If you need assistance completing this application, please ask an Office of Public Assistance staff member icon

If you need assistance completing this application, please ask an Office of Public Assistance staff member


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1DPHHS-HCS-250 STATE OF MONTANA

(Rev07/09) Department of Public Health and Human Services


If you need assistance completing this application, please ask an Office of Public Assistance staff member.


COMPLETION INSTRUCTIONS:

The Montana Department of Public Health and Human Services (DPHHS) offers several programs to help you.


Use this application to apply for:

  • Medicaid

  • Medicare Savings Programs

  • Supplemental Nutrition Assistance Program (SNAP) benefits

  • Temporary Assistance for Needy Families (TANF) cash assistance

  • Refugee Cash Assistance (RCA), Refugee Medical Assistance (RMA) or Refugee Social Services (RSS) – including Refugee Employment & Training (RET).



1. If you don't have time to complete the full application now, complete the entire first page, including signature, and turn in only the top copy of the first page today.

2. If you are eligible for SNAP benefits or RCA, benefits may start from the date the front page of the application is received. If you are eligible for TANF cash assistance, benefits may start from the date the front page of the application is received, or the date you enroll in the WoRC program, if referred, whichever is later. If you are eligible, Medicaid may begin up to three (3) months prior to the month of application. If you are eligible for RMA, benefits start the first of the month in which you applied or the date your refugee/asylee status was granted, which ever is later.

3. You may be entitled to receive SNAP benefits within seven days (expedited service). See the back of page 1 for details.

4. Complete the entire application to the best of your ability.

5. Please use black or blue ink (it is easy to read and copies best). Print your answers.

6. If more space is needed to answer any question, attach an additional sheet with appropriate information about each additional person.

7. The application should be filled out by a household member or an authorized representative who knows the financial situation of all household members. The person completing the application is responsible for the answers given.

8. Any question that refers to “household” is referring to those persons applying for assistance and those financially responsible for them. For Medicaid, Refugee Medical and SNAP benefits, you need to enter the Social Security number and citizenship.

9. All questions are marked to indicate the program(s) to which they apply.

M for Medicaid, (Medicaid or Refugee Medical Assistance)

S for SNAP Benefits

^ C for TANF or Refugee Cash assistance


Please pay particular attention to these codes in the white section of the application.

10. If NOT applying for Medicaid or Refugee Medical Assistance (M), you can skip questions 35 through 41 (light blue background).

11. If NOT applying for SNAP Benefits (S), you can skip questions 42 through 51 (green background).

12. If NOT applying for TANF or Refugee Cash Assistance (C), you can skip questions 56 through 59 (light orange background).



^ 1 DPHHS-HCS-250 STATE OF MONTANA

(Rev. 07/09) Department of Public Health and Human Services


APPLICATION FOR ASSISTANCE

Date Application Received:_____________________

Case Number _______________________________

Date of Interview: ____________________________

 TANF  FS  Exp.  MA  MSP

1^ GRAY SHADED AREAS ARE FOR INSTRUCTIONS AND AGENCY USE ONLY.

Name: County : ___________________

Street Address: ___________________________ City:___________ Zip:_____Day Phone Number: ____________________ Mailing Address: ___________________________ City:___________ Zip:_____Message Phone Number: _______________

E-Mail Address: ___________________________________________

Do you live within the geographic boundaries of an Indian Reservation? ____ Yes ____ No

If you do not live at a street address, on a separate piece of paper describe how to get to your home.

Fill in all required blanks for everyone who lives with you either permanently or temporarily. You must list yourself first, then your spouse and children, including unborn children, then other adults and children. (Individuals under age 22 must list their parents if living in the same home with their parents.) If you are only applying for SNAP benefits, please list yourself, your spouse, children under age 22, and any others who purchase and prepare meals with you.

