Confirmation

Congratulations!

You have successfully submitted an application for . The application was submitted on . You may print a receipt to keep for your records. You may print a copy of the summary pages to keep for your records.

For Food Benefits:

If your application was submitted after working hours or on a day that DHS is closed, your filing date will be on the date DHS reopens.

If you have applied for Cash, Child Care or Medical benefits:

We will review your application and decide if you qualify for benefits. You may need to have an interview for these benefits. We will let you know if we need anything else.

Contact Method

You have told us that you prefer to talk to a worker

Basic Information

Personal information

Additional Case Information

Authorized Representative

Alternate Payee

SSN Information

Household Information

Income Information

Household Costs

Shelter Costs

Other Shelter Information

Utility Costs

Agreements

These pages have legal requirements for the programs you are applying for.

You will read about:

Your rights and responsibilities

Assignment requirements for medical

Reporting changes

Program penalties

At the end of this section we will ask you to tell us you understand what you have read. We will also ask you to tell us you have given true and correct information on the application. When you are finished, you can submit your application. Your typed name is your signature for this application. It is an electronic signature and is created when you submit your application. It is the same as writing your name on a paper application.

Your Rights (Things you can expect from DHS)

You can ask Department of Human Services (DHS) staff to explain the Rights and Responsibilities if you do not understand.

DHS will treat you with respect in a fair and polite way.

DHS will give you information about its payments and services. DHS may also refer you to other services you need.

You have the right to ask about and apply for any program.

You can ask for a receipt for any form you turn in to the DHS office.

You can ask for a meeting with a worker. You can also ask to talk with a person in charge.

You can ask for an interpreter to help you apply, fill out forms or report changes.

DHS will give you information in a format or language you can understand.

DHS will do its best to meet your special needs if you have a disability. DHS follows the Americans with Disabilities Act and Section 504 of the Rehabilitation Act.

You can ask to see what is written about you in your case file.

You may not get Senior Farm Direct checks if you are in a Senior Farmers Market Nutrition Program in another State.

You can ask not to work with child support if you have "good cause". This means that working with child support would be a danger to you or your children. DHS will give you forms that explain good cause. These forms tell you how the Oregon Child Support Program may be able to help you get child support and still keep you and your children safe. DHS will also answer your questions about good cause.

DHS will tell you if you qualify for benefits: Within 30 days of the date you file an application for Food benefits. If you qualify for faster benefits, you will find out within 7 days. Within 45 days of the date that you apply for Cash, Child Care or Medical benefits. Within 90 days of the date you ask for a medical decision about your disability.

You can ask for a hearing if you disagree with a DHS decision. For Cash, Child Care or Medical benefits, you must use the Administrative Hearing Request form, (DHS 0443). Someone at your DHS office can help you fill it out. If you get Food benefits, you can ask for a hearing on the DHS 0443, by phone, in writing or in person. For Cash, Child Care or Medical benefits, you must ask for a hearing within 45 days of the date on the notice about the decision. For Food benefits, you must ask for a hearing within 90 days of the date on the notice.



Your Responsibilities (Things you must do)

You are agreeing to do certain things when you, your spouse or your partner get benefits from Department of Human Services (DHS). You may lose benefits if you do not do these things. You may also be asked to repay benefits if you get too many.

If you are in any DHS program, you must:

Give DHS true, correct and complete information.

Give proof of the things you report. If you cannot get proof, let DHS help you.

Take part in an employment program if you are required. This includes finding, accepting and keeping a job.

Help DHS if your case is chosen for a review. Cases are chosen at random.

Allow DHS staff to visit your home to get information about your case.

Let the Child Support Program share information with DHS.

Report changes to DHS within 10 days after they occur.

If you get Food Benefits, you must also:

Not quit a job or reduce your work time to less than 30 hours a week.

If you get Temporary Assistance to Needy Families (TANF), you must:

Help get child support unless: You are in the JOBS Plus, State Family Pre-SSI/SSDI (SFPSS) or Post-TANF Program. It would mean danger to you and your children. Be sure to tell DHS if it would be dangerous.

