us-hi/policy/acf/tanf-plan

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us-hi/policy/acf/tanf-plan · Axiom

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Page | 1 Part A - Program Goals, Administration, and Implementation

1.0 GOALS AND OBJECTIVES

Hawaii's Temporary Assistance for Needy Families (TANF) program provides cash assistance benefits to needy families with (or expecting) children, and case management, employment, and supportive services to adult TANF recipients through the First-To-Work (FTW) program, to enable them to obtain and retain employment, exit TANF, and become financially independent.

The following statements were used as guiding principles in the design of Hawaii’s TANF program when welfare reform was executed under the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA):

A. Welfare is temporary and not a way of life. B. Parents, not government, are responsible for the support and maintenance of their children’s well-being. C. Parents who are able to work, must work. D. Families must be financially better off by going to work than staying on welfare.

To achieve these objectives, the program uses a combination of positive incentives and adverse actions to challenge applicants and recipients to move away from welfare dependency and toward a future of financial self-reliance. The adverse actions include the sixty-month time limitation and welfare grant reductions for households that contain at least one (1) work eligible individual, and penalties for failure to participate in work activities. The positive incentives include exclusion of the earned income of dependent children who are full-time students; disregard of assets and resources; exclusion of all educational loans, grants, and scholarships; and increased earned income disregards so that a family remains eligible for welfare assistance until their gross income exceeds 185% of the federal poverty guideline (FPG) or their net earned income exceeds 48% of the FPG by household size (Note: Hawaii's FPG is legislatively capped at the FPG for 2006).

2.0 PROGRAM ADMINISTRATION

The State Department of Human Services (DHS)

DHS is the single state agency responsible for administering the TANF program in Hawaii, in accordance with Title IV-A of the Social Security Act, as amended by the PRWORA and the Deficit Reduction Act of 2005 (DRA), and all other applicable federal laws and regulations and provisions of this State Plan.

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Page | 3 5.0 PROGRAM AND FISCAL INTEGRITY

5.1 Regulations, Policies and Procedures

The TANF program operates using uniform policies on all islands (counties). The Department's regulations are promulgated in accordance with the Hawaii Administrative Procedures Act, Chapter 91, Hawaii Revised Statutes (HRS), which provides the public with an opportunity for notice, review, and comment.

Approved regulations are distributed to all state and contracted staff, who are responsible for TANF program operations, via the Hawaii Administrative Rules (HAR) manual. Policy clarifications and emergency bulletins are also distributed to all affected staff statewide on an as needed basis.

5.2 Fraud and Financial Integrity

DHS identifies situations in which there are questions or suspected fraud such as, but not limited to, a recipient receiving financial assistance to which the individual is not entitled to receive. The suspected fraud may be the result of willful misrepresentation of the individual's circumstances or the intentional concealment of information from the Department.

In the BESSD organization, the Investigations Office investigates suspected fraud and refers cases, as appropriate, to law enforcement officials.

The methods of investigation used by the Department do not infringe on the legal rights of the persons involved and allow these individuals due process of law.

Administrative rules governing the Department's fraud provisions can be found in Chapter 17-604.1, Hawaii Administrative Rules.

5.3 Public Law 112-96

Hawaii has implemented Public Law 112-96, Section 4004, requiring policies and practices to prevent assistance from being used in any electronic benefits transfer (EBT) transaction in any liquor store; any casino, gambling casino, or gaming establishment; or any retail establishment which provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment by utilizing client notification and agreement. Initially to meet the requirements, a mass mailing of the notice was sent to current recipients in July 2014 with information on the restriction along with a list of restricted locations. Additionally, all recipients are notified at the point of applying for TANF that there is a restriction on accessing TANF benefits at specific locations. This information on the restriction on the use of TANF benefits from prohibited locations or establishments is included in form DHS 1240, Application for

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Page | 4 Financial and SNAP Assistance. By signing the application form (also used the annual recertification form), the applicants and recipients agree to abide by the restriction. The instruction pamphlet on the use of the EBT card has also been revised to include the restriction.

See Attachments A-2, form DHS 1240, Application for Financial and SNAP Assistance, and A-3, pamphlet, How to Use Your Hawaii EBT Card.

6.0 CLIENT PROTECTIONS 6.1 Confidentiality

The rules regarding the use and disclosure of information about individuals and families receiving assistance are consistent with the rules that guided the program under Title IV-A of the Social Security Act of 1935 prior to the enactment of the PRWORA. The rules protect the rights of individuals and permit the release of information to programs operating in connection with the TANF program, i.e., federal funded or federal assisted programs providing assistance based on need, or for appropriate audit purposes, or to appropriate local, state, and federal law enforcement officials. Pertinent administrative rules governing confidentiality can be found in Chapter 17-601, HAR.

6.2 Administrative Hearing and Appeals Process

Hawaii provides a timely and adequate notice to the recipient that is mailed at least ten (10) days prior to an adverse action (i.e., reduction or termination of benefits) and provides opportunities for clients who have been adversely affected to be heard in a state administered appeals process. There is a set time limit for a client to request an administrative hearing; and for the Department to conduct the hearing and render an administrative decision. Administrative hearings are presided over by impartial hearing officers. Clients are allowed to present their appeals independently; be represented by legal counsel or authorized representative; bring witnesses to the hearing; ask questions and cross-examine during the hearing; and present additional evidence to support their appeal. If dissatisfied with the decision rendered by the hearing officer, the client may file a notice of appeal with the circuit court. Administrative rules governing administrative hearings can be found in Chapter 17-602.1, HAR.

6.3 Limited English Proficiency

Hawaii has policies and procedures for providing interpreter and translation services. We provide a bilingual interpreter at no charge and have entered into a Resolution Agreement with the U. S. Department of Health and Human Services, Office for Civil Rights, related to this effective August 18, 2008.

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Page | 5

7.0 MAJOR STATE POLICIES AND ADMINISTRATIVE PROVISIONS

7.1 State Temporary Assistance for Other Needy Families Program

Hawaii provides assistance to eligible non-U.S. citizen households, as defined in the Welfare Reform, paid with segregated state maintenance-of-effort funds, under the Temporary Assistance for Other Needy Families or TAONF program. TAONF is a parallel program that has the same payment and program eligibility requirements as TANF. TAONF households include an eligible non-U.S. citizen member, or is a minor single- or two-parent household living independently.

7.2 Domestic Violence Option

In March 2002, the State implemented its domestic violence policy. Domestic violence status is limited to six (6) months with a possible extension of an additional six (6) months. Work eligible individuals who are granted a domestic violence status are assessed by contracted service providers that specialize in domestic violence and advocacy services. The work eligible individuals are required to participate in activities that will address the domestic violence crisis and their family’s needs. Domestic violence services are provided statewide. Compliance with services is a condition of receiving TANF or TAONF assistance and the domestic violence status which grants good cause from meeting work requirements. Effective January 17, 2008, non-compliance with services will result in a full family sanction.

Please refer to subsection 13.9 for more information on the domestic violence status.

7.3 Temporary Disability

7.3.1 Hawaii recognizes that work eligible individuals, who are temporarily disabled, may not meet work activity requirements or obtain and maintain employment. Work eligible individuals, who claim a physical or mental disability, may be granted good cause from work requirements if the disability is certified by the medical evaluation board (see subsection 7.3.2 below). The temporarily disabled individual must comply with their substance use disorder treatment plan, or vocational rehabilitation or treatment services, or both, which may reasonably expect to lead them to employment and financial independence. Individuals diagnosed as temporarily disabled with a substance use disorder or with a physical and/or mental disability receive vocational rehabilitation case management services from a contracted service provider. The entire household is sanctioned if the disabled work eligible individual refuses or fails to comply with treatment (see subsection 13.5).

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Page | 6 7.3.2 Effective January 2005, medical evaluation services, conducted by a board of licensed physicians and psychologists, are provided to determine whether a work eligible individual's disability is temporary or permanent and interferes with their ability to engage in any substantial gainful employment of at least thirty (30) hours per week at a job for which he or she is equipped by education, training, or experience. The medical evaluation board ensures that TANF recipients between the ages of eighteen (18) and sixty-five (65) years are afforded a fair and consistent evaluation of disability and determines appropriate treatment services, vocational rehabilitation services, or work activities that the individual can be expected to perform.

7.4 Work Eligible Individuals with Good Cause from Work Requirements

A special work participation status, referred to as an “other work eligible individual” or “OWEI”, for a work eligible individual who is unable to engage in work activities or employment due to one of the following reasons:

A. The individual is unable to engage in full-time employment as defined by the work participation requirements of the Social Security Act, 42 U.S.C. section 607, at a job for which he or she is equipped by education, training, or experience, for a period of more than thirty days from the onset of an illness, incapacity, or disability due to a physical or mental impairment or substance use disorder, as determined by a licensed physical or psychologies (see subsections 7.3 and 13.4 for more information on temporary disability); B. Domestic violence crisis situation involving the TANF household or member(s) of the TANF household (see subsection 7.2 and 13.9 for more information on the domestic violence option); or C. The individual is sixty-five years of age or older. An OWEI, who meets one of the above criteria, is granted good cause from meeting the work activity requirements described in 45 CFR Part 261, section 261.31.

7.5 Extended TANF Sixty-Month Time Limit Due to Hardship

Pursuant to 45 CFR Part 264, section 264.1(c), Hawaii provides TANF or TAONF assistance beyond the sixty-month time-limit if the household is experiencing hardship that impedes their ability to engage in work activities or obtain and maintain employment. Hardship is defined as follows:

A. The household has been confirmed to be in a domestic violence crisis by a domestic violence advocacy service provider (see subsections 7.2 and 13.9); or

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Page | 8 Part B - Assistance and Eligibility

8.0 APPLICATION AND ELIGIBILITY DETERMINATION

8.1 Application Process

Households requesting financial assistance through the TANF program must file an application form; completed an eligibility interview conducted by an employee designated by the Department; and provide information and documentation pertaining to the household unit or individual household member(s) when requested by the Department designee. Form DHS 1240, Applications for Financial and SNAP Assistance, may be obtained and submitted at any processing center statewide or online through the Public Assistance Information System or PAIS. Families may request an application form to be mailed by calling the Public Assistance Information Line at 1-855-643-1643. Processing centers are open during regular business hours, Monday through Friday, but are closed on all state holidays.

During the application eligibility interview, forms DHS 1242, TANF Memorandum of Understanding; DHS 1259, First-To-Work Referral and Requirements; and DHS 1247, Notice of Requirement to Cooperate with Child Support Enforcement Agency and Right to Claim Good Cause, are reviewed with the applicant. The applicant household is informed of the sixty-month time-limit to receive financial assistance benefits, work program participation requirements, cooperation to child support establishment as a condition of TANF eligibility, and the consequences if requirements are not met.

The Department must make a disposition on an application within forty-five (45) days. The 45-day period begins on the date a processing center receives the application form containing, at a minimum, the applicant's full name, address, and signature. The 45-day period ends when financial assistance benefits are authorized or when a notice is mailed to the applicant household that their application for financial assistance has been denied or discontinued.

8.2 Eligibility Redeterminations and Reporting of Household Changes

8.2.1 A household is certified eligible for benefits for a period of twelve (12) months following their initial eligibility determination for TANF financial assistance. The household must be recertified on an annual basis by submitting a new DHS 1240 application form; completing an eligibility interview; and providing information and documentations necessary to determine continued eligibility for the subsequent twelve (12) months.

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Page | 9 8.2.2 A TANF recipient household with no elderly or disabled members, who have earned income and receives SNAP benefits, is required to complete a simplified report form, semi-annually, to confirm that no changes occurred during the previous six (6) months that would alter their continued eligibility. The household is required to report on the simplified report form and provide documentation of changes to their household composition, income, and other eligibility factors. The processing center will determine whether the household continues to be eligible for financial assistance for the remaining six (6) months of their certification period. 8.2.3 In addition to the semi-annual and annual eligibility redeterminations, a recipient household must report and provide verification of any changes to their household composition and/or income within ten (10) days of the date the change became known to the household.

9.0 ASSISTANCE UNIT

9.1 Definition of Eligible Family

9.1.1 To be categorically eligible for TANF, a family must include a needy dependent child under the age of eighteen (18) years and the child’s natural or adoptive parent(s) or a specified relative if the child’s parents are absent. A child aged 18 years may remain eligible if the child is a full-time high school student or is enrolled in a program of an equivalent level of vocational or technical training, until graduation or when the child reaches age nineteen (19), whichever occurs first.

A. A specified relative is defined as the designated relative who provides care and supervision of the dependent child and lives in the same household. The specified relative may include the following individuals in relation to the child:

1. Brother, sister, half-brother, half-sister, uncle, aunt, uncle half- blood, aunt half-blood, great uncle, great aunt, great uncle half- blood, great aunt half-blood, grandfather, grandmother, great grandfather, great grandmother, first cousin, first cousin once removed, nephew or niece, great-great grandfather, great-great grandmother, great- great-great grandfather, great-great-great grandmother, great-great uncle, great-great aunt, great-great uncle half-blood, great-great aunt half-blood; 2. Stepfather, stepmother, stepbrother, and stepsister;

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Page | 10 3. Other natural or legally adopted children and relatives of the adoptive parents; 4. A hanai father or hānai mother. “Hanai”, in the Hawaiian culture, refers to the informal adoption of a child, taken permanently to be reared, educated, and loved by someone other than the child’s natural parents at the time of the child’s birth or in early childhood. A hanai parent may be a relative or not related to the minor child. The child was given outright, and the natural parents renounced all claims to the child; and 5. The legally married spouse of any of the persons specified above, even after the marriage ended in death or divorce.

B. A specified relative must apply for TANF benefits on behalf of the dependent child, and the relationship between the child and the specified relative must be verified through birth certificates, marriage certificates, or other legal documents such as a divorce decree or court documents establishing guardianship (i.e., for hanai parents or custody in divorce). A specified relative, who does not need assistance, may be excluded from the TANF household for the purposes of determining eligibility and the amount of TANF benefits for the needy household members.

9.1.2 In situations where the state has obtained legal custody of a child and has placed that child under the care and supervision of a person other than the parent, the following shall apply:

A. The parental relationship shall not be recognized for the purpose of determining the TANF household composition, even if the natural, adoptive or hanai (i.e., formal and informal adoption) parent is living in the same household; and B. The sibling relationship shall not be recognized if the natural, adoptive or hanai parent is living in the same household and has other children or stepchildren living in the home for whom the state has not obtained legal custody.

9.1.3 In situations where an adopted child is living with both the adoptive parent and a natural or hanai parent the following shall apply:

A. The natural or hanai parent relationship shall not be recognized for the purpose of determining the TANF household composition; and B. The sibling relationship shall not be recognized if the natural or hanai

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Page | 11 parent has other children or stepchildren living in the household who have not been adopted.

9.2 Pregnant Woman Without Dependent Children

A needy pregnant woman with no dependent child may be eligible for TANF financial assistance from the first of the month in which the woman begins her ninth month of pregnancy, provided:

A. There is a doctor's written statement to verify the pregnancy and the expected date of birth of the child. B. The pregnant woman and the unborn child together is considered as one person for the purpose of determining the amount of TANF assistance; and C. The income of the unborn child’s father shall be counted towards determining eligibility for the pregnant woman if they are married and residing in the same household, otherwise, the father’s income will not be counted in determining eligibility until the child is born. 9.3 Minor Child

Hawaii defines a minor child as a needy dependent child under age eighteen (18) years, or under age nineteen (19) years if the child is a full-time student in a secondary school or in a vocational or technical training program of equivalent level. Effective January 15, 2008, a needy child under the age of eighteen (18) years is required to participate with the FTW program if the child is not a full-time student or has completed secondary school or an equivalent level of vocational or technical training.

