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GENERAL INFORMATION

With this application, you may apply for one or more of the following assistance programs:

• Auxiliary Grants (AG) • General Relief – Unattached Child (GR) • Refugee Cash Assistance (RCA) • Supplemental Nutrition Assistance Program (SNAP) • Temporary Assistance for Needy Families (TANF) • TANF Diversionary Assistance (TANF DA) • TANF Emergency Assistance (TANF EA)

Note that an application for TANF will be treated as an application for SNAP. Be sure to mark TANF-No SNAP in the Household Composition section if you only want to apply for TANF.

COMPLETING THE APPLICATION

If you need help completing this application, a friend or relative or your eligibility worker can help you. If you are completing this application for someone else, answer each question as if you were that person. If you need to change an answer or make a correction, write the correct information nearby and put your initials and date next to the change. If there are more than 6 people living in your home and you need more space to list everyone, tell the agency you need extra pages. If you have a disability or have difficulty with English, you may receive extra help to make sure you get the assistance or services you are eligible to receive. Make sure you sign this application on Page 11.

COMPLETE AND ACCURATE INFORMATION

You must give complete, accurate, and truthful information. If you do not give needed information, we may not be able to determine your eligibility for assistance. If you knowingly give false, incorrect, or incomplete information, or fail to report changes, you could lose your benefits and be arrested, prosecuted, fined and/or imprisoned. If you knowingly give false, incorrect, or incomplete information to help someone else receive benefits, you could be arrested and prosecuted for fraud.

FILING THE APPLICATION

You may apply for benefits by leaving a completed application at the agency or by leaving a partially completed application with at least your name, address, and signature, or, for SNAP only, by tearing off and leaving the half-sheet on Page iii with your name, address, and signature. You must complete the rest of this application before your eligibility can be determined. For some programs, including SNAP, you must also be interviewed, but you may turn in your application before your interview. You may turn in your application any time during office hours the same day as you contact your local agency. You have the right to turn in your application even if it looks like you may not be eligible for benefits. This is important because, if you are eligible for the month in which you apply, your benefit amount will be based on the date you turn in your application.

VERIFICATION AND USE OF INFORMATION

Information you give on this application, including Social Security numbers (SSN), may be matched against federal, state, and local records. These records include:

• Virginia Employment Commission (VEC) • Department of Motor Vehicles (DMV) • Internal Revenue Service (IRS) • US Citizenship and Immigration Services (USCIS) • Social Security Administration (SSA) • Income and Eligibility Verification System IEVS)

Any difference between the information you give and these records will be investigated. Information from these records may affect your eligibility and benefit amount. Information may be used to: • determine the correctness, accuracy, and truthfulness of the application; • verify your identity and citizenship; verify wages and salary, unemployment benefits, and unearned income, such as Social Security and Supplemental Security Income (SSI) benefits; verify quarters of coverage under Social Security for an alien, or to verify the status of aliens; • prevent receipt of benefits from more than one social service agency at the same time; • make required program changes; • allow disclosure for official examination and to law enforcement officials to assist in apprehending persons fleeing to avoid the law; or • assist in SNAP claims collection actions.

Your information may also be used or disclosed to study public benefit programs, such as SNAP or TANF.

Information regarding your race and ethnicity is not required and will not affect your eligibility or benefit amount. This information is requested to be sure that program benefits are provided without regard to race, color, or national origin.

032-03-1100-40-eng (02/2024) Commonwealth of Virginia Department of Social Services Return your completed application to: _____________________________ County/City DSS ____________________________________________ ____________________________________________