Take part in any training plan offered to you by DHS or its partner agencies, unless you have "good cause". You can talk to your worker about good cause.

Take any medical exam that is needed to see if you qualify for services.

Apply for and use any other benefits or money you qualify for. You must do this for yourself and any others you want help for.

Accept social Services that are ordered by the court or are related to training or employment.

Go to mental health and drug or alcohol programs, if DHS determines you need the help. You only have to do this if you can get into a program that is free to you.

Cash (TANF) time limits Oregon has a five (5) year time limit. Please talk to your worker about how this could affect you.

If you get Medical benefits, you must also:

Tell medical providers if you have other health insurance. They should bill the other insurance before they bill DHS for your medical care.

Try to get health coverage and medical cash support from a parent who does not live with your child. This is to help pay for your child's medical expenses.

Apply for and use other benefits and money you qualify for. This also applies to others you are getting help for.

Take a medical exam if needed. We may need this to see if you can get benefits or services mailed to you each month.

Pay a fee each month to keep getting Medical or Service benefits, if you have to. A bill will be mailed to you each month.

Allow DHS to be the beneficiary for you or your spouse's annuity.

Do you understand these responsibilities?

Yes, I agree to these responsibilities

No, I don't understand. Please explain during my interview

Assigning Rights and Support - Cash for families

Cash for families is also known as Temporary Assistance for Needy Families or TANF.

What you need to know about "assigning support"

"Support" means money you get for you or your children, like alimony or child support. When you get cash benefits, you are assigning the state the right to keep the support you or anyone in your family get from another person. The money goes to repay the state for the cash you get.

By signing this form, you agree to "assign" to DHS all rights to these payments for anyone who is covered by your public assistance. That means yourself and other family members (including any child born in the future).

By signing this form, you agree to help DHS find and obtain these payments. There is a limit on how much DHS can take in payments. It cannot take more than the amount it has paid in assistance for you and your family.

NOTE: This does not apply during any period of time that you receive cash benefits from JOBS Plus, State Family Pre-SSI/SSDI Program (SFPSS) or the Post-TANF Program.

This means that while you are getting cash benefits:

The state will keep part of the support payments (for both current and past-due payments) received for you and members of your family. The state will not keep all your child support. The state will send you $50 of current child support received per child per month up to $200 per family per month. The state will not count this money as income when figuring your eligibility and benefits.

NOTE: If you are an applicant for cash assistance or you are in SFPSS or JOBS Plus, the state will generally not keep any of your child support. When determining your eligibility and benefits, $50 (per child per month up to $200 per family per month) of current child support received will not be counted towards your monthly income.

When you leave the cash program:

Current support payments will go to you.

Any past-due payments for months you were on cash assistance will be kept by the state.

Any past-due payments for months you were not on cash assistance may go to you.

Working with Child Support

While you are getting cash benefits, you will need to work with the state's Child Support Program.

Important: You do not have to work with child support if you think it would mean danger for you or your children.

Working with child support can mean:

Helping to locate your child's other parent (unless you think it would mean danger for your or your children).

Legally naming the child's father (establishing paternity).

Getting a support order.

If you are applying for medical benefits:

When you get DHS medical benefits, DHS will pay your medical bills for covered services. During this time, you must let DHS have any money you get from private health insurance or from an injury. DHS will not take more than the amount paid in assistance for you and your family.

Working with Office of Private Health Partnerships

DHS works with the Office of Private Health Partnerships (OPHP) to provide Healthy KidsConnect medical coverage for your children. While your children are getting Healthy KidsConnect benefits, you may need to fill out and submit forms to OPHP. OPHP will let you know if you need to do anything further.

Helping get other medical coverage

You will need to work with DHS to try and get medical coverage or money for medical care from other sources. This means:

For yourself: You must try to get things such as:

Health insurance from your employer (DHS may be able to help you pay for this).

Insurance payments because of an injury.

Medical coverage from the Veteran's Administration.

For your children: If the other parent isn't living with you, you may need to work with the state's Child Support Program to get health care coverage and medical cash support for the children.

