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BY MY SIGNATURE BELOW, I DECLARE:

• I read the information at the beginning of this application and the Change Reporting and Penalties section of this application.

• I understand that if I refuse to cooperate with any review of my eligibility, including a review by Quality Control, my benefits may be denied until I cooperate.

• I understand that if my application is for SNAP benefits, failure to report or verify any of my expenses will be seen as a statement by my household that I do not want to receive a deduction for these expenses.

• I have given true and correct information on this application to the best of my knowledge and belief. I understand that if I give false information, withhold information, or fail to report a change promptly or on purpose, I may be breaking the law and could be prosecuted for perjury, larceny, and/or welfare fraud. I understand that if I help someone complete this form in order to get benefits he or she is not entitled to receive, I may be breaking the law and could be prosecuted.

• As a condition of receiving TANF, I agree to assign all of my rights to financial support paid to me and to anyone for whom I am receive TANF. After my application for TANF is approved, I agree to give any support payments I receive to the Division of Child Support Enforcement.

• I authorize the Department of Social Services and refugee service contractors to obtain any verification necessary to both determine and review financial assistance eligibility. This authorization is valid for one year from the date of my signature below. I understand that this time limit does not apply as long as my medical assistance case is open or to investigations regarding possible fraud.

• As an applicant for Auxiliary Grants, I understand that my application will be evaluated for Medicaid. I agree to assign my rights to medical support and other third-party payments to the Department of Medical Assistance Services (DMAS). I also agree to assign the rights of anyone for whom I am applying for Auxiliary Grants to medical support and other third- party payments to DMAS. If I do not agree to assign these rights, I will be ineligible for Medicaid.

• I understand that, to the extent allowed by federal law, information about this application may be shared with agencies under the Secretary of Health and Human Resources for Virginia. Information about applicants for and recipients of services may be shared to: 1) streamline administrative processes and reduce administrative burdens on the agencies; 2) reduce paperwork and administrative burdens on appllicants and recipients; and 3) improve access to and the quality of services provided by the agencies.

• I understand that different state agencies provide different services and benefits. Each agency must have specific information to determine eligibility services and benefits.  I allow  I do not allow the Department of Social Services to disclose certain information about me to other state agencies, including information in electronic databases, for the purpose of determining my eligibility for benefits/services provided by that agency. This disclosure will make it easier for agencies to work together efficiently to provide or coordinate services and benefits. Agencies include, but are not limited to, the Department of Health, and the Department for Aging and Rehabilitative Services. I can withdraw this authorization at any time by notifying my eligibility worker.

I filled in this application myself  YES  NO. If NO, it was read back to me when completed.  YES  NO.

______________________________________ _________ _______________________________ ___________

Applicant’s Signature or Mark Date Witness To Mark or Interpreter Date

_________________________________________ _________ Signature of the Spouse or Authorized Representative Date

Complete the section below only if this application was completed for the applicant by someone else.

___________________________________________ _________ ____________________________________________ Name of Person Completing Application Date Address

________________________ _________________________ _________________________ Primary Telephone Alternate Telephone Relationship to Applicant

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