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PART III: PENALTY WARNING

If you give false or misleading information or withhold information to receive benefits, you may be prosecuted or referred for an Administrative Disqualification Hearing. You also may be required to repay any benefits you erroneously received. If your household receives SNAP benefits, you must not (1) give or sell SNAP electronic benefit cards to anyone not authorized to use them; (2) alter any SNAP electronic benefit cards to get benefits you are not entitled to receive; (3) use SNAP benefits to buy unauthorized items, such as alcoholic drinks, tobacco, or paper products; and (4) use another household’s SNAP electronic benefit card for your household.

Any member of your household who breaks any of these rules on purpose could be barred from the Supplemental Nutrition Assistance Program for 12 months, 24 months, or permanently and may be fined, imprisoned, or both. Anyone court convicted of trading SNAP benefits for a controlled substance could be barred for 24 months or permanently, and permanently if court convicted of trading SNAP benefits for firearms, ammunition, or explosives. Anyone who intentionally gives false information or hides information about identity or residence to get SNAP benefits in more than one locality at the same time could be barred for 10 years.

PART IV: YOUR SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM RIGHTS

In accordance with federal law and U.S. Department of Agriculture policy, we are prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, and disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC. 20250-9410 or call (202) 720-5964 (Voice and TDD). USDA is an equal opportunity provider and employer.

PART V: CERTIFICATION AND SIGNATURE

I understand the questions on this application and the penalty for withholding or giving false or misleading information. I certify, under penalty of perjury, the information I have given is correct and complete to the best of my knowledge. I authorize the release of any information necessary to review actions related to this application. I understand that if I disagree with the decisions made on my application, I have a right to ask for a fair hearing. I understand my household may be selected for a federal or state review to examine actions taken in connection with this application.

Signature (Mark) of Applicant or Authorized Representative: ________________________________ Witness of Mark: __________________________ Date: _____________

Signature of Worker: _____________________________________ Worker Number: __________________________ Date: _____________