10.0 ELIGIBILITY, INCOME, AND RESOURCES The Hawaii Legislature sets the income standard, in state statutes, at a percentage of the FPG. The monthly gross income standard is 185% of the standard of need (SON). Effective July 1, 2007, the SON is set at one hundred percent (100%) of Hawaii’s 2006 FPG in accordance with section 346-53, HRS. Effective July 1, 2009, the standard of assistance (SOA) is 48% of the SON. The SOA is further reduced by 20% if the TANF household includes a work eligible adult and the household has received their first two (2) full months of assistance at the 48% standard.

To determine eligibility, the household must meet specific income requirements. The prospective income (earned plus unearned) of each household member is evaluated. If not excluded by rule or regulation, the household’s monthly income is tested prospectively against the gross income standard based on the applicable household size.

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If the household meets the gross income standard, then deductions are applied to the household’s earned income, if applicable. The sum of the household’s unearned income and adjusted earned income (i.e., after deductions) is then compared to the SOA. The difference between the SOA for the applicable household size and the sum of the household’s countable income will be the household’s monthly financial benefit amount. If the sum exceeds the SOA, then the household is not eligible for TANF financial assistance.

10.1 Gross Income Test

A household’s countable gross income is determined based on all actual unearned and earned income, unless excluded by rule or regulation. In accordance with section 17-676.54.1, HAR, a household’s total monthly gross income may not exceed one hundred eighty-five percent (185%) of Hawaii’s 2006 FPG for the applicable household size.

10.2 Earned Income Deductions

The following deductions are applicable to earned income only.

10.2.1 If a household meets the gross income standard, then following deductions are applied for each countable earned income:

A. Standard Deduction of 20%; B. Flat Rate Deduction of $200; C. Earned Income Disregard of 36% or 55% (see subsection 10.2.2 below); and D. Deduction for Dependent Care Expense, when applicable.

After the above deductions are applied, the total remaining income is compared to the SOA to determine the household’s financial benefit amount (see subsection 10.3 below).

10.2.2 Households who received twenty-four (24) months or less of TANF benefits and are employed, are eligible for an Earned Income Disregard (EIDR) at fifty-five percent (55%) prior to determining the amount of assistance. Employed families who received more than twenty-four (24) months of TANF benefits are not eligible to receive the higher EIDR; therefore, the EIDR remains at 36%.

Gross Income

Minus 20% Standard Deduction Minus $200 Flat Rate Deduction Minus EIDR 55% (0 – 24 TANF months) or 36% (25+ TANF months)

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Page | 13 Minus $175, or Minus $165 Cost of care for a disabled adult household member up to $175, if applicant is full-time employed, or $165 if part-time employed. Remainder Countable income compared to the SOA (see subsection 10.3 below)

10.3 Determining Amount of Assistance

The difference between the SOA for the applicable household size and the household’s countable income after deductions (subsection 10.2 above) will be the household’s monthly financial benefit amount.

SOA for applicable household size Minus Countable income after deductions Household monthly benefit amount

If the household’s countable income after deductions exceed the SOA for the applicable household size, then the family is not eligible for TANF financial benefits.

10.4 Deemed Income

TANF has specific deeming requirements when there is a 1) husband, wife, or parent living in the same home, but not on assistance due to failing to furnish a Social Security Number, or an Intentional Program Violation disqualification, or being an ineligible immigrant parent; 2) stepparent living in the same home but not on assistance; and 3) parent of a minor parent living in the same home but not on assistance.

10.4.1 Deemed Income of Disqualified individuals

Any countable unearned and earned income of an individual who is disqualified from receiving assistance for failure to furnish a Social Security Number or due to Intentional Program Violation, is deemed available to the household provided the other household members may be claimed by the individual as dependents for federal income tax purposes. Income test described in subsection 10.1 is applied to determine eligibility; however, the disqualified individual is excluded from the household size when the amount of assistance is determined in accordance with subsections 10.2 and 10.3.

10.4.2 Stepparent or Parent of a Minor Parent:

A. Obtain the monthly total earned and unearned income of the stepparent. B. From the stepparent's monthly gross earned income, deduct a standard deduction of 20%. C. From the remainder, subtract the Department's specified SON to meet the needs of the stepparent and any other dependents who are living in the home who are not part of the financial assistance unit.

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Page | 14 D. From the remainder, subtract the actual amount paid by the stepparent for the support of dependents who are not living in the home (e.g., child attending school away from home). E. From the remainder, subtract all payments made by the stepparent for alimony and child support for persons not living in the household; and F. All the remaining income shall be considered available to meet the needs of the individuals receiving financial assistance.

10.5 Assets All assets are disregarded when determining eligibility for TANF financial assistance benefits.

10.6 Residency

Applicants/recipients must be residents of the state, but there is no minimum period a person must be living in the state to establish residency. Hawaii treats new families moving to the state the same as families already residing in the state. 10.7 Felony Substance Abuse The 1997 Hawaii Legislature passed Act 128 which specified that section 115(a) of Public Law 104-193 shall not apply in Hawaii to persons with a felony conviction which has as an element, the possession, use or distribution of a controlled substance, provided these individuals are complying with treatment or have not refused or failed to comply with treatment. This statute became permanent when the 1999 Hawaii Legislature passed Act 27 to remove the sunset clause.

10.8 Fleeing Felons A fleeing/fugitive felon interface is done semi-annually with the National Crime Information Center to identify any individuals who meet these definitions and who are receiving assistance in Hawaii. Any individual identified on this match is removed from financial assistance immediately.

10.9 Temporarily Absent from the Home “Temporarily absent” means the dependent child or the caretaker relative is not present in the home for a period not to exceed sixty (60) days, or for a household receiving supportive services through a plan approved by the department, not to exceed one hundred and eighty (180) days, provided that from the date of departure, there was a planned date of return.

There are no good cause exceptions for temporary absence beyond the allowable periods explained above.

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Page | 15 11.0 INCOME AND BENEFIT STANDARDS, ACCESS TO BENEFITS

11.1 Income and Benefit Standards

Effective July 1, 2009: HH Size SON1 Gross Income2 SOA3 SOA4 1 $939 $1,737 $450 $360 2 $1,265 $2,340 $607 $485 3 $1,590 $2,941 $763 $610 4 $1,916 $3,544 $919 $735 5 $2,242 $4,147 $1,076 $860 6 $2,568 $4,750 $1,232 $986 7 $2,894 $5,353 $1,389 $1,111 8 $3,220 $5,957 $1,545 $1,236 For each addit’l HH mem $326 $603 $156 $126 1. Standard of Need (SON) is 100% of the 2006 Hawaii FPG, established by the federal government effective July 1, 2006. 2. Gross income standard is 185% of the SON. 3. SOA is 48% of the SON. 4. SOA is reduced by 20% after the family received their initial two (2) full months of benefits and is applicable to mandatory work required TANF households, effective July 1, 2009.

11.2 Access to Benefits

11.2.1 TANF financial assistance is issued monthly to eligible households as direct cash assistance through the household’s EBT account, direct deposit into a personal bank account, or an imprest check. Imprest checks are issued only when the applicant faces an emergency and meets the emergency criteria.

Benefits are deposited automatically into the household’s EBT cash account each month and are available on the third (3rd) day of the month if the primary household member’s last name begins with letters A – I, or on the fifth (5th) day of the month for last names beginning with J – Z. Those who opted to receive their benefits via direct deposit into their bank accounts, will receive their benefits by the third (3rd) bank day of the month regardless of last name. Also, those with direct deposit who receive SNAP assistance will receive their SNAP benefits on the 1st calendar day of each month.

11.2.2 Households receive an EBT card to access their benefits. Benefits may be withdrawn from automated teller machines or ATM and point of sale or POS terminals to make a cash purchase or to obtain cash back within retail stores. Hawaii ensures access to assistance by providing two (2) free ATM transactions per month and ensuring there are ATM and or POS terminals in all geographical

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Page | 16 areas. There is no transaction fee when accessing benefits by way of a POS terminal. Recipients are also issued an EBT brochure, How to Use Your Hawaii EBT Card (Attachment A-3) which includes information on where benefits may be accessed. Any surcharges assessed by the ATM owner are the responsibility of the recipient. Excess transaction fees and surcharges are deducted from the recipient's account balance. Hawaii also has a process in place to address problems with access such as, but not limited to, when the recipient loses their EBT card or when the EBT card does not work. Recipients may also elect to access benefits by way of a direct deposit to a personal bank account designated by the primary payee. Recipients electing direct deposit are not issued an EBT card as access to benefits will be through their financial institution and any fees associated with their personal bank account is the responsibility of the recipient.

12.0 TIME LIMITS

12.1 Sixty-Month Time Limit

Receipt of TANF assistance is limited to sixty (60) months in the lifetime for all recipient households when there is an adult member who is deemed to be a work eligible individual. The time limit begins when the TANF household first receives assistance on or after December 1, 1996. A time eligible month is credited to each adult household member, for each month that the household received assistance. The determination of the number of months of assistance that has been received by a household is based on the adult household member that has the greatest number of used time eligible months.

12.2 Assistance Beyond the Sixty-Month Time Limit Due to Hardship

Pursuant to 45 CFR section 264.1, subsection (c), the state provides TANF or TAONF assistance to households beyond the 60-month time limit if the household is experiencing hardship. Please refer to subsection 7.5 for the state’s definition of hardship and the application of the hardship policy.

12.3 Time Limit Provision for Dependent Children

The time limit provision is not applied to minor dependent children who receive assistance and for child-only households in which the dependent children are the only recipients in the household.

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Page | 17 13.0 PROGRAM REQUIREMENTS, PENALTIES AND SPECIAL PROVISIONS

13.1 Up-Front Universal Engagement

Effective October 1, 2008, as a condition of eligibility for TANF benefits, applicants, determined to be work eligible individuals, are required to comply with work activity requirements within a twenty-one (21) day period, starting from the date of intake conducted by the FTW program. Work participation compliance prior to TANF approval is referred to as the Up-front Universal Engagement or UFUE. The Department conducts an initial assessment to determine if the applicant is required to participate in the FTW program. One adult in a two-adult household, must attend the FTW program orientation and an intake session within five (5) workdays from the date of eligibility interview.

13.2 Child Support Enforcement Agency (CSEA) When a biological or adoptive parent is absent, the family is required to comply, as a condition of eligibility, with the following requirements by cooperating with the CSEA: A. Identify the absent parent(s) of any child(ren) for which assistance is being applied for and provide information to locate the absent parent(s). B. Establish paternity if the child(ren) were born out of wedlock. C. Help to establish and obtain child support and medical coverage for the child(ren) who are receiving assistance, including past due child support. D. Determine rights to future Social Security, veteran, or other government benefits; and E. Reimburse the State any money given directly by the absent parent while the family receives financial assistance benefits. Applicants and recipients are notified of the child support requirements during their initial and annual eligibility interview (for recertification) and are provided with a copy of form DHS 1247, Notice of Requirement to Cooperate with Child Support Enforcement Agency and Right to Claim Good Cause.

An applicant or recipient is provided the opportunity to claim good cause if they believe cooperating with CSEA would not be the best interest of their family. The applicant or recipient will be required to provide evidence to support their good cause claim. If an applicant or recipient refuses to cooperate without good cause, the family will be determined ineligible for TANF benefits.

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Page | 18 13.3 Work Participation Requirements for Work Eligible Individuals (WEI)

Hawaii requires a parent or specified relative, who is determined to be a WEI and receives assistance, to engage in employment or work activities through the FTW program. An individual’s work program status is determined at the point of application, reassessed at their annual recertification, and when the individual's circumstance has changed. Individuals who are determined to be WEIs are referred immediately to the FTW program.

13.4 Work Participation Requirements for Other Work Eligible Individuals with a Disability (OWEI)

13.4.1 Work eligible individuals, who claim they are unable to work due to substance use disorder, or a physical or mental disability, are referred to contracted examiners for an assessment and a medical evaluation board for a determination whether the disability prevents the individual from working thirty (30) hours a week. If the medical evaluation board determines an individual to be temporarily incapacitated and unable to work, the individual’s work participation status is changed from WEI to other work eligible individual or OWEI, and is referred to the FTW Vocational Rehabilitation (FTW-VR) unit. The FTW-VR units provide case management services; monitor the OWEI’s compliance to a treatment or individualized service plan; and provide job preparation services. The work participation status is reviewed at the point of application, reassessed at their annual recertification, and whenever the individual's circumstances have changed.

13.4.2 An individual, who the Department has determined disabled due to a physical or mental impairment, including substance abuse, must engage in treatment services and vocational rehabilitation activities that may reasonably be expected to lead to employment (see subsections ).

13.5 Penalty for Non-Compliance

When a TANF recipient, who is a work eligible individual or other work eligible individual and is required to participate in the FTW program, does not comply without good cause to participate in the FTW program; refuses without good cause to accept full-time employment; terminates full-time employment without good cause; reduces full-time employment to less than thirty (30) hours per week without good cause; or does not comply with their treatment plan for a recipient who was determined disabled or recovering from substance use disorder, the entire household’s TANF benefits are terminated (i.e. case closure) and a sanction is imposed as follows:

A. For the first (1st) sanction, the household is ineligible for TANF until the household reapplies for benefits.

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Page | 19 B. For the second (2nd) sanction, the household is ineligible for a minimum of two (2) months or until the household reapplies for benefits, whichever is longer; or C. For any subsequent sanctions, the household is ineligible for a minimum of three (3) months or until the household reapplies for benefits, whichever is longer.

The sanctioned household must serve the entire sanction period. The household may reapply following the sanction period by submitting a new application form and meeting the UFUE requirements to re-establish eligibility for TANF (see subsection 13.1).

13.6 Good Cause Provisions

Good cause exists under the following circumstances:

A. Child care for a child under six (6) years of age is necessary for the individual to participate or continue participation in the FTW program or accept employment, and such care is unavailable. B. The employment would result in the household of the individual to experience a net loss of cash income. Net loss of cash income shall be determined as follows: 1) The Department shall determine the household's total projected gross income. The total projected gross income shall include, but is not limited to, earnings, unearned income, and cash assistance that would have been received if the individual had not refused or terminated employment. 2) The Department shall determine the total amount of necessary work-related expenses which would have been incurred if the individual had not refused or terminated employment. Work-related expenses shall include, but is not limited to, mandatory payroll deductions, actual cost of child care, transportation expenses, and cost of meals. 3) The necessary work-related expenses shall be deducted from the household's total projected gross income. 4) The net income amount determined in subsection 12.1 shall be compared to the financial assistance the household received at the time the offer of employment is made; and 5) The Department shall determine that there is a net loss of cash income when the net income amount determined in subsection 12.1 is less than the financial assistance the household received at the time the offer of employment is made.

