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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