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Case Name ______________ Case Number ____________

Rights and Responsibilities

 I declare that I reviewed a listing of my rights and responsibilities in writing about applying for or receiving public assistance benefits such as Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) benefits.

 I declare that a representative of the _____________________ agency discussed rights and responsibilities with me.

__________________________ __________________________ ___________________

Printed Name Signature Date

Agency Use

 I declare that I discussed applicant and recipient rights and responsibilities with ___________________________ on ________________________ during a telephone interview or other contact.

__________________________ __________________________ ___________________

Printed Name Signature Date

032-03-0440-00-eng (06/12)