination compiaint, a Complainant should complete a Form AD-3027, USDA Program. scrim i which can be obtained online at: https: zt les [Link], from any USDA office, by calling (866) 632-9992, 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 far Civil Rights (ASCR) about the nature and date of an alleged cll rights violation. The completed AD-3027 form or letter must be submitted to: MAIL: FAX: EMAn: Food and Nutrition Service, USDA (833) 256-1665 or (202) 690-7442; or _FNSCIVILRIGHTSCOMPLAINTS@usda gov 1320 Braddock Place, Room 334 Alexandria, VA 22314; or ‘This institution is an equal opportunity provider. ‘Note: Please do not send any application materials to the address above. The address above is for civil rights complaints only. MO 886-0460 (1-2025) Page 5 0f 8 FS (1-2025)DSS NON-DISCRIMINATION STATEMENT: The Missouri Department of Social Services (DSS) is committed to the principles ‘of equal employment opportunity and equal access to services. DSS applicants for, or recipients of, services from DSS are treated equitably regartiess of race, color, national origin, ancestry, sex (inciuling pregnancy and gender identity), sexual ofientation, age, disability, religion, or veteran status. Appropriate interpretive services will be provided as required for the visualy or hearing impaired and for persans with language barriers. Anyone who requires an auxilary ald or service for effective communication, or 2 modification af policies or procedures to participate in a program, service, or activity of the Department of Soctal Services should natify DSS as soon as possible. To request an accammodation: visit your focal DSS office, contact DSS by phone, TDD/TTY: (800) 725-2966; Relay Missouri 711; or contact the DSS ADA Coordinator by phone at (800) 776-8014 or via email at HRC OCR@[Link]. DSS will provide reasonable accommodations as required by law. FSD FAIR HEARING RIGHTS: You have the right to a hearing if you have applied for or are receiving SNAP benefits, and the following happens: * FSD decides that you are not eligible and you think you are. + FSD provides you with SNAP benefits and then reduces or stops the benefits and you think the reasons are wrong. + You disagree with the information used to determine the benefit amount or disagree with the benefit amount. ++ FSD refuses to take your application. ‘+ FSD does not act promptly on your request for help and you think that they have had enough time to do so. |Fyour application has been refused or rejected or any action on your case has already been taken, you may request a ‘hearing within 90 days of the refusal or action. if the proposed action will change or stop your benefits and you request a hearing within ten days from the date of the notice, you may continue to receive the same benefits until the hearing decision. You or your representative may request a hearing by phone, in-person, or in writing. Your case can be presented bya household member, or a representative such as legal counsel, relative, friend or other spokesperson. ‘YOU MAY BE DISQUALIFIED FROM RECEIVING SNAP BENEFITS IF YOU: * Sell your SNAP benefits for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with athers, or acting atone. * le or hide information to get SNAP benefits that your household should not get. ‘* Use SNAP benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit accounts. * Purchase a product with SNAP benefits that has a container requiring a return deposit with the intent of obtaining cash by discarding the product and returning the container for the deposit amount. + Intentionally purchase products with SNAP benefits in exchange for cash. For example, do not purchase food to make products for resale. ** Pay for food purchased on credit with SNAP benefits. ‘+ Use or have in your possession EBT cards that are not yours. ‘+ Trade or sell EBT cards or pravide food purchased with SNAP benefits to non-household members. NOTIFICATION AND ACKNOWLEDGMENT OF FRAUD PROVISIONS {tis against the law to lie to receive SNAP or to sell or trade your SNAP benefits. Excessive Electronic Benefit Transfer {€BT) card replacement requests may result in a referral for fraud investigation. 7 USC 2015(b){2) any person who has ‘been found by any state or federal court or administrative agency to have intentionally made a false or misteading statement, or misrepresented, concealed or withheld facts or committed any act that constitutes a violation of this act, the regulations issued thereunder, or any state statute, for the purpose of using, presenting, transferring, acquiring, receiving, or possessing SNAP benefits shall, immediately upon the rendering of such determination, become ineligible for further participation in the program for a period of 1 year upon the fist occasion of any such determination, 2 years for the second occasion and permanently upon the third occasion. + Applicants cannot violate the Food and Nutrition Act of 2008 which includes the following: ‘* Any member who breaks any of the rules on purpose can be ineligible from the SNAP Program for one year, upto Permanently, fined up to $250,000, imprisoned up to 20 years or bath. S/he may alsa be subject to prosecution under ‘other applicable Federal and State laws. S/he may also be barred from SNAP far an additional 18 months if ordered bya court. ‘Any member of your household who intentionally breaks the rules may te ineligible to receive SNAP for one year for the first offense, tuo years for the second offense, and permanently for the third offense. + tf court of law finds any household member guilty of using or receiving benefits in a transaction involving the sale of a controlled substance, you will not be eligible for benefits for two years for the first offense, and permanently for the second time. ‘+ Ifa court of law finds you guilty of having used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you will be permanently ineligible to participate in the Pragram upon the frst occasion of ‘such violation. * Ifyou are found to have made a fraudulent statement or representation with respect to the identity or place of residence in order to receive muitipte SNAP benefits simultaneously, you will be meligible to participate in the Mo 886-0460 (12025) , Page 6 of F5-1 (62025)Program for a period of 10 years. °° Ifa court of law finds you guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently ineligible to participate in the Program upon the first occasion of such violation. The information ‘you provide on the application will be subject to verification by Federal, State ar local officials to determine if the information is foctual; that if any information is incorrect, SNAP benefits may be denied and you may be subject to ‘criminal prosecution for knowingly providing incorrect information. Information available