M - required for Medicaid/Medicare Savings Program (MSP) and Refugee Medical Assistance, S - required for SNAP or

C - required for TANF or Refugee Cash Assistance

1^ Name

(Last, First, Middle)

Relation-ship To You

Requesting

Yes/No

Birth date

(M,C)


Place

of Birth

(M,C)


Sex

Social Security

Number

(M,C)


Marital

Status

U.S. Citizen

Yes/No

Medicaid

Medicaid/MSP

SNAP

TANF

1.

SELF




























2.































3.































4.































5.































6.































1(S) SNAP Expedited Service Questions


What is the total income before deductions your household

has received or expects to receive this month?

If zero, enter zero. $____________

How much do the members of your household

have in cash and savings? (Give your best estimate)

If zero, enter zero. $____________

How much is your monthly rent/mortgage?

If zero, enter zero. $____________

How much are your current monthly utilities?

If zero, enter zero. $____________

Is anyone in your household a migrant or seasonal

farm worker? ___ Yes ___ No

County Use


Income less than $150 and

cash and savings no more

than $100? ___ Yes ___ No

(If yes, expedite)

Combined income and resources

less than rent/mortgage and

utilities? ___ Yes ___ No

(If yes, expedite)

Destitute migrant/seasonal farm

worker with liquid resources not

exceeding $100? ___ Yes ___ No

(If yes, expedite)

Screened for expedited services: ___Yes ___No ___ Yes ___ No

Eligible for expedited services: ___Yes ___No ___ Yes ___ No

__________ Worker Initial

^ Penalty Warning: I swear or affirm that the statements made on this application are true or correct.


X

Signature or Mark of Applicant (or legal guardian/authorized representative). Date




Witness to Mark (necessary only if applicant cannot sign full name) Date

1Distribution: White - County, Yellow - to remain attached to application form

1INTERVIEW:

1. After your application is filed, you will be notified of the time and date of your interview (if needed). An interview is not required, but is recommended for Medicaid. Complete as much of the application as you can. A worker will help you with any unanswered questions at the interview. If you do not have all necessary information, this could delay a decision on your application.

2. For SNAP benefits, TANF cash assistance and Refugee programs, if you cannot keep your appointment (if needed), you must schedule another appointment within 30 days of the application date. If you do not schedule another appointment, your application will be denied.

3. If you are not able to appear for an interview or you are unable to find someone to represent you, call your County Office of Public Assistance to schedule a home visit or phone interview.


^ TO GET SNAP BENEFITS WITHIN 7 DAYS (EXPEDITED SERVICE): You may be entitled to expedited services if your income and resources are not enough to cover your monthly rent/mortgage and utilities, or you have very little income or resources, or your household includes a migrant or seasonal farm worker.

1. Complete the application and provide proof of identity of the person listed as number 1 on the first page. If an authorized representative applies for the household, the identity of the person listed as number 1 on the first page and the authorized representative must be verified.

2. If you do not have time to complete this form now, complete the front page and turn it in now. This will ensure your benefits start from today if you are eligible for SNAP benefits.

3. You must complete all questions not marked with a specific code and all questions marked with the letter S.

4. If you are eligible for expedited service, you will receive SNAP benefits for this month even if you cannot provide all the proof needed at this time.

5. If you feel you are eligible for expedited services but your worker says you are not, you may ask for an administrative review or may request a fair hearing either orally or in writing.

6. If you are not eligible for expedited service, your application will be processed within 30 days following the date the signed application was received.


^ RIGHTS AND RESPONSIBILITIES:

1. You have the right to file an application on the same day you contact us. You may either leave the entire application or completed front page or mail it to your County Office of Public Assistance.

2. You do not have to be interviewed or have a scheduled appointment before filing the application.

3. Your application will be processed within 30 days for SNAP benefits and Cash Assistance, and 45 days for Medicaid and Refugee Medical Assistance from the date of application except in unusual circumstances as defined by regulation.

4. Applicants soon to be released from an institution may make application for SNAP benefits prior to their release. The application filing date for pre-release applicants is the date of release from the institution.

5. For SNAP benefits, do not:

 trade or sell SNAP benefits;

 use SNAP benefits to get ineligible items such as alcoholic drinks, tobacco, or pay on credit accounts; or

 use someone else's SNAP benefits for your household or let someone use your benefits.

