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A. APPLICANT INFORMATION Your Contact Information

Your Name (last, first, middle initial)

Your Street Address (include apartment number)

City, State, ZIP

Your Mailing Address (if different from your street address)

City, State, ZIP

In what city or county do you live?

Email Address

Primary Telephone Number

Alternate Telephone Number

What is the primary language spoken in your household?  English  Spanish  Cambodian  Vietnamese  Farsi  Haitian-Creole  Laotian  Chinese  Korean  Somali  Kurdish  Arabic  French  German

 Japanese  Other (specify): _________________ Primary Method of Correspondence If you would like to receive either text or email messages notifying you that some notices about your benefits may be accessed electronically through CommonHelp (www.CommonHelp.Virginia.gov), select one of the choices below. List either a cell telephone number or an email address. Once you choose a preferred electronic method of correspondence, it will be used for all programs on the case for which you have applied. If you do not choose to be notified by text or email, you will receive all written correspondence through the U.S. mail. If you are completing this application on behalf of another individual as an authorized representative, all correspondence to you will be mailed. The applicant may contact the local department of social services to learn how to change the method of correspondence.  Text  Email Cell Phone Number ________________________ Email Address __________________________________  YES  NO 1. Have you or anyone for whom you are applying ever applied for, or received, or are currently receiving any benefits from a social services agency, including SNAP (Food Stamps), TANF, Medicaid, General Relief, Auxiliary Grant, Foster Care, Adoption Assistance, or Refugee Cash Assistance? If YES, enter the information below. Name:________________________ Type of Benefit Received:________________________________ When:_________________________________ From What County, City, or State:_________________________

 YES  NO 2. Have you or anyone for whom you are applying ever been convicted of making false or misleading statements about your identity or address to receive TANF, SNAP, or Medicaid in two or more states at the same time? If YES, give date and place of conviction.__________________________________________________________

 YES  NO 3. Have you or anyone for whom you are applying ever been disqualified from participating in TANF, SNAP, or Medicaid? If YES, give date and place of all disqualifications.________________________________________

 YES  NO 4. Are you or anyone for whom you are applying in violation of parole or probation or fleeing capture to avoid prosecution or punishment of a felony? If YES, explain _____________________________________________

 YES  NO 5. Have you or anyone for whom you are applying ever been convicted of a felony as an adult on or after February 8, 2014 for the following: a. Aggravated sexual abuse under Title 18 United States Code (USC), Section 2241 or a similar state offense?  YES  NO b. Murder under Title 18 USC, Section 1111 or a similar state offense?  YES  NO c. An offense under Title 18 USC, Chapter 110 (sexual exploitation and other abuse of children) or a similar state offense?  YES  NO d. A federal or state offense involving sexual assault, as defined in Section 40002(a) of the Violence Against Women Act of 1994 (42 USC 13925(a)) ?  YES  NO If YES to any of the above, who? __________________________________________. If YES to any of the above, are you in compliance with the terms of the sentence?  YES  NO

032-03-1100-40-eng (02/2024 Commonwealth of Virginia Department of Social Services

APPLICATION FOR BENEFITS Return your completed application to: _________________ County/City DSS ________________________________ ________________________________