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Page | 22 13.9.3 Domestic Violence Status

An individual is considered eligible for the domestic violence status if he or she has or has had a relationship to the alleged perpetrator of the violence as a spouse, reciprocal beneficiary, former spouse, former reciprocal beneficiary, person with whom the individual has a child in common, parent, child, person related by blood, person jointly residing or formerly residing in the same dwelling unit, or person with whom the individual has or has had a dating relationship regardless of whether they lived together at any time, and the victim has had to take one (1) or more of the following actions as protection or as a result of the domestic violence inflicted by the alleged perpetrator:

A. Has a current court order protecting the individual or other household members from the alleged perpetrator. B. Is a party to a pending divorce or custody action which involves issues of current or past domestic violence. C. Within the past twelve (12) months, has stayed in a domestic abuse shelter. D. Within the past twelve (12) months, has stayed with a friend or relative after having fled the home to escape or avoid a domestic violence situation, as supported by a sworn statement from that friend or relative. If the friend or relative is not available, another person who has personal knowledge of the Domestic violence situation may provide a sworn statement. E. Within the past twelve (12) months, has experienced an incident of domestic violence which resulted in the arrest, arraignment, or conviction of the alleged perpetrator of the violence. F. Within the past twelve (12) months, has been in inpatient or outpatient treatment for psychological, physical, or emotional abuse resulting from domestic violence. G. Within the past twelve (12) months, has been hospitalized, been in community placement or received emergency room treatment for medical or psychological injuries resulting from domestic violence; or H. Within the past twelve (12) months, has been subject to threats of death or grievous bodily injury to self or family and loved ones by the alleged perpetrator.

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Page | 25 Part C- TANF Work Program and Services

16.0 FIRST-TO-WORK (FTW) PROGRAM

In accordance with Title IV-A of the Social Security Act [42 U.S.C. 602], the state administers a statewide mandatory work program, First-To-Work (FTW), for families who apply for or receive TANF or TAONF benefits. The FTW program assists participants with job readiness training, education, employment-related activities, and case management and supportive services. Supportive services are offered to participants such as child care subsidies, transportation reimbursement, assistance with education and work- related expenses, job readiness training, and job development and placement services. Additional supportive services are available through contracted service providers who provide domestic violence advocacy and legal services, subsidized employment, and home visiting services. FTW also provides services to other work-eligible individuals who are unable to work due to a temporary disability, domestic violence crisis, or treatment from substance use disorder.

The FTW program utilizes a “work focused” approach which requires adults to participate in appropriate work activities as a condition of receiving assistance. The FTW program provides a wide array of services and supports that are designed to assist recipients to enter and remain in the workforce. FTW participants are required to meet specific weekly participation requirements based on the number of adults and the age of the children in the household.

17.0 SCREENINGS, ASSESSMENTS AND SUPPORT SERVICES PLAN

17.1 FTW Program Intake Assessments Individuals who are determined to be work eligible individuals (WEI) or other work eligible individuals (OWEI) are referred immediately to the FTW program and are scheduled to attend an orientation and intake session. During intake, a preliminary self- assessment is conducted to identify needs, strengths, and determine if the participant has any psycho-social, health, educational/skill, employment, and communication concerns that may be barriers to employment. Following the orientation and intake session, the participant completes an in-depth interview and the Hawaii Assessment and Personal Appraisal (HAPA) to further assess the participant’s employability. The interview includes questions about social capital, personal issues including relationships, current or past involvement with child protective services, physical, mental, and emotional health, criminal history, and substance abuse. The participant may be scheduled to take reading and math tests. The results of the testing and interview are scored and summarized to determine if the participant moves on to the Employability Assessment or if an in-depth Barrier Assessment is needed. The Employability and Barrier Assessments will result in the development of an Employment Plan, and/or a

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Page | 26 Barrier Reduction Plan. The Plans outline the goals, and the steps and activities that are necessary to achieve the goals.

17.2 Employability Assessment and Support Services Plan

The FTW program conducts an in-depth employability assessment that results in an Employment Plan (EP) and a Support Service Plan (SSP). The EP is a signed written agreement between the participant and the Department, that outlines the participant’s employment goal and the planned activities the participant will need to fulfill to achieve his/her employment goal. The SSP identifies the supportive services the participant may need to successfully participate with the FTW program and engage in their planned activities.

18.0 WORK ACTIVITIES

18.1 Unsubsidized Employment

Unsubsidized employment means full or part-time employment in the public or private sector that is not subsidized with TANF funds or any other public program. This includes employment with private for-profit and non-profit employers; government agencies; employment supported by the Work Opportunity Tax Credit and the Welfare-to-Work Tax Credit; and self-employment. Self-employment is defined as receiving income directly from one’s own business, trade, or profession rather than earning a specified salary or wages from an employer.

18.2 Subsidized Employment in the Private Sector – Supporting Employment Empowerment (SEE) Program

The SEE program was developed in October 2006. It is designed to assist FTW participants to obtain employment in the private sector. Under this program, the Department offers prospective employers’ reimbursement for wages paid and transportation expenses incurred for participants, and additional subsidies equal to 14% of the SEE wage reimbursement to assist employers with other incurred costs when employing FTW participants, such as training, unemployment insurance, workers compensation, and Federal Insurance Contributions Act or FICA deduction. The FTW participants are employed through the SEE program for a period not to exceed six (6) months.

The SEE program offers participating employers with reimbursements for wages paid, training costs, and transportation expenses incurred for the participant if they agree to hire FTW participants. Employment through the SEE program is for a period up to three (3) months; however, employment may be extended up to an additional three (3) months, not to exceed a total of six (6) months.

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Page | 27 18.3 Community Work Experience Program

Community Work Experience Program or Work Experience means a work activity, performed in return for public assistance, that provides a participant with an opportunity to acquire the general skills, training, knowledge, and work habits necessary to obtain employment. Participants may be placed with a public or private non-profit agency.

18.4 Job Readiness and Job Search Assistance

These are activities that focus on job readiness and job search assistance for participants, or short-term treatment for substance abuse, mental health, or rehabilitation for those who are otherwise employable. The immediate goal of these activities is for participants to gain full or part-time employment. Job search assistance is directed to the participant's interest and the local job market conditions and may serve participants in either group or individual job-seeking activities, or a combination of both methods. Job readiness training is conducted as group activities where participants learn to develop their resumes, acquire job searching skills, learn the appropriate etiquette for interviews, and soft skills, before they begin to seek employment opportunities.

18.5 Community Service Programs

Community Service Programs are structured programs in which participants perform work for the direct benefit of the community in return for public assistance. Participants are provided the opportunity to gain work experience and acquire job skills training through placements with public agencies or private non-profit organizations with community projects that serve a useful public purpose.

18.6 Vocational Education Training

The participants receive structured, specialized training from educational programs, other than a baccalaureate or advanced degrees that prepare individuals with technical knowledge and skills that are prerequisites for employment in current or emerging occupations.

According to the State Department of Business, Economic Development and Tourism (DBEDT), hospitals and nursing facilities and specialty health care services had the greatest number of jobs between 2010 and 2020 (DBEDT Hawaii's Targeted & Emerging Industries 2021 Update Report). In 2020, there were about 43,688 jobs in the hospitals and nursing facilities. The specialty health care services saw the great growth at 6.0% between 2010 and 2020 producing about 13,358 jobs.

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Page | 28 In accordance with P1 2011-06, Hawaii, as part of its vocational educational component, assists participants to obtain training that led to occupations in the health care industry. Training courses are not exclusive to a specific area of care; however, the learned skills are transferable between the various types of care including occupations that provide direct services in long-term care facilities and eldercare such as, but not limited to, certified nurse aid (CNA), massage therapist, and adult residential care home (ARCH) operator.

The FTW program supportive services include subsidies to cover course fees for FTW participants enrolled at a University of Hawaii (UH) community college campus for non- credit vocational programs in the healthcare industry such as nursing, CNA, ARCH services, and community health. Participants may earn certifications or credentials that allow them to work in long-term care facilities or work for community-based organizations that provide direct services in communities such as home visiting services. The FTW program encourages participants who are interested in the health care industry to enroll in these programs and assists participants to obtain employment after graduation or program completion.

18.7 Provision of Child Care Services to an Individual Who is Participating in a Community Service Program

This activity involves the provision of childcare services to an individual who is participating in a community services program.

18.8 Job Skills Training Directly Related to Employment

This is a post-secondary educational activity offered at the UH community colleges, or post-secondary vocational training programs that lead to recognized careers for which there is or will be a demand in the job market. Such trainings are utilized where there is potential for upgrading a participant's skills and employment prospects. Job skills training must be combined with any of the work activities above and can only be counted after a participant has completed their requisite core hours.

18.9 Education Directly Related to Employment

This activity includes education that expands a participant's ability to obtain employment, advance or earn a promotion, or adapt to the changing requirements of an occupation. Such activities may include adult basic education, English as a second language, or General Educational Development (GED) or high school equivalency. This activity must be combined with any of the work activities above and can only be counted after a participant has completed their requisite core hours.

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Page | 29 18.10 Satisfactory Attendance at Secondary School or Course of Study Leading to GED if the Recipient Has Not Finished Secondary School

A custodial parent under twenty (20) years of age (i.e., teen head of household), who has not completed high school or an equivalent course of education, is required to participate in these educational activities. The activities entail regular classroom attendance, in accordance with the requirements of the secondary school, course of study at a secondary school, or course of study that leads to a certificate of general equivalence.

Satisfactory attendance for teen heads of households, who are attending a secondary school or pursuing education directly related to employment, is defined as classroom attendance with no more than three (3) unexcused absences per semester. More than three (3) unexcused absences may result in a sanction.

19.0 POST-SECONDARY EDUCATION COMPONENT Hawaii developed an education component that encourages and supports FTW participants who are enrolled as full-time students at a post-secondary educational institution. The component provides an incentive to full-time student participants to continue their education by reducing their work participation requirement to twenty (20) hours per week, of which a minimum of four (4) hours per week must be of paid employment. Part-time students must fulfill the overall participation requirement of thirty (30) hours per week. For part-time students, once the educational hours are determined, the remainder of the required hours may be in either paid or unpaid work activity. This educational component was extrapolated from the Section 1115 waiver program granted to Hawaii entitled, “Creating Work Opportunities for Hawaii's Families," which was eventually merged into the Pursuit of New Opportunities or PONO waiver which expired in 2004.

All other components offered under the program are the traditional education, training, and work activities. Hawaii believes the combination of these activities provides the best opportunities to assist TANF participants to become self-sufficient.

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Page | 30 20.0 WORK PARTICIPATION REQUIREMENTS 20.1 Required Hours of Work Participation FTW participants are expected to perform thirty (30) hours per week of overall participation to simulate a full-time workweek. Of the overall participation requirement, twenty (20) hours per week must include participation in TANF core work activities. See section 18.0 above for descriptions of allowable work activities. Please refer to section I of the Hawaii TANF Work Verification Plan, amended March 28, 2016, for more information on work activities. 20.2 Work Requirements for Special Populations

Non-custodial minor parents: Hawaii does not require non-custodial, non-supporting minor parents to fulfill community work obligations and attend appropriate parenting or money management classes after school.

Other populations: Hawaii has contracted services for survivors of domestic violence, individuals with physical or mental disabilities and those suffering from substance abuse. Specialists in the appropriate field screen each of these individuals. If they meet the required standards, they are referred for contracted services, which include case management, compliance requirements, treatment, and employment planning. Please refer to subsections 13.9 and 25.18 for domestic violence status and services.

20.3 Unavailable Child Care

Hawaii will not sanction a single-parent household with a child under the age of six (6) years who is unable to obtain employment or engage in work activities through the FTW program due to the following reasons:

A. Unavailability of appropriate child care within a reasonable distance from the parent’s home or work site; B. Unavailability or unsuitability of informal child care by a relative or under other arrangements; or C. Unavailability of appropriate and affordable formal child care arrangements.

The FTW staff will assist the parent (i.e., FTW participant) by eliciting referrals to child care resources and reviewing the participant’s case to determine the availability of care. The parent will continue to participate with the FTW program, receive case management and supportive services, and receive financial assistance until such time child care is secured.

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Page | 32 Part D - Supportive Services

The supportive service programs described below are provided to TANF benefit recipient families and families who do not receive benefits but are determined TANF eligible, through a combination of state administered programs and programs provided by contracted service providers. Unless otherwise specified, families who meet the following criteria are deemed TANF eligible: A. There is a dependent child between the ages of zero and 23 years living with their custodial parent or other adult specified relative. B. Family or individual members who receive the services, are U.S. citizens or qualified immigrants who are residing lawfully in the U.S. in accordance with the Immigration and Nationality Act, 8 U.S.C. 1601 and P.L. 104-193, section 401; and C. Family’s monthly gross income does not exceed 300% of the 2022 FPG. A family must either be a TANF benefit recipient or meet the above criteria to receive State Maintenance of Effort (MOE) funded supportive services classified as TANF Purpose 1, 2, 3 or 4. Federal-funded supportive services provided under TANF Purpose 3 or 4 are not means-tested.

22.0 WORK SUPPORTS

22.1 Child Care Subsidies

TANF financial assistance recipients who are FTW program participants and TANF eligible families who are employed may be eligible to receive child care subsidies. The subsidies are based on the hours of child care provided or the hours of the parent's employment, whichever is less. Once the need is established, the subsidy payments will be the actual cost up to the established maximum rate, according to the type of care. There is no limit to the length of time that a family may receive child care subsidies. See Attachment C-1.

Child care subsidies are provided in support of TANF Purposes 1 and 2 and are funded with federal TANF and State Maintenance of Effort funds.

22.2 Transportation Assistance

In addition to child care subsidies, TANF recipients who are active with the FTW program, may be eligible to receive assistance for transportation costs such as reimbursements for mileage and parking, monthly bus passes, and other means determined appropriate by the Department.

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Page | 33 22.3 Educational Expenses

FTW participants may be eligible to receive assistance for educational expenses if the participant has been accepted or is currently enrolled with a post-secondary education institution or a vocational educational program. FTW participants must provide verification of the expense which may include, but are not limited to, tuition or registration fees, books, mandatory tools and supplies, and uniforms. FTW participants who are pursuing a degree through a college or university, will be required to apply for student financial aid, and if approved, the participant will be required to reimburse the Department for any duplicative benefits received.

22.4 Work-related Expenses

FTW participants may be eligible to receive assistance for work-related expenses if the participant has received a job offer or is currently employed. FTW participants must provide verification of the expense which may include, but are not limited to, automobile down payment, automobile inspection fees, automobile repairs, motor vehicle registration, clothing, tools, equipment, and equipment repairs.

22.5 Public Health Nursing Services

The Department, in collaboration with the Department of Health, developed a pilot that incorporates the public health nursing services into the FTW program, utilizing the two- generational approach, with the goal of assisting FTW participants and their family members with their health concerns that may impede their ability to become employed and gain financial independence and to help families to develop their capacity to meet health needs for themselves and their family members. Public health nursing services include, but are not limited to:

A. Identifying predominant cultural and ethnic health practices. B. Identifying health needs and hazards in the home. C. Identifying support systems and family strengths and resources to maintain basic family health needs. D. Identifying family relationships. E. Assisting families with access to recommended health services intended to improve or maintain their health. F. Providing education regarding preventive health care including, but not limited to, oral health, injury prevention, and family planning specific to the needs of the family; and

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Page | 34 G. Monitoring families’ health.

The above services are funded with State Maintenance of Effort funds and are not covered by Medicaid.

22.6 Bridge-To-Hope

Bridge-to-Hope is a partnership between the University of Hawaii and the Department to offer subsidized on-campus student employment for FTW participants who are enrolled full-time at any University of Hawaii campus. National research shows that having a college degree significantly increases an individual’s earning capacity.

23.0 SUPPORTIVE SERVICES TO STRENGTHEN FAMILIES 23.1 Home Visiting Program The Department’s home visiting program and family support services are available to families in support of TANF Purpose 4. The purpose of the home visiting and family support services is to promote positive parent-child relationships with children ages zero to three years, through a family-centered, strengths-based, and culturally appropriate support services within a family’s natural environment to prevent child maltreatment. Services may include, but are not limited to: A. Assessments to identify risks and needs of a family referred for home visiting services. B. Development of individualized family service plan which include collaborative efforts with other social services providers to address the family’s risks and needs. C. Coordinated referrals to other service providers and to provide treatment readiness counseling until a placement for services is made. D. Identify, assess, monitor the health status and health care needs of the family, and refer the family to community health resources for services as appropriate; and E. Provide family strengthening services that include therapeutic interventions and child development and parenting skills education.