6. For SNAP and RCA benefits you will be required to repay any benefits for which you aren’t eligible, including errors caused by this agency. You will be required to repay any TANF, RMA and/or Medicaid, benefits that you aren’t eligible to receive for any reason other than this agency’s error.

7. In accordance with federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, marital status*, political beliefs, religion or disability. (*Marital status is protected under State Law.)

To file a complaint of discrimination, contact USDA or HHS. For SNAP write USDA, Director, Office for Civil Rights, 1400 Independence Avenue SW, Washington D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). For Medicaid and Cash Assistance write HHS Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue SW, Washington D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TDD). USDA and HHS are equal opportunity providers and employers.


^ SNAP WORK REQUIREMENTS:

1. Individuals who are physically and mentally fit and between the ages of 16 and 60 shall be ineligible if they: (1) refuse without good cause to provide sufficient information to allow a determination of their employment status or job availability; (2) voluntarily and without good cause quit a job; or (3) voluntarily and without good cause reduce their work effort (and after the reduction, are working less than 30 hours a week).

2. Individuals who reside in a county with a SNAP Employment and Training Program may attend this program.

3. Cash Assistance work requirements do not apply to SNAP.


^ TIME LIMITED BENEFITS:

1. The household may not be eligible for TANF cash assistance benefits if a member of the household has received 60 months of TANF cash assistance benefits in any state. TANF time limits do not apply to Medicaid, SNAP benefits or Refugee programs.

2. An individual who is an able bodied adult without dependents may not be eligible for SNAP benefits if they have received 3 months of SNAP benefits in a 36-month period, unless they meet an exemption, or meet the work requirement.

3. Refugee Cash Assistance and Refugee Medical Assistance are only available to eligible refugees/asylees for 8 months from date of entry or from the date their asylum status was granted. However, Refugee Social Services, such as employment and training assistance, could extend up to five years from date of entry/ date asylee status was granted, depending on federal funding. This application form is not required to apply for Refugee Social Services. For more information about the Refugee Social Service Program, please ask your Office of Public Assistance Case Manager.


^ PENALTIES: SNAP AND TANF CASH ASSISTANCE PROGRAMS:

1. It is unlawful for you to knowingly make false statements, misrepresent facts, or conceal information to obtain benefits.

2. Individuals who knowingly and intentionally break a rule can be prosecuted and fined. Under SNAP, the fine may be up to $250,000 or you may be imprisoned up to 20 years, or both. Individuals are also subject to prosecution under other applicable federal laws. Individuals may also be barred for an additional 18 months if court ordered.

3. Any household member who knowingly and intentionally breaks a SNAP or TANF cash assistance rule can be barred from the program for one year for the first violation; for two years for the second violation; and permanently disqualified after the third violation.

4. Any SNAP recipient who has been found guilty in a federal, state or local court of trading SNAP benefits for controlled substances (illegal drugs or certain drugs for which a doctor’s prescription is required) will be disqualified from participation for two years for the first offense and permanently for the second offense.

5. Any SNAP recipient who has been found guilty in a federal, state or local court of trading SNAP benefits for firearms, ammunition, or explosives will be permanently disqualified from participation upon the first occasion of such violation.

6. An individual shall be permanently disqualified from SNAP if he/she is convicted of trafficking SNAP benefits of $500 or more.

7. An individual shall be ineligible to participate in SNAP for ten years if he/she is found to have made a fraudulent statement or representation with respect to identity and/or residence in order to receive multiple benefits simultaneously.

8. For TANF cash assistance, an individual shall be ineligible to participate in the TANF cash assistance program for 10 years if he/she is found to have made a fraudulent statement or representation with respect to where they live or benefits received in another state in order to receive multiple benefits simultaneously.