Working with child support

While you are getting medical benefits you will need to work with the state's Child Support Program.

NOTE: This does not apply if your children are receiving Childrens Health Insurance Program benefits or Healthy KidsConnect benefits.

Important: You do not have to work with child support if you think it would mean danger for you or your children.

Working with child support can mean:

Helping to locate your child's other parent.

Legally naming the child's father (establishing paternity).

Getting an order for health care coverage.

Getting an order for cash to help with your child's medical expenses.

If you are pregnant and you only want state medical coverage for yourself, you do not have to work with child support.

What you need to know about "assigning support"

"Support" means money you get for you or your children, like alimony or child support. It includes cash ordered to help you pay for your child's medical expenses. When you get DHS medical for your child, you are "assigning" the state the right to keep the medical cash support anyone in your family gets from another person. The money goes to repay the state for the medical benefits your child gets.

This means that while you are getting DHS medical benefits:

The state will keep all medical cash support payments received for you to help pay for your child's medical expenses. This includes current and past-due payments.

When your child leaves the medical program:

Current support payments will go to you.

Any past-due payments for months your child was on medical assistance will be kept by the state.

Any past-due payments for months your child was not on medical assistance may go to you.

If you have other insurance:

If you or a member of your family have other medical insurance, tell the provider (doctor, clinic or hospital) before you get care. They must bill the other insurance company before they bill DHS.

If DHS pays a medical bill that should have been paid by insurance, DHS will take action to get its money back. For example:

If DHS pays a bill that private insurance should have paid, DHS will try to get the money back from the insurance company.

If DHS pays a medical bill and the provider also gets paid by an insurance company, DHS will try to get its money back from the provider.

If DHS pays a medical bill and an insurance company sends you a check for it, DHS will try to get its money back from you.

Reporting Changes

You must report certain changes that affect you, your spouse or partner, or anyone you get benefits for. You must report changes within 10 days of them occurring. Your benefits could stop or be late if you do not report changes on time. Anyone in your home who is age 18 or older could be asked to repay benefits if they get too many.

If you get Food benefits and are in Simplified Reporting, you only need to report a change in:

Your income, if it goes over the limit for the program.

If you get Food benefits and are not in Simplified Reporting, you must report a change in:

Who lives with you.

A change in your address.

Housing and utility costs after you move.

If you must legally pay child support.

Where you get your money. This includes getting, losing or quitting a job.

Your income from work, if the change is more than $100 per month.

Your other income, if the change is more than $50 a month.

If you get money, items worth money, or sell property. This includes buying or changing vehicles.

NOTE: You may want to report changes in your living costs even if you don't have to. Increases in housing, medical or child care costs or in how much child support you pay, may help you get more Food benefits.

If you get Cash, Child Care or Medical benefits for families (not the Oregon Health Plan or Healthy KidsConnect), you must report a change in:

Who lives with you.

A change in your address.

Marital status.

If you get or change medical coverage.

If you are involved in an injury accident.

When someone who gets benefits becomes pregnant and when a pregnancy ends.

The birth of a child.

Where you get your money. This includes getting, losing or quitting a job.

Your income from work, if the change is more than $100 per month.

Your other income, if the change is more than $50 a month.

If you get money, items worth money, or sell or give away property. This includes buying or changing vehicles.

When you start getting cash benefits, the amount of your food benefits will go down.

If you get Oregon Health Plan or Healthy KidsConnect you must report a change in:

Name for anyone getting benefits.

If you get or change medical coverage.

When someone who gets benefits becomes pregnant and when a pregnancy ends.

The birth of a child.

When someone receiving Healthy KidsConnect moves out of the house.

A change in your address.

If you get child care benefits, you must report changes in:

Who lives with you.

Where you get your income. This includes getting, losing or quitting a job.

Your rate of pay.

Who provides your child care.

Do you agree to report changes?

Yes, I agree to report changes.

No, I don't understand. Please explain during my interview

Penalties in the food Benefits Program (Supplemental Nutrition Assistance Program)

You, your spouse or partner could be disqualified from receiving food benefits if you do any of the following things.

