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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