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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