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F. Earned Income Has anyone started or stopped a job?  Yes  No If YES, please send proof. If YES, name of the employer: ________________________ Amount earned? _____________ How often paid? _________ Expenses Child support: Is anyone required to pay child support? If YES, what is the amount paid or owed?

Enter the monthly amount billed, owed, or paid Medical (total amount)

Prescriptions

Insurance

Doctor

Other

Child/adult Care

Shelter

Rent/mortgage

Utilities

Taxes/Insurance

Other

 YES  NO 8. 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 9. Have you or anyone for whom you are applying ever been convicted as an adult on or after February 8, 2014 for the following: m. Aggravated sexual abuse under Title 18 United States Code (USC), Section 2241 or a similar state offense?  YES  NO n. Murder under Title 18 USC, Section 1111 or a similar state offense?  YES  NO o. An offense under Title 18 USC, Chapter 110 (sexual exploitation and other abuse of children) or a similar state offense?  YES  NO p. 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, are you in compliance with the terms of the sentence?  YES  NO 10. You may appoint someone to apply for SNAP benefits on your behalf, receive and use your SNAP benefits on your behalf, or receive copies of your program notices. If you want to name a representative, please give the information below Name, Address and Telephone Number of the Authorized Representative Check () each duty authorized for that person

 Apply for SNAP benefits Receive correspondence  Access or use SNAP benefits

BY MY SIGNATURE BELOW, I DECLARE, UNDER PENALTY OF PERJURY, THAT THE INFORMATION PRESENTED HERE IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I understand: • If I give false, incorrect, or incomplete information, or do not report required changes on time, I may be breaking the law and may be prosecuted. • If I refuse to cooperate with any review of my eligibility, including reviews by Quality Assurance, my benefits may be denied until I cooperate. • If I fail to report or verify my expenses, my household will not receive a deduction for the unreported or unverified expenses.

My signature authorizes the release to this agency of all information necessary to both determine and review my eligibility This authorization is valid for one year from the date of my signature below. I understand that this time limit does not apply to investigations regarding possible fraud.

___________________________________________

________________________________ Your Signature or Authorized Representative's Signature or Mark

Date

____________________________________________ ________________________________ Witness to Mark or Interpreter

Date

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