Homeless families may receive additional case management and transitional services regardless of their income. Homeless families, by the very reason of homelessness, are not subject to the eligibility requirements to receive these services.

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Page | 35 The above services are funded with federal TANF and State Maintenance of Effort funds and are not covered by Medicaid. 23.2 Family Preservation Services Hawaii encourages and supports the formation and maintenance of two-parent families. The following are brief descriptions of services and programs provided under TANF Purpose 4 and are in effect January 1, 2023. A. The Susannah Wesley Community Center offers home-based parenting and family counseling services for families residing in the Kalihi area on Oahu. B. The Salvation Army – Family Treatment Services offers home-based parenting and family counseling for graduates of substance abuse treatment and their families. C. The Nanakuli Housing Corporation offers homeownership assistance for TANF eligible families on the Leeward coast of Oahu. Homeownership assistance includes classes in home repair, access to reusable home building materials, financial literacy, and the essentials of home ownership. D. The Department’s Social Services Division provides case management and advocacy services to address the needs of TANF eligible families who are temporarily residing at a domestic violence shelter, and family strengthening services to reduce the incidence of child abuse and neglect in the community. E. The Department’s Social Services Division provides home visiting services that promote positive parent-child relationships for families with children ages zero to three years old, through a family-centered, strengths-based, and culturally appropriate support services within a family’s natural environment.

23.3 Employment Services for Non-Custodial Parent The Department has collaborated with the Child Support Enforcement Agency (CSEA) and Goodwill Industries of Hawaii to develop a Non-Custodial Parent (NCP) pilot program to provide employment support and placement services for NCPs who are unemployed, underemployed, or are in arrears and have difficulty paying their child support obligation, in support of TANF Purpose 2. The employment related services include the following: A. Employment supportive services such as job readiness training, job coaching, counseling to support job retention, and monitoring progress of placement. B. Placements into both subsidized and unsubsidized employment. C. Comprehensive employment-based assessments.

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Page | 36 D. Transportation assistance for employed NCP in the form of a city bus HOLO card. To participate in the pilot program, the NCP must be a U.S. citizen, a lawfully admitted permanent resident immigrant, or is granted admission to the U.S. under the provision of Public Law 99-239; and the household’s total annual gross income does not exceed 300% of the current FPG. Currently, the pilot program is available to eligible NCPs on the island of Oahu. 23.4 Out of Wedlock Births

In 1995, the “Children's Vision,” a benchmarking initiative was started with 6,000 young people describing the type of Hawaii they wanted to live in. In September 1995, the Hawaii Adolescent Wellness Team was formed to attend a two (2) day Maternal and Child Health conference. The Wellness Team committed to developing a holistic framework and resource document. The Hawaii's Adolescent Wellness Plan - Laulima in Action (or many hands working together) was the result of that commitment. In May 1997, Laulima in Action was finalized as a systemic approach in moving Adolescent Wellness forward on multiple levels. This strategic planning framework, based on best practices approaches, could prevent, or reduce critical indicators among adolescents aged ten (10) to eighteen (18) years. The teen pregnancy rate has steadily declined since 2006. This is a continual collaboration between the Department of Human Services, the Department of Health, and the Department of Education (DOE). The Department of Human Services is a member of the Adolescent Wellness Team. 23.5 Teen Pregnancy Prevention Efforts of the Department of Human Services According to the Hawaii Health Data Warehouse, the birth rate in 2015 for females between the ages of fifteen (15) and nineteen (19) years was 20.6%. In 2021, the birth rate for the same age group was 12.3%, a decrease of 8.3% within a six-year period. The Department collaborates with private non-profit providers and DOE through contracts and Memoranda of Agreement (MOA) respectively. The services encompass the Teen Pregnancy Prevention effort to include alternative activities for children with after-school programs and community-based involvement. The Department’s goals are to continue its support of youth programs and services, maintain partnerships with other government agencies and service providers, and to ensure the teen birth rate continues to decline, by 12% by 2025. The services discussed above and described below are implemented to prevent and reduce the incidence of out-of-wedlock pregnancies, TANF Purpose 3. According to the “Helping Families Achieve Self-Sufficiency: A Guide on Funding Service for Children and Families through the TANF Program,” potential activities that would be reasonably calculated to accomplish Purpose 3 may include abstinence programs, services for

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Page | 37 youth, teen pregnancy campaigns, and after-school programs that provide supervision when school is not in session. All programs and services under this purpose are provided to youth in a before or an after-school setting. The following is a brief description of each service or program provided under TANF Purpose 3 and is in effect through December 31, 2026. Services were re-procured and effective January 1, 2023. A. Ola I Ka Hana Program, provided by Goodwill Industries of Hawaii, services at- risk youth with positive youth development, assistance to complete school, obtain and maintain employment, and to address social challenges. B. Youth Mentoring Program, provided by the Big Brothers Big Sisters of Honolulu. Community-based and site-based mentoring services are provided to at-risk youth on Oahu, Hawaii, Kauai, and Maui islands. C. Outreach Services for Homeless Youth services are provided by Hale Kipa, Inc. Services are provided to at-risk homeless youth between the ages of twelve (12) and twenty-two (22) in the geographic area of Waikiki. D. Positive Mentoring Services, provided by the Boys and Girls Club of Hawaii, includes positive mentoring and computer training, through after-school activities, for youth residing on the island of Kauai. E. Uniting Peer Learning, Integrating New Knowledge (UPLINK) is an activity based after-school program, through an agreement between DHS and DOE, to proactively prevent middle and intermediate school students from engaging in risky behaviors during the late afternoons when schools are not in session, in support of TANF Purpose 3. UPLINK provides homework assistance, remediation tutoring, and extra-curricular activities that promote positive character traits, i.e., 5Cs – character, confidence, competence, connection, and contribution. The UPLINK program is not part of the DOE system; therefore, participating middle and intermediate schools opt to administer and provide the program on their campus for their enrolled students. Participating UPLINK schools must provide the following mandatory components: 1) Teen Pregnancy Prevention and/or Character Development through activities that focus on five core concepts (Five Cs)—Competence, Confidence, Character, Connections, and Contribution. 2) Academic Supports that include homework assistance, tutoring, and remediation to assist students to maintain daily classroom performance and academic achievement. 3) Extracurricular activities based on the interests of the students such as

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Page | 38 performance/fine arts, agriculture and culinary arts, sports and other physical activities, science/technology/engineering/mathematics or STEM, service and cultural learning opportunities, and life skills training. 4) Family engagement activities to encourage and promote family involvement with the students. 5) Career exploration activities to expose students to various career pathways and occupations. F. Pregnancy prevention services, provided by Child and Family Service, for students enrolled with the Hale O Ulu School, offer vocational services, computer training, pregnancy prevention, and responsibility coaching. Hale O Ulu is an alternative school for at-risk youth who have been expelled or suspended from a DOE school. G. Positive After-School Program, provided by the Honolulu Community Action Program, offers creative afterschool Science, Technology, Engineering, Mathematics or STEM activities for children in grades two to eight, to promote academics and proactively prevent students from engaging in risky behaviors during the late afternoons when schools are not in session. Activities include tutoring and mentorship, and are provided in a safe, after-school setting with the goal to stimulate positive academic and social skills, increase family and community involvement, and develop the next generation of science and technology leaders, in support of TANF purpose 3.

H. Positive Youth Development Services, provided by Parents And Children Together, through the Family and Economic Opportunity Center and Teen Center, offers after-school mentoring, community service learning, recreation and sports activities, performing/visual arts activities and tutoring for children five to eighteen years, to proactively prevent students from engaging in risky behaviors during the late afternoons when schools are not in session.

I. Positive Youth Development and Pregnancy Prevention Services, provided by Hale Opio Kauai, offers pregnancy prevention and family strengthening activities for youth on the island of Kauai. Positive mentoring and skill building, through after-school activities, for youth residing in the Kalihi area of Oahu are provided by Kokua Kalihi Valley.

23.6 Sexual Health Education Effective school year 2015-2016, the Hawaii Board of Education passed Policy 103.5, requiring DOE to provide sexual health education that includes education on, 1) abstinence, contraception, and prevention methods of unintended pregnancy and sexually transmitted infection including human immunodeficiency virus;

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Page | 39 2) communication skills to form healthy relationships that are based on mutual respect and affection, and are free from violence, coercion, and intimidation; 3) critical thinking, problem solving, decision making, and stress management to make healthy decisions about sexuality and relationships; 4) communication with parents, guardians and/or other trusted adults about sexuality; and 5) available community resources for students. The purpose of the sexual health education policy is to promote abstention from sexual intercourse as a guaranteed prevention of unintended pregnancies, sexually transmitted diseases, and healthy and unhealthy or abusive relationships including statutory rape.

Supplementing DOE’s sexual health education and to provide education and training on the problem of statutory rape, assuring that teenage pregnancy prevention programs are expanded in scope to include boys and men, the department participates with other state agencies in both juvenile and adult sex offender treatment teams to ensure that offenders receive appropriate treatment to prevent sexual abuse; and for families under the jurisdiction of the department and family court, counseling is provided to educate victims, offenders and other family members in the dynamics of sexual abuse to prevent further abuse. 23.7 Individual Development Account Program The Department does not administer an Individual Development Account (IDA) program for TANF recipients. However, the Department recognizes IDAs established by other approved agencies for the benefit of TANF recipients. All assets including IDA accounts are disregarded for TANF eligibility and allotment determination. 23.8 Non-assistance Payments

In accordance with 45 CFR 260.31, the Department provides non-assistance payments that are designed to deal with a specific crisis or episode of need; not intended to meet recurring or ongoing needs; and do not extend beyond four months.

23.8.1 Disaster Relief

In response to a natural disaster or an emergency proclamation issued by the Governor, the State, at its option, may implement a program that provides non- recurring short-term (NRST) payments to assist families who may be in a specific crisis situation or have an episode of need as the result of the natural disaster or emergency proclamation. A family’s total gross income may not exceed 350% of the current FPG to qualify to qualify for disaster relief NRST payments.

Emergency administrative rules will be promulgated to establish the program; describe the crisis or episode of need; identify the target population; outline the eligibility criteria and requirements; and types of payments (e.g., housing, utility

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Page | 40 expenses, clothing, etc.) and payment limits, not to exceed four months of payments for each type.

23.8.2 Other NRST Payments

Other NRST payments may be provided to eligible needy families, whose household’s gross income does not exceed 300% of the 2022 FPG, to obtain common household appliances, emergency food and housing placement assistance. Other examples of NRST benefits recognized by the Department include, but are not limited to crisis intervention utility payments, distribution of food, household furnishings and diapers supplies.

23.9 TANF Outreach

Since October 1, 2010, the State conducts outreach services to inform the public of the TANF program benefits and services that are available to eligible individuals. The Department distributes brochures that contain general TANF eligibility information, available services and how they can be accessed. This brochure is used to determine eligibility for SNAP benefits using the broad-based category eligibility. The eligibility requirement for this program is that the family's monthly gross income may not exceed 200% of the FPG. The brochure may be found on the DHS website (link provided below).

https://humanservices.Hawaii.gov/bessd/files/2022/07/DHS-1464-TANF-Brochure-REV-04-2022.pdf

24.0 TRANSITIONAL BENEFITS AND SERVICES

24.1 Post-Sixty (60) Month TANF Benefits and Services

At the conclusion of the TANF sixty (60) month time limit, all assistance units will be assessed for continued eligibility in the following programs and services:

A. SNAP. B. Participation with the SNAP Employment and Training Program. C. Child Care Subsidies.

24.2 Transitional Child Care (TCC) Subsidy Payments

The State provides TCC subsidy payments to full-time employed TANF recipient families who voluntarily terminate their benefits or become ineligible as the result of new or increased earned income. Eligibility for TCC continues until the household receives twelve consecutive months of child care subsidies payments or until the household’s adjusted gross income exceeds the child care eligibility standard which is 85% of the

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Page | 42 Part E – MAINTENANCE OF EFFORT (MOE) 25.0 MOE The following is a complete list of all MOE activities and programs (state TANF/basic MOE, separate state programs, and third-party MOE). Hawaii offers benefits and services to TANF benefit recipients and families who do not receive benefits but are determined TANF eligible, through a combination of state TANF MOE programs and activities (direct and contracted), separate state programs, and third-party programs and activities. Unless otherwise specified, families who meet the following criteria are deemed TANF eligible: A. There is a dependent child between the ages of zero and 23 years living with their custodial parent or other adult specified relative. B. Family or individual members who receive the services, are U.S. citizens or qualified immigrants who are residing lawfully in the U.S. in accordance with the Immigration and Nationality Act, 8 U.S.C. 1601 and P.L. 104-193, section 401; and C. Family’s monthly gross income does not exceed 300% of the 2022 FPG. 25.1 TANF Administration: Costs associated with the administration of the TANF program including payroll and benefits, operational costs, fraud prevention and investigations, eligibility determinations, systems development and maintenance, ongoing program capacity development, and training. (TANF Purposes 1 – 4 / State basic MOE) 25.2 Subsidized Employment: The department provides subsidized employment services through the SEE and Bridge to Hope programs for TANF benefit recipients who are participants of the FTW program. (TANF Purpose 2 / State TANF/Basic MOE and SSP- MOE) 25.3 Educational and Vocational Training: Educational and career pathways services and programs provided by state Department of Education and University of Hawaii to eligible TANF benefit recipients who are FTW participants and individuals who meet the definition of TANF eligible. (TANF Purpose 2 / State TANF MOE) 25.4 Pre-employment and Job Readiness: Supportive services and activities including job coaching, resume development, interview skills, and job search assistance provided to TANF benefit recipients who are FTW participants and individuals who meet the definition of TANF eligible, by the City and County of Honolulu, Institute for Human Services, Parents And Children Together, YWCA of Oahu, Ka Hale A Ke Ola Homeless Resources Centers, Inc., and Goodwill Industries of Hawaii. (TANF Purpose 2 / State TANF MOE, SSP-MOE, and 3rd Party MOE)