If you do the following... You will lose food benefits...



Hide information or make false statements

Use EBT cards that belong to someone else

Use food benefits to buy alcohol or tobacco

Trade or sell benefits or EBT cards

Dump containers only for the cash redemption value

Resell food bought with food benefits for cash

12 months for the first offense

24 months for the second time

Permanently for the third time



Trade food benefits for controlled substances such as drugs



24 months for the first offense

Permanently for the third time



Trade food benefits for firearms, ammunition or explosives



Permanently



Trade, buy or sell food benefits of $500 or more



Permanently



Give false information about who you are or where you live so you can get extra food benefits



10 years for each offense

You can also be fined up to $250,000 or put in prison for up to 20 years, or both, for doing these things. You may also be charged under other federal laws.

If you do the following... You may be...



Use EBT cards which are not yours

Transfer your EBT cards to other people

Acquire or possess EBT cards which are not yours

Dump containers for the cash redemption value

Resell food bought with food benefits for cash

Guilty of a felony or misdemeanor

Fined

Put in prison

Ineligible for food benefits for a period of time

Penalties in the Cash (Temporary Assistance for Needy Families) Program

If you knowingly do the following... You will lose Cash benefits...



Give false information about yourself or someone you are applying for

Hide information about yourself or someone you are applying for

Give false information about where you live

12 months for the first offense

24 months for the second time

Permanently for the third time

You will also have to pay back all the TANF you were not supposed to get. Your food benefits will not go up even though you get less in TANF if you told us something that was not true or did not tell us something that was true.

Do you understand these penalties?

Yes, I understand these penalties

No, I don't understand. Please explain during my interview

Civil Rights

Discrimination:

The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) You can file a complaint if you think DHS discriminated against you because of any of these reasons.

If you wish to file a Civil Rights program complaint of discrimination, please read the Client Discrimination Complaint Information form (DHS 9001), found online at: (right click to open in a new window).

In addition, you may file a complaint at any USDA office, or call (866) 632-9992 to request the USDA Program Discrimination Complaint Form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov

Social Security Information

Why we need your Social Security Number (SSN):

When you apply for benefits, the Department of Human Services (DHS) will need the Social Security Number (SSN) for you and the other people who want benefits.

If you are applying for someone else, and not for yourself, we do not need your SSN or citizenship status. We will not contact immigration services for anyone not seeking benefits. If you do not have a SSN yourself, other family members who do have SSNs may still qualify.

DHS will use your SSN to help decide if you are eligible for benefits. Your SSN will be used to verify your income, other assets, and to match with other state and federal records such as IRS, Medicaid, child support, Social Security and Unemployment benefits.

DHS may use your SSN to prepare aggregate information or reports requested by funding sources for the program you apply for or receive benefits.

DHS may use or disclose your SSN:

If it is needed to operate the program you apply for or receive benefits from.



To conduct quality assessment and improvement activities.



To verify the correct amount of payments and recover overpaid benefits.



To make sure you get the correct benefits.

Federal laws (42 USC 1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920 and 42 CFR 457.340(b)) and DHS rule (OAR 461-120-0210) requires anyone applying for cash, food or medical benefits to give DHS their SSN.

Information and referrals for low-income households

Where to find help It is not always easy to find out where to call when you need help. This list of services may be helpful to your family. It includes phone numbers and Web addresses for many of the services. You can find other local numbers in the government services section of your phone book. You can access the Internet at most public libraries. If you need help finding one of these services, ask your worker.

Prevention services Boys and Girls Aid offers pregnancy information, counseling and referral. Call 1-800-342-6688 or go to www.boysandgirlsaid.org. The Family Planning Unit in the county health department helps with pregnancy prevention services. Look in county government listings of your phone book or go to www.oregon.gov/DHS/ph/lhd/lhd.shtml.

