HSD100 2/24/2020 Page 14 of 27
16. Please Sign This Application (Your authorized representative may also sign here)
Your signature makes this application valid. This application cannot be processed unless signed. Your signature also is an indication of the following:
What I have said and written to HSD is true and complete. If I give incorrect facts, I can be charged with a crime. If I hide or leave out facts, I can be charged with a crime. If HSD learns that I have given
untrue or incomplete factual information, my SNAP may be denied or reduced.
Privacy Act statement: The collection of the application information, including the social security number (SSN) of each household member, is authorized under the Food Stamp Act of 1977, as amended, 7 U.S.C. 2011-
2036. The information will be used to determine whether your household is eligible or continues to be eligible to participate in the Food Stamp Program. We will verify this information through computer matching
programs. This information will also be used to monitor compliance with program regulations and for program management. This information may be disclosed to other Federal and State agencies for official examination,
and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. If a food stamp claim arises against your 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. Providing the requested information, including the SSN of each household member, is voluntary. However,
failure to provide an SSN will result in the denial of food stamp benefits to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household
members.
The filing date is different if the household is in an institution and applying for SNAP and SSI at the same time. The filing date will be the date of release from the institution.
I am declaring the identity of the children under age 16 for whom I am applying.
If asked, I will give proof of things I report to HSD. If I cannot get proof, I know that I can ask HSD to help me and I will let HSD contact other people, and companies to get proof.
I will let HSD give limited information to approved agencies that offer related assistance for which I may be eligible.
I understand that if I receive benefits for which I am not eligible, that I may have to pay HSD back for those benefits.
I know that HSD will check the information that I give. HSD may use computers or other ways to check the information on this form.
I know that HSD will check the immigration status of people who apply for or get benefits. I understand that immigration status for any household member that I am applying for may be subject to verification by USCIS
(INS), and that it may affect the household's eligibility and level of benefits.
I understand that I must cooperate with Quality Control (QC). QC is a part of HSD. QC reviews cases to make sure we determine who can get help correctly.
I have been given an information sheet explaining my rights and responsibilities including, expedited SNAP/food assistance, SNAP/food penalties and program violations, fair hearing rights and more. I understand that
these will also be explained to me during my appointment for an interview.
I understand that by providing the account numbers for my household energy supplier(s) I am authorizing the energy provider(s) to provide details about the account and energy use to HSD for the purposes of eligibility
and determination of this and future applications, benefit determination, and program evaluation and analysis.
I understand that by providing application information I am authorizing HSD and its authorized agents to share and report the data provided against federal, state, county, energy provider, employer and landlord
databases or records.
I understand if eligible for energy assistance benefits, I may be referred to other residential energy programs.
I understand the information collected on this form may be disclosed to energy programs operating under HSD. HSD may share and use information collected for purposes of referral, research, evaluation and analysis.
I understand that my utility companies will not have control over the data disclosed pursuant to this consent, and will not be responsible for monitoring or taking steps to ensure that HSD maintains the confidentiality of the
data or uses the data as authorized.
TRUSTS - I understand that if I, or the person(s) for whom I am applying, have set up a trust, or are the beneficiaries of a trust, I must give HSD a copy of the trust document, including all attachments and related
information. HSD will analyze the trust to see if it affects the Medicaid benefits for which I am applying.
ESTATE RECOVERY- I understand that, after my death, HSD can file a claim against my estate to recover the amounts that the state pays or paid on my behalf for medical assistance provided under the Medicaid
program. This process is called “Estate Recovery.” “Estate Recovery” is required by federal and state law where Medicaid recipients are 55 years of age or older and the state makes medical assistance payments on their
behalf for nursing facilities services, home and community based services, and/or related hospital and prescription drug services. The amount recovered by HSD will not exceed the amount of medical assistance
payments made on behalf of the Medicaid recipient. Some exclusions may apply.
I understand that I must give HSD any money I receive for medical services which have already been paid for by Medicaid. If I fail to do so, I, or the person(s) for whom I am applying, may lose Medicaid coverage for at
least one year and until the amount owed to Medicaid has been paid back in full.
A person who is applying for or receiving Medicaid or Cash Assistance shall assign to HSD all rights against any and all individuals for medical support or payments for medical expenses paid on the applicant’s or
recipient’s behalf and the behalf of any other person for whom application is made or assistance is received.
For parents who qualify for Medicaid: I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my
children, I can tell the Child Support Enforcement Division (CSED) and I may not have to cooperate. Non-cooperation with CSED may result in termination of my Medicaid eligibility.
I, as the Authorized Representative, affirm and agree to be legally bound to maintain the confidentiality of any information regarding the applicant or beneficiary, shall not reassign any provider claims, if applicable, and
shall adhere to all requirements set forth in 42 CFR 435.923(d) and 7 CFR 273.2(n).
To withdraw your application for any program, initial the box of the program ► SNAP Medicaid Cash LIHEAP
Name of Witness (Witnessed only if applicant signs by mark or thumbprint)
Signature of Applicant’s Authorized Representative (if
applicable)
Signature of Witness (Witnessed only if applicant signs by mark or thumbprint)