through the Income Eligibility and Verification System (IEVS) will be requested, used and may be verified through eolteral contacts when discrepancies are found bythe State, and that such information may affect the household's eligibility and level of benefits. ‘The collection of information on the application, including the SSN of each household member, is authorized under the Food and Nutrition Act of 2008 (formerly the SNAP Act}, as amended, 7 USC 2011-2036. The information will be used to determine whether your household is eligible or continues to be eligible to participate in the SNAP. We will ‘verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. This information may be disclosed to other Federal and State. ‘agencies for official examination, and to law enforcement officals for the purpose of apprehending persons fleeing to avold the law. Ifa SNAP claim arises against your household, the information on this application, including SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action, Pursuant to section 570.030 RSMO the stealing of public assistance benefits is a class “D” felony if the value of benefits is $750.00 or more, but less than $25,000.00. Punishment includes imprisonment for up to seven years and a fine not to exceed $5,000.00. Stealing of $25,000.00 or more is a class “C” felony. if the value of the benefits is less than ‘$750.00, the crime is @ class “A” misdemeanor. Punishments and fines may increase for repeat offenders. Pursuant to Section 578.377 (570.400 effective 1/1/17), RSMo, untawful receipt of public assistance benefits or EBT ‘ards, you understand that itis against the law to obtain or attempt to obtain SNAP benefits to which you are not entitled, or obtain, or attempt to obtain SNAP benefits in the amount greater than these to which you are entitled. ‘YOU UNDERSTAND THAT ANY FALSE CLAIM, STATEMENT, OR CONCEALMENT OF ANY MATERIAL FACT WHATSOEVER, IN WHOLE OR PART, ON THIS FORM OR DURING THE INTERVIEW, MAY SUBIECT YOU TO CRIMINAL AND/OR CIVIL PROSECUTION. You will be asked to complete an interview with the Family Support Division to complete this application process. You will be required to provide prof of some of the information you provide on this application and/or in the interview. Your signature acknowledges that you agreed to the terms outlined in this application and during the interview. WORK REGISTRATION ‘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) Register for work at time of application and recertification. 8) Not quit.a job of 30 or mare hours/week without good cause. C) Not reduce work hours under 30 hours per week without good cause. D} Not refuse to accept a bona fide offer of suitable employment without good cause, Anyone ‘who does not follow the work requirements may be disqualified from receiving SNAP. This form also acts as a work registration notice. You, along with other nonexempt household members, will be considered work registered and must comply with the requirements associated with work registration once this form is signed. WORK AND/OR TRAINING REQUIREMENT (ABAWD) Individuals identified as Able Bodied Adults Without Dependents (ABAWDs) are not eligible to participate in the SNAP Program as a member of any household if the individual received SNAP benefits for three countable months during a three year period. Countable months are months during which an individual receives SNAP benefits for the full benefit month while not fulfiling the work requirement by working and/or attending training 20 hours per week, averaged ‘monthly for a total of at least 80 hours. ‘An ABAWD is 18-54 years old; has no children under age 12 in the SNAP household; is nt disabled; is not pregnant; is ‘ot @ full-time student; not caring for an il or incapacitated household member; not receiving unemployment (in any state); is not a veteran; isnot homeless; did not age out of foster care; and is not attending a drug or alcohol treatment program. The time limit (three months) applies to ABAWDs only and ABAWDs may regain eligibility by meeting the work/training requirement for at least 80 hours in the last 30 days. (MO 886-0460 (1-2025) Page 7 of 8 FSi (1-2025)READ THIS PAGE CAREFULLY BEFORE SIGNING. When you sign, you are certifying you understand the statements on this application. You are certifying, under penalty Of perjury, you understand the information that you provide on this form and during the interview must be true and accurate, including information concerning citizenship and immigration status. You understand that any expenses you do not report, and verify when requested, will not be used to determine your SNAP benefits. You ate authorizing the Director of Famity Support Division or his/her appointee to verify your circumstances and statements via Federal, State or local officials to determine if the information you pravided is factual. Pursuant to Section 578.385 (570.408 effective 1/1/17), RSMo, under the penalty of perjury, you certify that you have given true, accurate, and complete statements ta the best of your knowledge, for each household member for whom ‘you are applying including the information concerning citizenship and alien status. ‘By signing this application on paper or electronically, you are giving us permission to deliver, or cause to be delivered, automated phone calls and text messages regarding your case at the primary phone number you provided ‘on page 1. You do not have to consent to this as a condition of eligibility. tf you do not want to be contacted in this ‘manner, you can opt out of getting these calls or messages. Check here: Clopt out of calls Clopt out of texts Clopt out of calls and texts + ‘SIGN HERE: our Signatures Date Dernakn}t deze Signature of witness theeded if you cannot sign your name): Date: Soe Find an office: Need help? * Visit [Link] to start a chat, check the status of your benefits, or report changes * Call 855-FSD-INFO (855-373-4636) to speak with a team member + Relay Missouri 741 ‘© T7Y users can call 800-735-2966 f you are blind or visually impaired and would like information about rehabilitation services for the blind, please call 800-592-6004, Establishing paternity is not required for SNAP benefits. However, if you want assistance in establishing paternity, please contact the FSD Paternity Hotline at 855-454-8037. If you are a Veteran in the state of Missouri and are interested in learning more about benefits and resources available to you and your dependents, visit: [Link] Orscan the QR code. ‘MO 886-0460 (1-2025) Page 8ofs. F5-1 (4-2025)‘MISSOURI 38. gcuss ND 4v exp 06/05/2030 44.0. No. $100191023 en, 8 1330 CO RD 450 POPLAR BLUFF, Mo 63901 om 5 00 241001140015 06/05/74 es 5-11" iseves BLU Doma! a21° 2411581001910231001 Rev 01/27/2020 06/05/1974 CLASS: ND-Nondriver identification ENDORSEMENTS: Sticker