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Page | 43 25.5 Job Development and Placement Services: Services and activities provided to TANF benefit recipients who are FTW participants and individuals who meet the definition of TANF eligible, by the Department of Human Services, the Department of Labor and Industrial Relations, and Goodwill Industries of Hawaii. (TANF Purpose 2 / State TANF MOE and SSP-MOE) 25.6 Barrier-removal Case Management: Services and activities provided to TANF benefit recipients who are FTW participants, by Goodwill Industries of Hawaii, to address and resolve barriers to successful work engagement such as alcohol and substance abuse disorder, and/or temporary physical or psychiatric disability. (TANF Purpose 2 / State MOE and SSP-MOE) 25.7 Work Supports: Services and benefits such as assistance in purchasing work-related clothing, tools, and equipment; transportation assistance; and education/training related expenses such as books and tuition. Work support services and benefits are provided through the FTW program for TANF benefit recipients. (TANF Purpose 2 / State MOE and SSP-MOE) 25.8 TAONF Financial Assistance Program: Monthly state-funded financial assistance, support services, work/education/training services, childcare, transportation, and other services typically offered under the Hawaii TANF program, to legal immigrant resident families or migrants under the Compact of Free Association, who are eligible under TAONF. (TANF Purpose 1 / State MOE) 25.9 Child Development and Afterschool Care: Full-day and full-year services outside of the Head-Start program and afterschool child care services through the Honolulu Community Action Program and DOE for TANF eligible families. (TANF Purposes 1 and 2 / SSP-MOE and 3rd Party MOE) 25.10 Financial Education and Asset Development: Financial literacy services and self-help home repair provided by Nanakuli Housing Corporation’s Holomua I Na`au`ao, and Alu Like, Inc. for TANF eligible families. (TANF Purpose 2 / SSP-MOE and 3rd Party MOE) 25.11 Non-recurring Short-term or One-time Benefits: Work- and education-related expenses, emergency food assistance, household goods and basic appliances, and rent subsidies and assistance, provided by the FTW program for TANF benefit recipients who are FTW participants, and by the Hawaii Foodbank, Inc., Helping Hands Hawaii, Hale Kipa, Inc., Child and Family Services, Catholic Charities of Hawaii, Maui Economic Opportunity, Inc., the Aloha Diaper Bank, Hawaii Children’s Action Network, and the Institute for Human Services for TANF eligible families. (TANF Purposes 1 and 2 / State MOE, SSP-MOE, and 3rd Party MOE) 25.12 Supportive Services: Housing placement and homeless shelter services, domestic violence advocacy and legal services, non-medical alcohol and substance use disorder treatment continuum of service, and sex offender and violence intervention services for

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Page | 44 TANF eligible families provided by services providers such as Catholic Charities of Hawaii, Family Life Center, Inc., Institute for Human Services, Hope Services Hawaii, Inc., Housing Solutions, Inc., and Ka Hale A Ke Ola Homeless Resources Centers, Inc, Child and Family Service and YWCA of Kauai, Legal Aid Society of Hawaii, the Salvation Army Family Treatment Services, and Parents And Children Together. (TANF Purposes 1 and 4 / State MOE, SSP-MOE, and 3rd Party MOE) 25.13 Transitional Support Services: Transportation benefits, and no-fault auto insurance coverage for TANF benefit recipient families who are full-time employed and exited TANF due to income or voluntarily terminated their TANF benefits. (TANF Purposes 1 and 2 / State MOE) 25.14 Education-related Supportive Services: Student and instructional support, outreach, counseling, and resources for TANF eligible families who are students at a University of Hawaii campus. (TANF Purpose 2 / 3rd Party MOE)

25.15 Pregnancy Prevention and Youth Development Activities: Mentoring, counseling, positive youth development activities, afterschool programs, at risk youth outreach services, and teen pregnancy prevention activities for youths of TANF eligible families. (TANF Purpose 3 / 3rd Party MOE) 25.16 Family Strengthening Services: Provided by various community-based organizations including Helping Hands Hawaii, Alu Like, Inc., and Kokua Kalihi Valley Comprehensive Family Services for TANF eligible families. (TANF Purpose 4 / 3rd Party MOE) 25.17 Home Visiting Services: Home-based parenting and family counseling provided by the Susannah Wesley Community Center for TANF eligible families. (TANF Purpose 4 / 3rd Party MOE) 25.18 Domestic Violence Services: Supportive services provided to TANF benefit recipient families and TANF eligible families, who are temporarily residing at a domestic violence shelter. Services may include counseling support, housing search and placement services, and basic needs (e.g., food and clothing). (TANF Purpose 1 / 3rd Party MOE) 25.19 Family Supportive Services: Supportive services to TANF benefit recipients and TANF eligible individuals, who are survivors of family violence or sex abuse, or families who need support during a crisis or difficult situation. Services may include individualized counseling and family group therapy not covered by Medicaid. (3rd Party MOE) 25.20 Homeless and Housing Placement Services: Services include, 1) emergency shelter services that include case management, counseling, and pre-housing placement assistance for eligible needy families who were temporarily residing at homeless shelters; 2) transitional shelter services for eligible needy families who were awaiting placement into long-term housing; and 3) program services include housing search

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Page | 46 Part F- Historical

26.0 HISTORICAL 26.1 Hawaii's TANF program is based on the PRWORA of 1996 and the DRA of 2005, which reauthorized the TANF program in February 2006. Hawaii used a planning task force for the development of the TANF program in 1996 when PRWORA was implemented and in 2006, when the DRA of 2005 was passed. The task force was composed of public and private sector individuals. The plan was presented numerous times in the community with an opportunity for public input and comment. All comments and recommendations were considered, and many were incorporated into the final program plan. Administrative rules were drafted to govern the program in 1996 in compliance with PRWORA. These rules were promulgated in accordance with the Hawaii Administrative Procedures Act (Chapter 91, Hawaii Revised Statutes). There was a public comment period of forty-five (45) days to allow individuals and local government organizations and public organizations to provide comments before finalization. The TANF program, according to the 1996 welfare reform, rules were implemented when our “Pursuit of New Opportunities” (PONO) waiver expired in October 2004. Administrative rules were drafted to comply with the DRA of 2005. 26.2 Hawaii’s PONO Program, was approved on August 16, 1996, as a Section 1115 waiver demonstration. The PONO program was an eight (8) year project, effective from December 1 to September 30, 2004. The PONO program initiated the State’s reform, mirroring the federal welfare reform policies. The PONO program encouraged and supported the formation and maintenance of two- parent families. One of the primary hypotheses of the PONO demonstration project was that families need two incomes to survive in our economy. Hawaii, therefore, ran parallel programs for one and two-parent families. There were no penalties for households that included two (2) adults. Compliance with the CSEA was a condition of eligibility. Families who failed to comply, without good cause, were ineligible for financial assistance until they complied. Additionally, the Department had discussions with CSEA regarding Welfare-to-Work eligibility for absent parents and financial incentives to encourage participation. 26.3 The domestic violence option and subsequent regulations were developed in collaboration with the Domestic Violence Clearinghouse and Legal Hotline, the Legal Aid Society of Hawaii, and a work group comprised of public and private agencies and individual citizens. These participants represented a cohort of domestic violence agencies and advocates statewide and private citizens. The administrative rules for the amended program were drafted and a Notice of Public Hearing was published the week

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Page | 47 of July 2, 2001, in a primary newspaper on each island. The public comment period was from July 2, 2001, through August 14, 2001. A public hearing was held on August 7, 2001. The rules were finalized and adopted on October 18, 2001.

26.4 The Department consulted with the Financial Assistance Advisory Council with regards to work eligible individuals who claim a disability that impedes in their ability to obtain and maintain employment. The administrative rules were drafted, and a Notice of Public Hearing was published the week of July 2, 2001, in a primary newspaper on each island. The public comment period was from July 2, 2001, through August 14, 2001. A public hearing was held on August 7, 2001. The rules were finalized and adopted on October 18, 2001.

26.5 The administrative rules regarding the medical evaluation board and the evaluation of work eligible individuals who claim a disability, were drafted, and a Notice of Public Hearing was published the week of November 14, 2004, in a primary newspaper on each island. The public comment period was from November 15, 2004, through December 14, 2004. A public hearing was held on December 14, 2004. The administrative rules were finalized and adopted on January 20, 2005.

26.6 Hawaii established employment subsidy placement services that was piloted in 2004- 2005. The Supporting Employment Empowerment (SEE) program was officially implemented as a supportive service through the FTW program in 2006.

26.7 The earned income disregard was increased on January 13, 2010, when the administrative rules were finalized. The earned income disregard for recipients increased from 36% to 55% from month one (1) through month twenty-four (24). The public comment period was from October 25, 2009. A public hearing was held on November 23, 2009.

26.8 The 2013 Hawaii Legislature passed an administrative bill submitted by the Department to disregard assets in determining TANF eligibility. The bill was signed into law by (former) Governor Neil Abercrombie on April 18, 2013.

26.9 The Department promulgated administrative rules to support Individual Development Account (IDA) programs. These administrative rules were finalized on January 22, 2002.

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Page | 49 31.0 CERTIFICATION THAT THE STATE PROVIDES INDIANS WITH EQUITABLE ACCESS TO ASSISTANCE

The State provides each member of an Indian tribe, who is domiciled in the State and not eligible for assistance under a tribal family assistance plan approved under section 412 of the Social Security Act, with equitable access to assistance under the State program funded under this part attributable to funds provided by the federal government.

32.0 CERTIFICATION OF STANDARDS AND PROCEDURES TO ENSURE AGAINST PROGRAM FRAUD AND ABUSE

The State established and is enforcing standards and procedures to insure against program fraud and abuse, including standards and procedures concerning nepotism, conflicts of interest among individuals responsible for the administration and supervision of the state program, kickbacks, and the use of political patronage.

33.0 PUBLIC AVAILABILITY OF STATE PLAN SUMMARY

The TANF State Plan is available to the public via the DHS website at https://humanservices.hawaii.gov/tanf-strategic-plans/.

34.0 OPTIONAL CERTIFICATION OF STANDARDS AND PROCEDURES TO ENSURE THAT THE STATE WILL SCREEN FOR AND IDENTIFY DOMESTIC VIOLENCE

The State has elected the option to develop standards and procedures to screen for and identify individuals with a history of domestic violence, while maintaining confidentiality, so that victims of such violence who are receiving assistance may be referred for counseling and supportive services. The State has developed regulations so that victims of domestic violence may be suspended from certain program requirements, such as work requirements and child support cooperation requirements, when compliance would place the individual or other household members in danger of further domestic violence.

35.0 CERTIFICATION ENACTED IN THE CONSOLIDATED APPROPRIATIONS ACT, 2022

Pursuant to the Consolidated Appropriations Act, 2022, the State: A. Establishes and enforces standards and procedures to ensure that TANF applicants and potential applicants are notified of assistance made available by the State to victims of sexual harassment and survivors of domestic violence, sexual assault, or stalking. B. Ensures that case workers and other agency personnel responsible for administering the TANF program are trained in the nature and dynamics of

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STATE OF HAWAII DEPARTMENT OF HUMAN SERVICES BENEFIT, EMPLOYMENT, AND SUPPORT SERVICES DIVISION IMPORTANT INFORMATION WHEN APPLYING FOR FINANCIAL ASSISTANCE AND SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) Information provided by the applicant in connection with the application will be subject to verification by Federal, State or local officials to determine if the information is factual; that if any information is incorrect, SNAP may be denied and the applicant may be subject to criminal prosecution for knowingly providing incorrect information. If any member of your household receives SNAP or Temporary Assistance for Needy Families (TANF) benefits, then all children in your household are eligible for free school meals if their school participates in the United States Department of Agriculture (USDA) meal program. Please call your child’s school if you have questions regarding the School Breakfast and Lunch Program. They will be able to provide you information when: • You think your child should get free meals but does not receive them, • You do not want your child to get free school meals, or • You have questions about the USDA meal programs. Information about TANF and other programs available under the Department of Human Services can be found at the following website: http://humanservices.hawaii.gov/bessd/ 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: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, 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: Mail: Food and Nutrition Service, USDA 1320 Braddock Place Room 334 Alexandria, VA 22314 Fax: (833) 256-1665 or (202) 690-7442 Email: FNSCIVILRIGHTSCOMPLAINTS@USDA.GOV This institution is an equal opportunity provider. Apply faster online at: https://pais-benefits.dhs.hawaii.gov Attachment A-2, Page 1 of 18

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Do you need help in another language? We will get you a free interpreter. Call 1-888-764-7586 to tell us which language you speak. (TTY: 711 or 1-888-764-7586). English 您需要其它語言嗎？如有需要, 請致電 1-888-764-7586 我們會提供免費翻譯服務 (TTY: 711 或 1-888-764-7586). Cantonese En mi niit alilis lon pwal eu kapas? Sipwe angei emon chon chiaku ngonuk ese kamo. Kokori 1-888-764-7586 omw kopwe ureni kich meni kapas ka ani. (TTY: 711 ika 1-888-764-7586). Chuukese Avez-vous besoin d’aide dans une autre langue? Nous pouvons vous fournir gratuitement des services d’un interprète. Appelez le 1-888-764-7586 pour nous indiquer quelle langue vous parlez. (TTY: 711 ou 1-888-764-7586). French Brauchen Sie Hilfe in einer andereren Sprache? Wir koennen Ihnen gern einen kostenlosen Dolmetscher besorgen. Bitte rufen Sie uns an unter 1-888-764-7586 und sagen Sie uns Bescheid, welche Sprache Sie sprechen. (TTY: 711 oder 1-888-764-7586). German Makemake `oe i kokua i pili kekahi `olelo o na `aina `e? Makemake la maua i ki`i `oe mea unuhi manuahi. E kelepona 1-888-764-7586 `oe ia la kaua a e ha`ina `oe ia la maua mea `olelo o na `aina `e. (TTY: 711 a 1-888-764-7586). Hawaiian Masapulyo kadi ti tulong iti sabali a pagsasao? Ikkandakayo iti libre nga paraipatarus. Awaganyo ti 1-888-764-7586 tapno ibagayo kadakami no ania ti pagsasao nga ar-aramatenyo. (TTY: 711 wenno 1-888-764-7586). Ilokano 貴方は、他の言語に、助けを必要としていますか ? 私たちは、貴方のために、無料で通訳を用意できます。電話番号の、1-888-764-7586 に、電話して、私たちに貴方の話されている言語を申し出てください。 (TTY: 711 または 1-888-764-7586). Japanese Korean 您需要其它语言吗？如有需要,请致电 1-888-764-7586 我们会提供免费翻译服务 (TTY: 711 或 1-888-764-7586). Mandarin Kwoj aikuij ke jiban kin juon bar kajin? Kim naj lewaj juon am dri ukok eo ejjelok wonen. Kirtok 1-888-764-7586 im kwalok non kim kajin ta eo kwo melele im kenono kake. (TTY: 711 ak 1-888-764-7586). Marshallese E te mana’o mia se fesosoani i se isi gagana? Matou te fesosoani e ave atu fua se faaliliu upu mo oe. Vili mai i le numera lea 1-888-764-7586 pea e mana’o mia se fesosoani mo se faaliliu upu. (TTY: 711 po o le 1-888-764-7586). Samoan ¿Necesita ayuda en otro idioma? Nosotros le ayudaremos a conseguir un intérprete gratuito. Llame al 1-888-764-7586 y diganos que idioma habla. (TTY: 711 o 1-888-764-7586). Spanish Kailangan ba ninyo ng tulong sa ibang lengguwahe? Ikukuha namin kayo ng libreng tagasalin. Tumawag sa 1-888-764-7586 para sabihin kung anong lengguwahe ang nais ninyong gamitin. (TTY: 711 o 1-888-764-7586). Tagalog ‘Oku ke fiema’u tokoni ‘iha lea makehe? Te mau malava ‘o ‘oatu ha fakatonulea ta’etotongi. Telefoni ki he 1-888-764-7586 ‘o fakaha mai pe koe ha ‘ae lea fakafonua ‘oku ke ngaue’aki. (TTY: 711 pe 1-888-764-7586). Tongan Bạn có cần giúp đỡ bằng ngôn ngữ khác không ? Chúng tôi se yêu cầu một người thông dịch viên miễn phí cho bạn. Gọi 1-888-764-7586 nói cho chúng tôi biết bạn dùng ngôn ngữ nào. (TTY: 711 hoặc 1-888-764-7586). Vietnamese Việt Nam Gakinahanglan ka ba ug tabang sa imong pinulongan? Amo kang mahatagan ug libre nga maghuhubad. Tawag sa 1-888-764-7586 aron magpahibalo kung unsa ang imong sinulti-han. (TTY: 711 o 1-888-764-7586). Visayan (Cebuano) Attachment A-2, Page 2 of 18

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STATE OF HAWAII Department of Human Services Benefits, Employment, and Support Services Division APPLICATION FOR FINANCIAL AND SNAP ASSISTANCE FOR OFFICIAL USE ONLY Case Name Case Number APPLICATION FILING: The day your application is received is the date from which your eligibility for benefits will be determined. Benefits will be paid from that filing date if you are eligible. If you are unable to fill out the application now, just complete your name, address, and sign below and turn it in. You must still answer the rest of the questions on the application form before benefits are issued. If you cannot complete the application the eligibility worker will help you. If you are currently living in a public institution and will be released within 30 days, you may file your application today, but the date of application will be the day of release from the institution. DATE SIGNED FORM RETURNED PLEASE PRINT CLEARLY I am not currently receiving one or both of these benefits and would like to apply for: SNAP Benefits Financial Assistance I am currently receiving benefits and would like to renew my: SNAP Benefits Financial Assistance YOUR NAME (Last, First, M.I.) YOUR SOCIAL SECURITY NO. BIRTHDATE PHONE NO. SPOUSE’S NAME (Last, First, M.I.) SPOUSE’S SOCIAL SECURITY NO. SPOUSE’S BIRTHDATE MESSAGE PHONE NO. ADDRESS WHERE YOU LIVE (NUMBER AND STREET OR DIRECTIONS TO YOUR HOME) APT/SPACE NO. CITY & STATE ZIP CODE MILITARY BASE (IF RESIDING IN BASE HOUSING) YOUR MAILING ADDRESS (IF DIFFERENT FROM THE ABOVE NUMBER AND STREET) APT/SPACE NO. CITY & STATE ZIP CODE HOW MANY PERSONS PURCHASE FOOD AND PREPARE MEALS WITH YOU? (INCLUDE YOURSELF) HOW MANY PERSONS DO NOT PURCHASE FOOD AND PREPARE MEALS WITH YOU? ARE THEY RELATED TO ANYONE IN YOUR HOUSEHOLD?  YES  NO HOW MANY CHILDREN LIVE WITH YOU? IS ANYONE IN YOUR HOME PREGNANT?  YES  NO IF YES, INDICATE WHO NAME: WHEN IS THE BABY DUE? DATE: CHECK THE BOX FOR EACH TYPE OF EMERGENCY ASSISTANCE YOU ARE APPLYING FOR:  Financial  SNAP Answer the EMERGENCY ASSISTANCE questions below only if you need help right away. If you meet EMERGENCY ASSISTANCE requirements, you will be interviewed and may be provided SNAP benefits within seven (7) days and your financial eligibility will be determined within two (2) working days. YES NO                 Is anyone in your home seasonal farm worker whose only source of income for the month terminated before applying and income of less than $25 is expected with the next 10 days? Does anyone in your home have cash or savings or bank accounts? Is yes, how much? Has anyone in your home received money this month? If yes, how much? Does anyone in your home expect to receive any money this month? If yes, how much? When? (Date) Are you currently paying any of the following shelter expenses? If yes, list the amounts: Rent/Mortgage Electric Gas

Water Phone Have you been served court papers to get out of your present living arrangements? (Attach papers) Are you living in a temporary facility and have to get out in five days? If yes, name of facility? Are you currently without a place to live? SIGNATURE OR MARK OF ADULT APPLICANT DATE SIGNATURE OR MARK OF SPOUSE OF OTHER ADULT APPLICANT DATE (This signature is required for Financial Assistance only) WITNESS IF SIGNATURES ARE “X” DATE DHS 1240 (REV 04/2024) Page 1 of 11 APPOINTMENT NOTICE: When your application is received, an Appointment Notice for your interview will be sent or given to you. You must be interviewed before you can receive benefits. A telephone interview may be conducted in lieu of an office interview. To shorten the processing time, you should submit proof of information and verification as noted on your appointment letter. You may be asked at the interview to submit more information. If you miss your appointment, or need to change it, you must call the local office to reschedule. The following action will be taken if you miss your appointment: • For SNAP, if you do not reschedule by the 30th day from the day you filed your application or the last day of your certification, your application will be denied. If your application is denied, you may be required to reapply to receive benefits. You may lose benefits for failing to appear at your interview. • For cash benefits, if you do not reschedule your appointment date, your application will be denied within the time limits specified by our policies. If you are currently receiving benefits, they may be stopped if you do not reschedule the missed appointment. If benefits are denied or stopped, you may reapply if you still want benefits. AFTER YOUR INITIAL INTERVIEW WE ENCOURAGE YOU TO REPORT CHANGES AS SOON AS THEY HAPPEN, THIS MAY PREVENT ANY DELAYS IN BENEFITS TO YOU. INTERVIEW INFORMATION: An interview must be completed before you can receive help. A single interview is sufficient when applying for SNAP and financial benefits. Appointments are scheduled according to the date you apply, with the earliest application given the first available appointment. You will be notified of the date and time of your appointment. YOU MAY GET SNAP WITHIN SEVEN (7) CALENDAR DAYS IF YOUR HOUSEHOLD: • Has monthly rent/mortgage and utilities that are more than your household’s gross monthly income and liquid resources; or • Has gross monthly income is less than $150 and your household’s liquid resources, such as cash or checking/savings accounts, are $100 or less; or • Is a seasonal farmworker household whose income terminated prior to applying, is not expecting income of $25 within the next 10 days and has liquid assets of less than $100. Attachment A-2, Page 3 of 18

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Refer to codes below for responses to questions marked with the corresponding asterisk symbols (*) 1. HOUSEHOLD MEMBERS On line #1, enter the name of the primary person who will receive the money and/or SNAP benefits for your household. If spouse is in the household, list spouse on line #2. Then list the other household members who are applying for assistance. For money assistance applicants, if anyone in the home is pregnant, list “unborn child” as a household member. All other household members not applying for assistance shall be listed under section #2. Last Name, First, M.I. SEX M/F (*) BIRTHDATE MO/DAY/YR SOCIAL SECURITY NUMBER (42 USC 1320b-7 requires that SSN’s be provided for each household member applying for assistance. (**) (***) (****) YES or NO D I S A B L E D H I G H E S T G R A D E NAME OF CHILD’S PARENT(S) IF NOT IN THE HOME (SKIP IF APPLYING ONLY FOR SNAP) Was child’s mother married to child’s father at time of birth? R E L A T I O N S H I P T O P E R S O N # 1 E T H N I C R A C E M A R I T A L S T A T U S C O M P L E T E D (Check one) Yes No 1. OTHER NAMES USED AGE: 2. OTHER NAMES USED AGE: 3. OTHER NAMES USED AGE: 4. OTHER NAMES USED AGE: 5. OTHER NAMES USED AGE: 6. OTHER NAMES USED AGE: 7. OTHER NAMES USED AGE: 8. OTHER NAMES USED AGE: 2. HOUSEHOLD MEMBERS WHO DO NOT WANT HELP Write in the names of others in your home who do not want assistance (include yourself if you do not need help.) These people do not need to give us information about their citizenship, immigration status or social security number. These people will not be considered applicants and will not be eligible, however, they may need to tell us about their income and answer the other questions on this form. 1. AGE: 2. AGE: 3. AGE: 4. AGE: 3. Is anyone temporarily out of the home? Yes No Name Date Left Date to Return Where Person Went (*) Relationship Codes to Person #1: (**) Ethnic Codes - Select only one code (***) Marital Status Codes: SP - Spouse PA - Parent CH - Child SI - Sibling AU - Aunt/Uncle NN - Niece/Nephew GR - Grandparent GC - Grandchild NR - Not Related OR - Other Related UB - Unborn FC - Foster Child EX - Ex-Spouse SS - Step Sibling ST - Step Parents CL - Common Law CO - Cousin SC - Step Child HI - Hispanic NH- Not Hispanic NM - Never Married ML - Married, Living with Spouse DI - Divorced LS - Legally Separated MS - Separated MI - Married, Involuntary Separation WI - Widowed CL - Common Law (***) Race Codes - Select one or more codes below WH - White BL - Black AI - American Indian or Alaskan Native HA - Hawaiian SA - Samoan JA - Japanese KO - Korean CH - Chinese FI - Filipino OA - Other Asian OP - Other Pacific Islanders (This question is optional to answer. Failure to answer will not affect eligibility) DHS 1240 (REV 04/2024) Page 2 of 11 Attachment A-2, Page 4 of 18

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FINANCIAL ASSISTANCE AUTHORIZED REPRESENTATIVE I permit the following individual to be my representative TO APPLY FOR FINANCIAL (CASH) ASSISTANCE on my behalf, as I am unable to do so myself (elderly, disabled, etc.). Enter the name and address of applicant’s representative below. Representative’s Name (Last, First, M.I.) Representative’s Address (Number, Street, Apt., City, State, Zip Code) Phone No. SNAP AUTHORIZED REPRESENTATIVES I permit the following individual to be my representative TO APPLY FOR SNAP assistance on my behalf. (Include individual’s name or the licensed alcohol or drug treatment facility or group living arrangement representative.) Representative’s Name (Last, First, M.I.) Representative’s Address (Number, Street, Apt., City, State, Zip Code) Phone No. ELECTRONIC BENEFIT TRANSFER AUTHORIZED REPRESENTATIVE I permit the following individual to HAVE ACCESS TO MY CASH ASSISTANCE. Yes No I permit the following individual to HAVE ACCESS TO MY SNAP BENEFITS and to purchase my food. Yes No This representative will be issued an EBT card and PIN (personal identification number). (Include the individual’s name or the licensed alcohol or drug treatment facility or group living arrangement representative. The date of birth and social security number will be used for security purposes only.) Representative’s Name (Last, First, M.I.) Date of Birth Social Security Number Representative’s Address (Number, Street, Apt., City, State, Zip Code) Phone No. QUESTIONS 4 THROUGH 34 ARE TO BE ANSWERED FOR ONLY THOSE WHO ARE APPLYING FOR ASSISTANCE. 4. Is anyone a disabled U.S. veteran or a disabled spouse or a child of a deceased U.S. veteran? Yes No If yes, name: 5. Is anyone (including children) disabled? Yes No If yes, name of disabled person(s): They could be eligible for Supplemental Security Income (SSI) or SSA Disability or Blindness benefits. 6. a. Is anyone in the household fleeing a felony warrant for arrest; a parole/probation violator; or been convicted of a Federal or State felony for possession, use or distribution of illegal drugs? Yes No If yes, name(s): b. Has anyone in the household been convicted as of February 7, 2014, of aggravated sexual assault, murder, or sexual exploitation of children? Yes No If yes, name(s): 7. Has anyone in the household been found guilty of misrepresenting residence to obtain assistance in two or more states? Yes No If yes, name(s): 8. CITIZENSHIP STATUS DECLARATION. One household member must certify under penalty and perjury the citizenship status of each household member. The Department of Human Services (DHS) may validate the alien status/document with the United States Citizenship and Immigration Services (USCIS), the USCIS will furnish information only as allowed by the IRCA legislation, the USCIS is not allowed to institute any adverse action against you based on the DHS inquiry, and the information received from the USCIS may affect your eligibility or amount of benefits from our Department. I CERTIFY UNDER PENALTY OF PERJURY THAT THE INFORMATION BELOW ON EACH HOUSEHOLD MEMBER IS CORRECT. (CHECK ONE) COMPLETE IF YOU ARE A NON-U.S. CITIZEN Name US US National Non-US Citizen Birthplace Date of Entry Immigration Status Effective Date of Status INS Form or Alien Registration Number Do you, your spouse, or parent have 40 qtrs. of work? (Y/N) Veteran or Active Military? (Y/N) Spouse or Dep. Child of Veteran or Act. Military? (Y/N) NOTE: If you are a permanent alien, you will be required to provide verification of work history. 9. If sponsored non-U.S. citizen or refugee, give name, address, and phone number of the sponsor(s). Name Address Phone DHS 1240 (REV 04/2024) Page 3 of 11 Attachment A-2, Page 5 of 18

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COMPLETE FOR SNAP ONLY DEDUCTIBLE EXPENSES Shelter Expenses are used as a deduction from your household’s countable income to determine the amount of SNAP benefits your household may be entitled to receive. Expenses that are not reported and verified will not be allowed as a deduction from your countable income in determining your SNAP benefit amount. To claim expenses in the future, your household will need to report and verify expenses in which adjustments to your benefits, if any, will take effect the month after the verification is received by the department. SHELTER EXPENSES 26. Does any person or agency outside your household help pay for or provide, at no cost to you, any of the expenses listed below? Yes  No If Yes, (  ) the expense(s): Rent  Utilities  Taxes  Mortgages  Personal Supplies  Food  Household Supplies Medical Care  Clothing  Other If Yes, what person or agency helps pay or provide the expense(s)? Do you need to pay them back?  Yes  No 27. 28. 29. Is anyone in your household working off any part of the rent?  Yes  No If Yes, indicate amount $ Do you live in Public Housing?  Yes  No Does your household pay any shelter and/or utility expenses (such as rent, electricity, property tax)?  Yes No Check Yes or No and complete information for each item below: YES NO ITEM HOW OFTEN BILLED (Monthly, Weekly) CURRENT BILLED AMOUNT YES NO ITEM HOW OFTEN BILLED (Monthly, Weekly) CURRENT BILLED AMOUNT Rent Gas Boat Slip Propane, Kerosene, Coal, Wood Mortgage/2nd Mortgage Telephone Sales/Local Property Tax/ Assessments Utility Installation Fees Homeowner’s Insurance Unoccupied Home Expenses Water Car Payment (If car is used as a home) Garbage, Sewer, Trash Collection Car Insurance (If car is used as a home) Electricity Other (Specify) LIST YOUR LANDLORD’S NAME, ADDRESS AND PHONE NUMBER 30. Are you billed separately for utility cost?  Yes  No If Yes, (  ) check the utilities: Electric/Gas  Water  Sewer/Trash If yes, choose one of the following options “A” or “B” for each utility billed separately: Electricity/Gas Water Sewer/Trash A. Standard Utility Allowance (SUA) The SUA is an amount which reflects the average statewide amount spent for specific utilities and other mandatory fees. You may choose to have either the actual cost or the SUA for each utility cost used in determining the SNAP shelter cost deduction amount. B. Actual Utility Costs If you Choose to use ACTUAL COSTS, you will need to verify these costs. 31. ANY QUESTIONS REGARDING THESE OPTIONS CAN BE DISCUSSED WITH YOUR WORKER. ONCE YOU SELECT AN OPTION, YOU CAN CHANGE IT ONLY ONE TIME IN 12 MONTHS. Does your room or rent payment include meals?  Yes  No If Yes, complete the following: PAYMENT ROOM/MEALS NO. OF MEALS PROVIDED PER DAY MONTHLY AMOUNT $ $ DHS 1240 (REV 04/2024) Page 8 of 11 Attachment A-2, Page 10 of 18

