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3.

Name (last, first, middle initial)

Relationship to You

Date of Birth (mm-dd-yyyy)

Social Security Number:_________________________

Assistance Requested:  SNAP Benefits  TANF  None Gender:  Male  Female

Place of Birth:________________________________________ (City, State, Country) Marital Status:  Married  Never Married  Separated  Divorced  Widowed

Is this Person a U.S. Citizen?  Yes  No — If not a U.S. Citizen, what is your status? _________________ Is this Person a Student?  Yes  No If yes, name of school ___________________________

Alien Registration Number:_____________________________ Highest Grade Completed:_______________________

Date started living in the U.S. (mm-dd-yyyy) _____/____/________ Providing the following information is voluntary and will not affect eligibility. Please check all that apply. Ethnicity:  Hispanic/Latino  Not Hispanic/Latino Racial Heritage:  White  Black/African American  Asian  Asian & Black/African American  Asian & White

 American Indian/Alaskan Native  Black/African American & White  American Indian/Alaskan Native & White

 Native Hawaiian/Other Pacific Islander  American Indian/Alaskan Native & Black  Other/Unknown

 YES  NO 1. Have any of your children received any immunizations since approval of your original application or since your most recent review? If YES, explain: ____________________________________________________________

 YES  NO 2. Have you or anyone for whom you are applying ever been disqualified from receiving TANF (AFDC) or SNAP benefits? If YES, explain: ____________________________________________________________________

 YES  NO 3. Is anyone in violation of parole or probation or fleeing capture to avoid prosecution or punishment of a felony? If YES, explain: ______________________________________________________________________________

 YES  NO 4. 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

By my signature below, I declare that the household member(s) for whom I am requesting TANF or SNAP benefits, is/are either a U.S. citizen(s) or alien(s) in lawful immigration status. I declare under penalty of law that all information on this form is correct and complete to the best of my knowledge and belief. I understand that if there is a TANF or SNAP claim against my household, the information on this application, including all SSNs, may be referred to federal and state agencies as well as private claims collection agencies for claims collection action.

________________________________________________ _________________________________________ Your Signature or Authorized Representative’s Signature or Mark

Date ________________________________________________ _________________________________________ Witness to Mark or Interpreter

Date