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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