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(1) SOCIAL SECURITY NUMBER(SSN): Pursuant to 42 USC 1320b-7, the SSNs of persons applying for and receiving help in the Financial and SNAP will be used to check identities of household members prevent duplicate participation, verify income/asset amounts and to do mass changes. SSNs will also be used in program reviews or audits and in computer matching with the Internal Revenue Service, State Department of Labor, and Social Security Administration to make sure your household is eligible. This may result in criminal or civil action of administrative claims against persons fraudulently participating in the Financial Program and SNAP. (2) YOU HAVE THE RIGHT: • To discuss any action regarding your case with your worker or the supervisor if you are dissatisfied. • To be notified in advance before your benefits are reduced or discontinued. • To ask for a hearing in writing, or orally for SNAP, if you are dissatisfied with any action by the DHS, and to ask the Legal Aid Society of Hawaii, or anyone you want, to help get a hearing. Your case may be presented at the hearing by any person you choose. • To have your record kept confidential. • To have a bilingual or sign-language interpreter. All our oral and written communication to you will be in English. If you do not understand what you hear or read, please contact your worker right away. • 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 based on race, color, national origin, sex, age, or disability. Under the Food and Nutrition Act and USDA policy, discrimination is prohibited also based on religion or political beliefs. To file a complaint of discrimination with the Department, contact the Civil Rights Compliance office at 1390 Miller Street Room 214, or call (808) 586-4955, or contact USDA or HHS Write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (202) 720-5964 (voice and TDD). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, SW., Washington, D.C. 20201, or call (202) 614-0403 (voice) or (202) 619-3257 (TDD). USDA and HHS are equal opportunity providers and employers. (3) APPLICANT RESPONSIBILITIES: • For SNAP and Financial Assistance, complete and sign the application. • Complete an eligibility interview. • Provide required information, documentation, and verification, such as birth certificates, government issued IDs, paystubs, bank statements, utility bills, etc. • For the financial assistance programs: Apply for and develop potential sources of income and assets. Applicants for SNAP and financial assistance who: fail to meet all of the eligibility factors, fail to cooperate with the department by providing the information and verification necessary to determine eligibility by department deadlines, fail to apply for and develop potential sources of income and assets, or refuses to inform the department of the amount of the unapplied for and undeveloped potential source of income and assets when known, shall be ineligible. (4) ELECTRONIC BENEFITS TRANSFER (EBT) You are responsible to report lost, stolen, or misused EBT CARDS immediately by calling the EBT toll-free customer service number, or by accessing the EBT website at www.ebtEDGE.com. There will be no replacement of any benefits accessed with an EBT card prior to the card being reported lost, stolen or misused. You are responsible to report immediately any changes in the status of your alternate payee. There will be no replacement of any benefits accessed by alternate payees or any other individuals using an EBT card and a valid PIN. Benefits not withdrawn for 112 days for cash assistance accounts and for 365 days for SNAP accounts will be returned to the state. (5) PENALTY WARNING: • Do not make any false statements or hide any information. Sanctions and court prosecution may be pursued under applicable state and federal laws. • Do not do anything dishonest to get money and SNAP benefits which you are not supposed to get. • Do not give, trade, or sell your SNAP benefits or EBT card to anyone else. • Do not alter or use someone else’s SNAP or EBT card for your household. • Do not use your SNAP benefits or EBT card to buy ineligible items such as alcoholic drinks and tobacco. • For the financial assistance program, an intentional program violation disqualification penalty is twelve months for the first violation, twenty-four months for the second violation and permanently for the third or more violations. • For SNAP, any household or family member who intentionally breaks SNAP rules, can be fined up to $250,000, imprisoned up to 20 years or both. A member of your household can be barred from SNAP for one year for the first violation; two years for a second violation and permanently for the third or any subsequent violation and an additional 18 months if court ordered. The individual may also be subject to further prosecution under other applicable Federal laws. A member convicted of using or receiving SNAP benefits in a transaction involving the sale of firearms, ammunition or explosives is permanently ineligible to participate in SNAP. Individuals convicted of trafficking SNAP benefits of $500 or more are permanently ineligible. Individuals found guilty to have used or received SNAP benefits in a transaction involving the sale of controlled substance are ineligible to participate for two years for first violation and permanently for the second violation. Individuals who have committed and been convicted of Federal or State felonies after 8/22/96 for possession, use or distribution of illegal drugs and who refused to comply with treatment or with a treatment program are ineligible for the program. An individual is ineligible to participate in the financial and SNAP for 10 years if found to have filed more than one application at the same time and have given false identification or residence information. Fleeing felons and probation/parole violators are ineligible for the financial and SNAP. DHS 1240 (REV 04/2024) Page 10 of 11 Attachment A-2, Page 12 of 18

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(6) YOUR AUTHORIZATION: • I agree that the information I provide to the Department will be subject to verification by Federal, State and local officials to determine if such information is factual; and if any information is incorrect, SNAP benefits may be denied; and I may be subject to criminal prosecution for knowingly providing incorrect information. • I authorize the Department to check with any financial institution, including, but not limited to, banks, savings and loan associations, thrift companies and credit unions, to verify that I am eligible for help. I authorize any financial institution to provide the Department information, including information on the existence and nature of and amount in any account I may have with the financial institution. • I agree to provide the necessary documents to verify the statements I have made. If documents are not available, I agree to give the name of person or organization (such as doctor, employer, State or Federal agency) whom the Department may contact for information about me which may be needed to show that I am eligible for help. • I agree to cooperate with the Department, Federal Quality Control reviewers and/or auditors if my case is selected for a review. • I understand that the Department may need to release information about me for purposes connected with the administration of the Department’s assistance program, or the administration of federally assisted programs which provides assistance on the basis of need. • I understand that the Department will obtain and exchange information about me to verify my income and eligibility from the Internal Revenue Service and exchange information about me with the Social Security Administration, Department of Labor for wages and Unemployment Compensation, and agencies in all states administering the Income Eligibility Verification System. • I understand that if SNAP benefits are issued before a determination of financial eligibility is made, that the amount of SNAP benefits may be reduced without further notice as long as I am notified of this possibility on the notice approving SNAP benefits. • I understand that my residence and business address may be released to law enforcement officers if needed for an official administrative, civil, or criminal law enforcement purpose, or to identify a recipient as a fugitive felon or a parole violator. • I understand that if my EBT account becomes inactive because I failed to access my benefits, the balance in my EBT account may be used to offset any outstanding overpayments that my household owes the Department. • I authorize the Department to release information from my case to the social security (SS) advocate contracted by the Department. This information will be used to help get SS benefits for me. The type of information which may be released shall include medical, income and asset information and work history. I also authorize the advocate to release information to the Department regarding the status of my claim for SS and any failure to comply with appointments and requests for information. • I understand that release of this information may affect my public assistance benefits. This consent is good until a final determination of eligibility for SS has been reached or the consent is withdrawn in writing. • I agree that I will not access my Temporary Assistance for Needy Families (TANF) financial assistance benefits through any electronic benefit transfer transaction in any liquor store; any casino; gambling casino, or gaming establishment; or any retail establishment which provides adult-oriented entertainment in which performers disrobe or perform in an unclothed state for entertainment. (7) ASSIGNMENTS AND AGREEMENT: • ASSIGNMENT OF RIGHTS: I understand that as a condition of eligibility for financial assistance, I am assigning to the State of Hawaii any rights to child and spousal support that I may have from another person, for myself or any person for whom I am applying or receiving assistance. This assignment includes rights to support from previous as well as present and future support. Such payments will be used to reimburse the State up to the amount of assistance granted. You may be exempt from this requirement if you fear physical or mental harm to yourself or your children. I also understand that when I assign child and spousal support to the State I must have the State’s permission to negotiate or seek a new court order or otherwise change the existing status of my child or spousal support agreement. I agree to cooperate with the State in establishing paternity for the minor children in my application. • REAL PROPERTY AGREEMENT: I give the Department permission to verify information on my property. I also agree to report to the Department within five days any money received from the sale, lease, exchange or transfer of such property. If I assign or transfer any property for less money than what I get in the open market, my dependents and I will become ineligible for further assistance. (8) SNAP PRIVACY ACT STATEMENT: Collection of information for this application, including the social security number (SSN) of each household member is authorized under the Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036. • The information will be used to determine whether your household is eligible or continues to be eligible to participate in the SNAP. • 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. • If a SNAP claim arises against your household, the information on the application, including all SSNs, may be referred to Federal and State agencies, as well as to private claims collections agencies for claims collection action. • The providing of the requested information, including the SSN of each household member, is voluntary. However, failure to provide this information will result in the denial of SNAP benefits to your household. (9) TANF Program Memorandum of Understanding TANF is time-limited cash assistance program for families with dependent children under the age of 18 years. Families may receive no more than sixty (60) months of cash assistance benefits in their lifetime. After receiving the first 2 full months, the TANF benefits will be reduced by 20% thereafter unless the household is exempt from this reduction. Non-cooperation with the TANF Program requirements without good cause will result in ineligibility for cash assistance benefits. As a condition of eligibility, families are required to: • Furnish a social security number for each household member; • Cooperate with the Child Support Enforcement Agency to pursue additional financial support for your child(ren) if there is an absent parent; and • Participate and comply with the work program requirement through the First-To-Work program. (10) YOUR CERTIFICATION (MUST BE SIGNED TO BE CONSIDERED A VALID APPLICATION): Before signing this application, go back and check that you have answered each question. Make sure you understand your rights and responsibilities, penalty warning, your authorization, your consent, your assignments, and agreements. • I certify under penalty of perjury, that my answers are correct and complete to the best of my knowledge. • I understand the questions on this application and the penalty for hiding or giving false information. • I understand the assignments and agreements and agree to fulfill them as a condition of eligibility. • I certify under penalty of perjury that the information provided on the Citizen Status Declaration on each applicant household member is correct. SIGNATURE (OR MARK) OF APPLICANT DATE SIGNATURE (OR MARK) OF SPOUSE OR OTHER ADULT APPLICANT (Required for money assistance only) DATE WITNESS IF SIGNATURE IS “X” (11) CERTIFICATION BY AUTHORIZED REPRESENTATIVE  OR OTHER PERSON ASSISTING IN FILLING OUT APPLICATION  : (Please check off one box) I helped the applicant fill out this form. I understand that anyone helping another person in dishonestly getting benefits is subject to criminal penalties. I certify that the answers given by me on this form  is what I know personally about him/her; or  was provided by the applicant/recipient. SIGNATURE RELATIONSHIP DATE HOME ADDRESS PHONE NO. (12) IN CASE OF EMERGENCY OR DEATH, THE PERSON TO CONTACT IS: (Please Print) NAME RELATIONSHIP PHONE NO. ADDRESS DHS 1240 (REV 04/2024) Page 11 of 11 Attachment A-2, Page 13 of 18

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State of Hawaii Processing Centers Oahu Kapolei Processing Center 601 Kamokila Boulevard, #117 Kapolei, Hawai‘i 96707 Phone: 1-855-643-1643 Fax: 808-692-7783 Ko‘olau Processing Center- Luluku 45-513 Luluku Road Kane‘ohe, Hawai‘i 96744 Phone: 1-855-643-1643 Fax: 808-233-5358 KPT Processing Center 1485 Linapuni Street, #122 Honolulu, Hawai‘i 96819 Phone: 1-855-643-1643 Fax: 808-832-3392 OR&L Processing Center 333 North King Street, #200 Honolulu, Hawai‘i 96817 Phone: 1-855-643-1643 Fax: 808-586-8138 Pohulani Processing Center 677 Queen Street, #400B Honolulu, Hawai‘i 96813 Phone: 1-855-643-1643 Fax: 808-587-5297 Wahiawa Processing Center 1008 California Avenue, Bldg. B Wahiawa, Hawai‘i 96786 Phone: 1-855-643-1643 Fax: 808-622-6484 Wai‘anae Processing Center 86-120 Farrington Highway, #A103 Wai‘anae, Hawai‘i 96792 Phone: 1-855-643-1643 Fax: 808-697-7184 Waipahu Processing Center 94-275 Moku‘ola Street, #300A Waipahu, Hawai‘i 96797 Phone: 1-855-643-1643 Fax: 808-675-0038 Maui County Maui Processing Center - Lunalilo 35 Lunalilo Street, #300 Wailuku, Hawai‘i 96793 Phone: 1-855-643-1643 Fax: 808-243-5114 Maui Processing Center - State Building 54 High Street, #125 Wailuku, Hawai‘i 96793 Phone: 1-855-643-1643 Fax: 808-984-8333 Lanai Sub-Unit 730 Lana‘i Avenue Lana‘i City, Hawai‘I 96763 Phone: 1-855-643-1643 Fax: 808-565-6460 Mailing Address: PO Box 631374 Lana‘i City, Hawai‘i 96763 Molokai Unit 55 Maka‘ena Place #1 Kaunakakai, Hawai‘i 96748 Phone: 1-855-643-1643 Fax: 808-553-1720 Mailing Address: PO Box 70 Kaunakakai, Hawai‘i 96748 Hawaii Island North Hilo Unit 13 Kekaulike Street Hilo, Hawaii 96720 Phone: 1-855-643-1643 Fax: 808-933-8856 South Hilo Unit Kino‘ole Plaza 1990 Kino‘ole Street, #108 Hilo, Hawai‘i 96720 Phone: 1-855-643-1643 Fax: 808-981-2819 Kamuela-Hamakua Unit State Office Building 1, #110 45-3380 Mamane Street Honoka‘a, Hawai‘i 96727 Phone: 1-855-643-1643 Fax: 808-775-8858 Ka‘u Sub-Unit Na‘alehu Civic Center 95-5669 Mamalahoa Highway Na‘alehu, Hawai‘i 96772 Phone: 1-855-643-1643 Fax: 808-929-9500 Mailing Address: PO Box 6 Na‘alehu, Hawai‘i 96772 South Kona Unit Captain Cook Civic Center 82-6130 Mamalahoa Highway, Bldg. 2 Captain Cook, Hawai‘i 96704 Phone: 1-855-643-1643 Fax: 808-323-4549 Mailing Address: PO Box 225 Captain Cook, Hawai‘i 96704 Kohala Sub-Unit State Office Building 54-3900 ‘Akoni Pule Highway Kapa‘au, Hawai‘i 96755 Phone: 1-855-643-1643 Fax: 808-889-7132 Mailing Address: PO Box 249 Kapa‘au, HI 96755 North Kona Unit 75-5722 Hanama Place, Ste. 1105 Kailua-Kona, Hawai‘i 96740 Phone: 1-855-643-1643 Fax: 808-327-4684 Kauai Kaua‘i Processing Center Former Lihu‘e Courthouse Building 3059 ‘Umi Street, #A110 Lihu‘e, Hawai‘i 96766 Phone: 1-855-643-1643 Fax: 808-335-8446 Attachment A-2, Page 14 of 18

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E kākau mai i nā helu hope 4 o kou Helu Mālama Ola ‘A‘ole loa‘a ia‘u ka Laikini Kalaiwa Hawai‘i, ke Kāleka Kuhikuhi Kanaka Moku‘āina ‘o Hawai‘i, a i ʻole ka Helu Mālama Ola ‘A‘ole loa‘a ia‘u ka Laikini Kalaiwa Hawai‘i, ke Kāleka Kuhikuhi Kanaka Moku‘āina ‘o Hawai‘i 2 1 3 4 6 7 8 3b Inoa Hope Inoa Mua Hua Inoa Waena Pākuʻina Kau Hope (Jr, II) Helu Laikini Kalaiwa Hawai‘i a i ‘ole Kāleka Kuhikuhi Kanaka Moku‘āina ‘o Hawai‘i inā ‘a‘ole loa‘a, e ho‘opiha i ka pahu 3b Lā Hānau Helu Kelepona Helu Leka Uila Helu Keʻena Noho Helu Keʻena Noho Kaona Kaona Helu Kuhi Helu Kuhi Inā ʻaʻohe helu o kou wahi noho, e kuhikuhi mai i kahi noho (nā alanui i kokoke, nā hōʻailona ʻāina paha) Helu Wahi Noho (Hōʻole ʻia nā P.O. Box, R.R., S.R.) Helu Leka ma Hawaiʻi Like me ka Helu Wahi Noho Ua hoʻokāinoa ʻia ʻoe e koho pāloka i kekahi mokuʻāina aʻe? ʻAe. ʻĀpono au i ke kapae ʻia o koʻu kūlana he mea koho pāloka ma kēia helu wahi, kalana, mokuʻāina a helu kuhi. Makaʻala: Inā waiho kekahi kanaka i ka ʻikepili hewa ma ke ʻike pū i ka hewa, e hoʻāhewa ʻia paha ʻo ia i ka peloni pae C. Ke hoʻohiki (a i ʻole hōʻoia) nei au i ka ʻoiaʻiʻo a me ka pololei o ka ʻikepili a pau i waiho ʻia ma kēia palapala. Lā Inā ‘a‘ole hiki ke pūlima, e kaha ma ka laina pūlima a e noi i kekahi kanaka ‘ike maka e pūlima a e waiho mai i kona helu wahi a helu kelepona. He kupa anei ʻoe o ʻAmelika Hui Pū ʻIa? ʻAe ʻAʻole Piha anei he 16 mau makahiki? (Pono he 18 mau makahiki e ʻae ʻia ke koho pāloka) ʻAe ʻAʻole He kanaka noho paʻa ʻoe ma ka Mokuʻāina o Hawaiʻi? ʻAe ʻAʻole No ka lilo ʻana i kanaka noho paʻa e like me ka mea i ʻōlelo ʻia ma kēia palapala hōʻike, ʻaʻole lawa ka noho wale ʻana ma kēia mokuʻāina, akā e kūkala kūhelu ʻia ʻo Hawaiʻi koʻu wahi e noho paʻa ai me ka lawe pū ʻana i nā ʻaiʻē a pau e pono ai. OFFICE USE ONLY ID Number Location Code Document Number E kāinoa ma ka pūnaewele ma elections.hawaii.gov Palapala Kāinoa Koho Pāloka E kākau mōakāka ʻia me ka ʻīnika ʻeleʻele. Hōʻike: ʻAʻole e hōʻike ākea ʻia ka ʻoihana hoʻokāinoa koho i kāinoa ai kekahi mea koho. He mea huna ka hōʻole ʻana a kekahi e kāinoa koho pāloka a hoʻohana ʻia ka ʻike no ka hoʻokāinoa poʻe koho pāloka wale nō (Kānāwai ʻo National Voter Registration Act o 1993) Kū anei ʻoe i kēia mau koina: 5 Inā hiki ʻole iā ʻoe ke heluhelu i nā hua paʻi maʻamau ma muli o kekahi kīnānā, makemake ʻia anei ka pāloka uila? ʻAe, ma muli o ke kīnānā, ʻaʻole hiki iaʻu ke heluhelu i nā hua paʻi maʻamau, no laila, ke noi nei au i ka hoʻouna ʻia o ka pāloka uila i kaʻu helu leka uila i waiho ma kēia palapala noi. He koina ka helu leka uila o ke kanaka koho i mea e pae aku ai ka pāloka uila. Inā ʻo “ʻAʻole” ka pane i kekahi o nā nīnau o luna, ʻAʻOLE e hoʻopihapiha ʻia kēia palapala kāinoa. E PŪLIMA MA ʻANEʻI 1438708-01 2023 Hawaii Votes_application_Hawaiian.indd 1 1/22/24 10:36 AM Attachment A-2, Page 15 of 18

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STATE OF HAWAII BENEFIT, EMPLOYMENT DEPARTMENT OF HUMAN SERVICES AND SUPPORT SERVICES DIVISION DHS 1259 (REV 06/2022) Page 1 of 1 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) WORK PROGRAM REFERRAL AND REQUIREMENTS Name of Applicant / Recipient Case Number Processing Center Date This form explains the referral and work program requirements of the TANF Program. The work program will help you and your family to move from receiving financial benefits to employment. Please read this form and keep for your records. If there are any questions regarding this form, please call the Public Assistance Information Line at 1-855-643-1643. PURPOSE: The TANF Program has work participation requirements, as a condition of eligibility for recipients who can work, as well as vocational rehabilitation services for recipients who may be temporarily unable to work. Recipients who can work will be referred to the First-To-Work (FTW) Program and will need to participate and meet participation requirements. Recipients who are unable to work full-time (at least 30 hours per week) will be referred to the FTW Vocational Rehabilitation (FTW-VR) office to receive services to help remove the temporary barriers. The FTW Program helps recipients to prepare for and find employment; assists with rehabilitation and treatment services; and pay for child care, transportation costs and other expenses while participating in the FTW Program. PART I – NON-WORK ELIGIBLE INDIVIDUALS: If any of the following reasons prevent you from working, you will not need to participate with the FTW Program. When you no longer meet any of the following conditions, you will need to participate with the FTW Program. 1) You are a single parent caring for your child who is under six (6) months old and have not used the lifetime exemption limit of twelve (12) months. 2) You are a parent caring for an ill or disabled family member living in your home, supported by medical documentation. 3) You are not applying for help for yourself but are applying for help for child(ren) that is not your own (non-needy caretaker). PART II – OTHER WORK ELIGIBLE INDIVIDUALS: If you feel that you are unable to work because you are disabled, receiving treatment for substance abuse disorder, or currently in a domestic violence crisis, you will be referred to the FTW-VR office as a condition of eligibility for financial benefits. You will be asked to submit verification if your family meets one of the following and must be certified by department authorized providers. 1) You have been disabled for thirty (30) days or more and cannot work. 2) You recently or currently in a domestic violence situation and cannot work. 3) You are sixty-five (65) years of age or over. PART III – PENALTIES FOR NON-COMPLIANCE: If you do not meet any of the criteria listed in Part I above, you must participate with the FTW Program. Participation with the FTW Program includes keeping appointments and completing work activities in your Employment Plan. If you do not complete your activities or refuse to participate without good cause, your family’s financial benefits will stop. The following are the sanction (disqualification) periods: FIRST SANCTION: Family will not be eligible until you reapply for benefits. SECOND SANCTION: Family will not be eligible for a minimum of two (2) months; and THIRD AND SUBSEQUENT SANCTIONS: Family will not be eligible for a minimum of three (3) months. Auth: Hawaii Administrative Rules Chapters 17-656.1 and 17-794.1 Attachment B-1

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STATE OF HAWAII BENEFIT, EMPLOYMENT DEPARTMENT OF HUMAN SERVICES AND SUPPORT SERVICES DIVISION DHS 1242 (REV 06/2022) Page 1 of 1 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) Memorandum of Understanding (MOU) Name of Applicant / Recipient Case Number Processing Center Date This MOU explains the requirements of the TANF Program. Please read this MOU and keep for your records. If you have any questions regarding this MOU, please call the Public Assistance Information Line at 1-855-643-1643. 1. Applicants of financial benefits through the TANF Program must attend an orientation session with the First-To-Work (FTW) Program and meet one week of participation requirements, within a three (3) week period, before the first financial benefits will be issued. 2. An able-bodied adult who does not have a child under six (6) months old or is not caring for an ill or disabled family member, will be referred to the FTW Program. The FTW Program helps families to prepare for and to become employed. Program requirements must be met, or the family will not be eligible for financial benefits. 3. If physical or mental disability or domestic violence prevents an adult family member from working, a referral will be made to the First-To-Work Vocational Rehabilitation (FTW-VR) office. The family will need to participate in the FTW-VR program and services. FTW-VR provides case management services, monitors treatment services, provides services to address domestic violence, provides specialized employment services, or other services. 4. Families may receive up to sixty (60) months of benefits, in a lifetime, if there is at least one (1) adult in the family who is able-bodied and can work. 5. The financial benefits received by a family will be reduced by 20% in the third (3rd) full month after the application interview if there is at least one (1) adult in the family who is able-bodied. This 20% benefit reduction will continue until the family receives sixty (60) months of benefits. 6. If a family member is employed, the department will apply allowable deductions so less of your family’s earnings will be counted towards determining your family’s benefits. If your family’s calculated net income does not exceed the 100% of the standard of need for your family size, your family will continue to be eligible for financial benefits or no- fault automobile insurance. 7. If child(ren) receives financial benefits but the adult(s) are not eligible, the adult(s) may still be required to participate in the FTW Program and meet program requirements as a condition of eligibility for the family. 8. If an adult in the family or any other member decides to go to school, the family will still be subject to the 60-month time limit and the 20% benefit reduction, but any educational loans, grants or scholarships received will not count in determining eligibility and financial benefits. 9. If an independent minor parent is receiving financial benefits with their own child(ren), the family will continue to be eligible for financial assistance if the minor parent stays in school and completes high school education or equivalency. Minor parents will be subjected to the five (5) year time limit, but the financial assistance benefits will not be reduced by 20% so long as the minor parent is in high school or equivalent. 10. Children in the family who are between sixteen (16) and eighteen (18) years old and not attending high school, must participate with the FTW Program. 11. While employed or participating with the FTW Program, a family may request help with childcare costs. Auth: Hawaii Administrative Rules, Section 17-647-54.1, and Chapters 17-656.1 and 17-794.1 Attachment B-2

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STATE OF HAWAII BENEFIT, EMPLOYMENT DEPARTMENT OF HUMAN SERVICES AND SUPPORT SERVICES DIVISION DHS 1260 (REV 07/2023) Page 1 of 1 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) PROGRAM SELF-DECLARATION SCREENING FORM TO CLAIM DOMESTIC VIOLENCE STATUS I. DOMESTIC VIOLENCE (DV) STATUS: A family, who has at least one (1) member determined to be a DV survivor by the domestic violence advocacy (DVA) service provider, shall be eligible for DV status. The DV status shall be for a period of six (6) months and shall exempt the family from the five (5) year time limit and the 20% benefit reduction. In certain situations, the DV status may be extended for an additional six (6) month period. The family must comply with the DVA services and participation with the First-To-Work (FTW) program as a condition of eligibility. Failure to cooperate with DVA services and/or with the FTW program will result in the denial of the DV status and/or termination of the II. DV STATUS CRITERIA: Please answer the following questions. YES NO 1. Are you working 20 hour or more each week? 2. Are you attending school for more than 6 credit hours each week? 3. Is it difficult for you to go to work or attend school due to DV situation(s)? 4. What is your relationship to the alleged perpetrator? 5. Which of the following protective actions have you taken as the result of DV situation(s) involving the perpetrator? a) I have a current court order protecting me or a member of my family from the alleged perpetrator. b) I am a party to a pending divorce or custody action which involves issues of current or past DV situation(s). c) Within the past 12 months, I have stayed in a DV shelter. d) Within the past 12 months, I had to stay with a friend or relative to escape from a DV situation and my friend or relative is willing to provide a written statement attesting to the DV situation. e) Within the past 12 months, I or a member of my family is a survivor of a DV situation which resulted in the arrest, arraignment, or conviction of the alleged perpetrator. f) Within the past 12 months, I or a member of my family received inpatient or outpatient treatment for psychological, physical, or emotional abuse as the result of a DV situation. g) Within the past 12 months, I or a member of my family was hospitalized or received emergency room treatment for medical or psychological injuries resulting from a DV situation. h) Within the past 12 months, the alleged perpetrator threatened me or a family member with death or grievous bodily harm. III. APPOINTMENT WITH THE DVA SERVICE PROVIDER: Your DVA appointment is scheduled on: Date:

Time: Address:

Phone Number: Bring this form with you to the appointment and any of the supporting documents listed below to support your claim. If it is unsafe, the Department may send this form directly to the DVA service provider. If you need to reschedule this appointment, please call the DVA service provider above. IV. SUPPORTING DOCUMENTS: You will need to provide supporting documents to the DVA service provider so determination can be made whether your family is eligible for the DV status. The following are examples of supporting documents that you can provide: 1. Court documents 4. Medical records, discharge documents 2. Police reports/records 5. Written statement from your friend or relative with whom you sought 3. Letter/verification from a DV service provider shelter to escape from a DV situation You will be informed by the DVA service provider of the decision after your scheduled appointment. NOTE: If you do not want this written decision or any other DV information to be mailed to your home, please advise your DHS worker. DO NOT MAIL THIS TO MY HOME. V. ATTESTATION AND CLAIM: I have read this notice and understand the information it provides. I would like to claim the DV status. I agree to submit any necessary supporting documents to the DVA service provider. Print Applicant/Recipient Name Signature Date Case Number Applicant/Recipient Mailing Address Phone Number Name of Referring DHS Office Mailing Address Phone Number Fax Number FOR DVA SERVICE PROVIDER USE ONLY. Supporting Documents Received: 1. is approved for the period from to . 2. Client failed to submit document(s) to support the DV claim. The request for the DV status is denied. 3. Client submitted document(s) 4. The request for the DV status is denied because: Name of DVA Advocate Signature Date Phone Number Attachment B-3

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STATE OF HAWAII BENEFIT, EMPLOYMENT DEPARTMENT OF HUMAN SERVICES AND SUPPORT SERVICES DIVISION DHS 1247 (REV 06/2022) Page 1 of 1 TEMPORARY ASSISTANCE FOR NEEDY FAMILIES PROGRAM NOTICE OF REQUIREMENT TO COOPERATE WITH CHILD SUPPORT ENFORCEMENT AGENCY AND RIGHT TO CLAIM GOOD CAUSE Name of Applicant / Recipient Case Number Processing Center Date This notice explains the requirement for families to cooperate in obtaining child and/or spousal support for you and your child(ren), and the right to claim good cause for not cooperating with this requirement. Please read this notice and keep for your records. If there are any questions regarding this notice, please call the Public Assistance Information Line at 1-855-643-1643. BENEFITS OF CHILD SUPPORT ENFORCEMENT Your cooperation to obtain child support from your child(ren)’s absent parent may be important to you and your child(ren) because it may help to: 1) Locate the absent parent; 2) Establish paternity; 3) Set up child support payments; 4) Determine rights to future Social Security, veterans or other government benefits; and/or 5) Establish medical coverage for your child(ren) from the absent parent. COOPERATION WITH CHILD SUPPORT ENFORCEMENT AGENCY In accordance with federal laws and as a condition of eligibility, your family is required to cooperate to obtain any support owed to you and your child(ren) for whom you want financial benefits unless you have good cause not to do so. Cooperating with the Child Support Enforcement Agency, you may be asked to do one or more of the following: 1) Identify the absent parent of any child applying for or receiving financial benefits and give information to help locate the absent parent; 2) Establish paternity if your child(ren) were born out of wedlock; 3) Help to obtain financial support and medical coverage owed to you and/or your child(ren) who are receiving assistance, including any past due child support; and 4) Reimburse the State any money given directly to you by the absent parent as you continue to receive your eligible financial benefit amount. You may be required to go to the appropriate Child Support Enforcement Agency office in-person to sign papers and/or provide necessary information. GOOD CAUSE You may have good cause not to cooperate in the State’s efforts to obtain child/spousal support and medical coverage. You may be excused from cooperating if you believe that it would not be in the best interest of your family and if you can provide evidence to support this claim. NON-COOPERATION WITHOUT GOOD CAUSE If you refuse to cooperate without good cause, your entire family will be ineligible for financial benefits. GOOD CAUSE CLAIM If you want to claim good cause: 1) You must inform the Processing Center whenever you think you have good cause not to cooperate; and 2) You must be given a second notice explaining the circumstances under which the eligibility worker may find good cause and the type of evidence or other information needed to justify your claim of good cause. Auth: Hawaii Administrative Rules, Chapter 17-653, and Sections 17-656.1-8, 17-656.1-11, and 17-676-32 Attachment B-4, Page 1 of 1

(2023)Hawaii TANF State Plan, effective October 1, 2023#

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