(M-S-C)1. Are you a Montana resident?  Yes  No


(C) If yes, please check how long.  Less than 1 Month  1-6 months  6-12 months  over 12 months


(C) 2. If you have lived in Montana 12 months or less, list the state or country you came from: _________________________________________________________________________________


Please check one reason why you moved to Montana:

 Work  Like Montana  Relatives  Cash Assistance (TANF) time limits used up in another state  Other


(M-C) 3. List the name, address and telephone number of anyone who acts as a legal guardian or has Power of Attorney for any household member. Bring copy of legal document (See question # 4 below to designate an authorized representative for SNAP, if desired.)








(M-S-C) 4. You can choose an AUTHORIZED REPRESENTATIVE to help you with your Medicaid, RMA, SNAP or Cash Assistance.


Do you want your authorized representative to help you with your cash
assistance or Medicaid card?  Yes  No


Do you want your authorized representative to help you apply for your
SNAP assistance?  Yes  No


Do you want your authorized representative to have access to your Montana
Access SNAP account and use your benefits to buy food for you?  Yes  No


^ Do you want your authorized representative to receive your letters or notices?  Yes  No


List the authorized representative’s name, address, and telephone number below. (You can name multiple authorized representatives for a case but for Medicaid and RMA, only one per individual. If additional representatives are named please complete the following information on an additional piece of paper.)





^ Last Name First Name Middle Initial Phone




Mailing Address City Zip


(M-S-C) 5. Is any household member temporarily out of the home?  Yes  No

If yes, list name, date left, date to return, where person went (such as in the hospital, away at school, looking for work, etc.)





(M-C) 6. Is anyone in your home pregnant?  Yes  No

^ Who is pregnant?


Expected date of delivery

Number of fetuses (twins?)

Name of father of unborn(s)

























(Medical proof of pregnancy will be required.)


(S-C) 7. Do you share your home with others not listed on the front page?  Yes  No

If so, please list names:


(M-S-C) 8. Has anyone listed on page 1 ever used another name (such as a maiden name, former

married name, etc.) or Social Security Number?  Yes  No

If yes, please provide details:






(M-S-C) 9. Is any household member currently attending school?  Yes  No

If Yes and applying for Medicaid, Refugee Medical Assistance, TANF or Refugee Cash, please complete the following box by entering data for each household member age 16 or older.

^ Household Member Name

Attending school (list name of school)


No Degree/

GED/

Diploma

High

School

Diploma/

GED



Associate’s

Degree



^ Bachelor’s Degree



Other Credentials

































































VOLUNTARY: Please complete questions 10 and 11 for all household members. These questions regarding ethnic and racial background will not be used to determine your benefit level or eligibility. If you do not answer, your worker will complete this section. Questions about ethnic and racial background are authorized by Title VI of the Civil Rights Act of 1964. The reason for the information is to assure that program benefits are distributed without regard to race, color, or national origin.

(M-S-C) 10. Please mark one ethnic category for each household member.

^ Household Member Name

HL

Hispanic/Latino

NH

Non-Hispanic/Latino





































^ IF MORE SPACE IS NEEDED, ATTACH A SEPARATE SHEET


(M-S-C) 11. Please mark one or more racial heritage categories for each household member.

^ Household Member Name

AI

American Indian or Alaskan Native

AS

Asian

PI

Native Hawaiian or Pacific Islander

BL

Black or African American

WH

White









































































^ IF MORE SPACE IS NEEDED, ATTACH A SEPARATE SHEET


(M-C) 12. If anyone in the household is an enrolled tribal member, enter the individual’s name, the name of the tribe, and the tribal enrollment number.

Name

Tribal Name

^ Tribal Enrollment Number





































^ IF MORE SPACE IS NEEDED, ATTACH A SEPARATE SHEET


(M-S-C) 13. Is anyone in your household a roomer or boarder (pays for room and/or meals)?  Yes  No

If yes, please list who.


(M-S-C) 14. Is anyone unable to work or disabled because of physical or mental health problems?

(If a payment is not being received, additional information or proof may be required.)  Yes  No

^ If yes, complete the following:

Name

Medical condition

^ Source of disability payment






















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