Protection The Oregon Department of Human Services (DHS) helps seniors and people with developmental and physical disabilities who are being abused or need protection. Call 1-800-232-3020 or go to www.oregon.gov/DHS/spwpd/abuse/home.shtml. DHS has a hotline for reporting child abuse or neglect. Contact a law enforcement agency or go to the local DHS child welfare office. See a list of locations at www.oregon.gov/DHS/localoffices/locations.shtml.

Food services The Supplemental Nutrition Assistance Program (SNAP, formerly food stamps) puts healthy food within reach for low-income Oregonians. Ask at a DHS or Area Agency on Aging (AAA) office.

Call 1-800-SAFENET (723-3638) or go to www.snap.oregon.gov. Food banks provide food boxes to people in need. See the social services section of the phone book. Loaves and Fishes delivers meals to the elderly and homebound in the Portland area See the social services section of the phone book or go to www.loavesandfishesonline.org. Meals on Wheels delivers meals to the elderly and homebound. See the social services section of the phone book. School meal programs help pay or pay for meals at lunch and before or after school. Call your local school. Women, Infants and Children (WIC) gives nutrition information and extra food to pregnant women and children younger than age 5. Call the county health department or go to www.oregon.gov/DHS/ph/lhd/lhd.shtml. Child care Ask DHS about child care programs that help with child care costs. Get information at www.oregon.gov/DHS/children/childcare/. Child care resource and referral agencies help families find child care providers. Call 1-800-342-6712 or go to www.oregonchildcare.org.

Employment services Many agencies help people gain the skills needed to find a job, get a job or keep a job. Contact DHS or the Employment Department. Go to www.oregon.gov/DHS/jobs/ or www.oregon.gov/EMPLOY. WorkSource Oregon programs refer displaced workers to services in their local area. Call 1-800-282-6514 or go to www.worksourceoregon.org.

Housing Community action agencies help families pay housing costs in an emergency. For information, find your local office in the phone book or go to www.oregon.gov/OHCS. Women's Crisis Line gives referrals to local shelters or safe homes. Call 1-888-235-5333. Each county housing authority has housing for low-income families or the elderly. They may also help pay rent for low-income families. See the phone book for your local county housing authority office. Shelters or safe homes offer short-term housing for the homeless or people leaving abuse. Call the local DHS office or go to www.oregon.gov/DHS/localoffices/locations.shtml.

Utilities Your utility or heating company may help with heating costs. Call your utility or heating company. Community action agencies help people pay heating costs. See the phone book. Oregon Telephone Assistance Program helps with basic telephone costs. Call your phone company or go to www.oregon.gov/PUC/rspf/otap.shtml.

Medical services County health departments offer health care for low-income families. See the white pages or get a list of health departments at www.oregon.gov/DHS/ph/lhd/lhd.shtml. The Family Health Insurance Assistance Program helps pay for insurance through your employer, if you have been uninsured for the last six months. Call 1-800-542-3104 or go to www.oregon.gov/OPHP/FHIAP. The Office of Private Health Partnerships administers low-cost health insurance plans for uninsured small businesses. Call 1-800-542-3104 or go to www.oregon.gov/OPHP. Medicare covers people who are age 65 and older or have a disability. Call 1-800-772-1213 or 1-800-633-4227, or go to www.medicare.gov. Counties offer mental-health services. Look in county government listings of your phone book. Oregon Health Plan provides health benefits. Call 1-800-359-9517 to apply or 1-800-699-9075 for information.

Go to www.oregon.gov/DHS/healthplan/. Healthy Kids Program provides health benefits to Oregon children. Call 1-800-359-9517 to apply or 1-877-314-5678 for information.

