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S N A P M A N U A L

30 3 . 3 S N A P A P P L I C A T I O N F O R M

The application form for SNAP benefits is the DSS Form 3800, Temporary Assistance for Needy Families (TANF) Application Supplemental Nutrition Assistance Program (SNAP) Application Refugee Cash Assistance (RCA) Application. The application form may be a paper document, on-line document or a recorded conversation. (1) Content This form contains: • A place on the first page of the application where the applicant can write his/her name, address, and signature. • Notification of the household's right to immediately file the application as long as it contains the applicant's name and address and the signature of a responsible household member or the household's authorized representative; • The option of answering only those questions relevant to the program or programs for which they are applying; • A statement that the information provided by the applicant in connection with the application for SNAP benefits will be subject to verification by Federal, State and local officials to determine if such information is factual; • A statement that if any information is incorrect, SNAP benefits may be denied to the applicant; and that the applicant may be subject to criminal prosecution for knowingly providing incorrect information; • A description of the civil and criminal provisions and penalties for violations of the Food and Nutrition Act of 2008 (as amended); • A statement to be signed by one adult household member which certifies, under penalty of perjury, the truth of the information contained in the application, including the information concerning citizenship and non-citizens status of the members applying for benefits; • A description of the expedited service rules (See Section 6.5 (1) Entitlement to Expedited Service); • Notification that benefits are provided from the date of application; and • The following nondiscrimination statement on the application itself even if the Agency uses a joint application form: o In accordance with federal civil rights laws 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. o 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