Go to www.oregon.gov/DHS/healthplan/app_benefits/main.shtml for information or to apply online. Oregon Medical Insurance Pool offers high-risk insurance if you have been turned down due to a preexisting condition. For information, call 1-800-542-3104 or go to www.oregon.gov/DCBS/OMIP. Oregon SafeNet is a health and social service hotline offering information. Call 1-800-SAFENET (723-3638) or go to www.oregonsafenet.org. Senior Health Insurance Benefits Assistance program provides free information about health insurance for seniors. Call 1-800-722-4134 or go to www.oregon.gov/DCBS/SHIBA. Oregon Department of Veterans' Affairs helps disabled veterans get medical services. Call 1-800-692-9666 or go to www.oregon.gov/ODVA. Other services DHS Division of Seniors and People with Disabilities helps older adults and people with disabilities get services. Call 1-800-282-8096 or go to www.oregon.gov/DHS. This hotline for alcohol and drug services helps alcoholics, addicts and their families. Call 1-800-282-7035 or go to www.orpartnership.org. The Alcohol and Drug Referral Center helps you find a treatment center. Call 1-800-923-4357 or go to www.orpartnership.org/web/services/crisislines.asp. The Division of Child Support (part of the Oregon Department of Justice) or the county district attorney can help you get child support. See state or county listings in the phone book.

Call 503-986-6090 or go to www.dcs.state.or.us. Gamblers Addiction Services are available. Call 1-800-233-8479 or go to www.1877mylimit.org. Legal Aid Service offers legal help. See the white pages. For more information, go to www.oregonlawhelp.org/OR. Oregon SafeNet is a social service hotline. Call 1-800-SAFENET (723-3638) or go to www.oregonsafenet.org. Social Security provides income to people who are retired or have disabilities. Call 1-800-772-1213 or go to www.ssa.gov. The Oregon State Police provides information about sex offenders. Call 1-800-551-2934 for information. VINE is a free service that provides information to victims about sex offenders. Call 1-877-674-8463, or go to www.vinelink.com. Unemployment benefits may help if you lose your job or your work hours have been cut. Call the local Employment Department office. Go to www.oregon.gov/EMPLOY/UI for information. Veterans' Affairs provides cash and medical help to disabled veterans. Call 1-800-692-9666, 1-800-827-1000 (national hotline) or go to www.oregon.gov/ODVA/. DHS provides training, benefits and help in finding work for people with disabilities. See state listings in phone book or go to www.oregon.gov/DHS/employment.shtml. Workers' compensation in Oregon Call 1-800-452-0288 or go to http://egov.oregon.gov/DCBS/wcd_info.shtml.

This document can be provided upon request in alternative formats for individuals with disabilities. Other formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications and other electronic formats. E-mail dhs.forms@state.or.us, call 503-378-3486 (voice) or 503-378-3523 (TTY), or fax 503-373-7690 to arrange for the alternative format that will work best for you.

DHS 3400 Revision January 2010

Declaration and Signature

I agree to the following:

DHS will request and use the Income and Eligibility Verification System (IEVS) data and this information may affect eligibility and benefit levels. This includes verification through third party contacts when discrepancies in information are found. Third party contacts may include matching with bank, income and unemployment-benefit records.

The Department of Justice Division of Child Support may release the child support records for children in my application to DHS.

Federal and state agencies who are doing reviews.

Law-enforcement officials. This is if it will help them arrest someone who is fleeing from the law.

Federal and state agencies and private collection agencies. This is if I have to repay benefits to DHS. DHS may give the information on this application to:

I agree to report changes as required.

I will not get Food benefits from the Tribal Food Distribution Program on Indian Reservations and the Supplemental Nutrition Assistance Program(Food benefits) at the same time. I also cannot get Tribal TANF from a tribe and TANF cash benefits from DHS at the same time.

I will give proof of the things I have told DHS. I will also let DHS contact other people and agencies to get proof. DHS can do this when the proof is needed to determine if my family is eligible for benefits.

Adults under age 60 must register for the state's employment program when they apply for Food benefits. They will be registered when I sign the form. The people I add to my Food benefits in the future will also be registered.

I have given DHS complete information. I affirm under penalty of perjury that statements made are true and correct. This is true for things I reported about persons in my home or about the people I am applying for. This includes how I reported citizenship, income, resources, property and anything else I have given DHS and their contractors.

You must sign this application before submitting it. You can do this by typing your name below. Your typed name below means you agree the information you gave is correct. Your typed name will serve as your signature for this application.

You have signed the application electronically.

Signature:

Voter Registration: