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Rights and Responsibilities

PRIVACY ACT/SOCIAL SECURITY NUMBERS

Federal Laws require the collection of information on the application, including Social Security Numbers (SSN). The providing of this information, including the SSN, is voluntary. However, failure to provide this information, including the SSN of each household member you are applying for, may result in the denial of benefits to your household or to a household member. You must give us the Social Security Numbers (SSN) for all household members you are applying for Cash Assistance, Child Care, Food Benefits and Medical Assistance. The Division of Social Services and the Division of Medicaid & Medical Assistance will ask for the SSN of anyone whose income is used to determine eligibility although it is not required. For Medical Assistance and Child Care, non-lawful aliens are not required to give an SSN. Non-lawful aliens may be eligible for emergency services and labor and delivery.

We will use the SSN to determine initial and ongoing eligibility, check the identity and citizenship of household members, prevent duplicate participation and help us make mass changes, such as the annual Cost of Living Adjustment. We will also use the SSN to check information you give us against information we have in our records and against other Federal, State and local government agency computer matching systems. This may mean that we will need to contact household employers, banks, or other parties.

If you receive benefits you are not entitled to, the information on this application, including the SSN of each household applicant, may be referred to State/Federal agencies, as well as private collection agencies, for claims collections. We will also use this information to monitor compliance with program regulations and for program management.  If you give us false information on purpose, legal action may be taken against you.

COOPERATION WITH SPECIAL REVIEWS

(Food Benefits, Cash Assistance, Child Care - not Medical Assistance.) I will cooperate fully with all State and Federal personnel, such as Quality Control and Audit and Recovery Management Services, in any special review of my case.  Failure to cooperate can result in your case being closed.

APPEAL / FAIR HEARING RIGHTS

I understand that I, or my representative, may appeal to Division of Social Services/Division of Medicaid & Medical Assistance, the U.S. Department of Health and Human Services, or the U.S. Department of Agriculture (USDA for food benefits) if I am not satisfied with any decision made by the Division, or if I feel that I have been discriminated against because of race, color, national origin, sex, religion, age, disability, or political beliefs. As part of the appeal process, I understand that I have a right to a fair hearing and that I may be represented at a hearing by any attorney or any other person I choose. If I am not satisfied with the decision on my fair hearing, I understand that I may request a judicial review in Superior Court in the County where I live. I also understand that I must file a request for a judicial review within 30 days of the date of my fair hearing decision.

Long Term Care

You have the right to ask for a hearing over a decision or failure to act which affects your benefits or that you feel is unfair or incorrect. You have 90 days from the date of a DMMA notice to ask for a hearing. At the hearing you may represent yourself or have someone else, such as lawyer, friend, or relative represent you. If you have a spouse that resides in the community, we may divert a portion of your income to the community spouse. If that amount is not sufficient to meet the community spouse’s needs, he or she may request a hearing in order to have a portion of resources protected.

DISCLOSURE OF INFORMATION

All information and documentation gathered for determining your Cash Assistance, Food Benefit, Child Care and Medical Assistance eligibility or other program related use is confidential. Each program provides safeguards, restricting the use and disclosure of information about you to purposes directly connected with the administration of the program.

Disclosure of information concerning your Cash Assistance, Food Benefit, Child Care and Medical Assistance eligibility to anyone not authorized to receive the information is a violation of State and Federal law. The failure of any authorized source to safeguard the confidential nature of your information may result in legal action.

While Cash Assistance, Food Benefit, Child Care and Medical Assistance programs will keep your eligibility information confidential, these provisions do not affect your right to give specific written consent to release information to other persons or sources.

For the Food Benefit Program

Division of Social Services/Division of Medicaid & Medical Assistance shall make available to law enforcement officers, on official duty, the address, SSN, and a photograph (if available) of a Food benefit recipient if the officer furnishes the recipient’s name and informs Division of Social Services that the individual is fleeing to avoid prosecution, custody or confinement for a felony, or is violating a condition of parole or probation, or has information needed for the officer to conduct an official duty related to a felony or parole violation.

For the Cash Assistance Program

Division of Social Services/Division of Medicaid & Medical Assistance shall make available to law enforcement officers, on official duty, the address of a Cash Assistance recipient if the officer furnishes the recipient’s name and informs Division of Social Services that the individual is fleeing to avoid prosecution, custody or confinement for a felony, or is violating a condition of parole or probation, or has information needed for the officer to conduct an official duty.

REPAYMENT AGREEMENT

I understand that I am obligated to repay Delaware Health and Social Services any assistance (Cash Assistance, Food Benefit, Child Care, or Medical Assistance) or medical service I receive that is more than I am entitled, even when I am no longer receiving a benefit.

I understand that a reduction will be made each month from my Cash Assistance or Food Benefits under procedures established in the Delaware Health and Social Services manual until the amount owed is paid back in full.

If and when my current case is closed, I will be obligated to pay the balance of any overpayment in full in one of the following ways:

  1. Monthly payments to Audit and Recovery Management Services

  2. Work Referral Program

  3. Voluntary garnishment of wages

  4. Intercept of State and/or Federal Income Tax Refunds

  5. Intercept of lottery winnings

  6. Withholding of Unemployment Compensation benefits or

  7. Withholding or reducing Federal Payments which include the following:

  1. Income tax refunds

  2. Federal salary pay including military pay

  3. Federal retirement, including military retirement pay

  4. Contractor/vendor payments

  5. Federal benefit payments, such as Social Security, Railroad Retirement, and Black Lung (Part B) benefits and

  6. Other Federal payments, including certain loans to you that are not exempt from offset.

I further understand that any unpaid balance will be automatically deducted should I return as a Cash Assistance or Food Benefit recipient.

PARENT/GUARDIAN RESPONSIBILITIES OF CHILD CARE APPLICANTS

As a participant in the Division of Social Services/Division of Medicaid & Medical Assistance Purchase of Child Care Services Program, I understand the following:

  1. That I may be required to pay a portion of the cost of my child’s child care expense. The copayment is based on my household income and family size. (Your worker will advise you of the amount of your copayment, or if you have to pay a copayment.)

  2. That if my child is absent Division of Social Services may pay my child care provider from between 1 to 5 absent days.

  3. That I must report within ten days changes that affect either my need for subsidized child care or income. I must report all changes that affect me, my spouse and my child(ren).

    • Some of the changes I must report are:

    • Getting a job, losing a job, changing jobs, taking a second job, no longer working at a second job, receiving child support, receiving VA benefits, receiving an increase or decrease in cash assistance, child support, Social Security or VA benefits of $75 or more a month, enrollment in an education or training class, completion of training, no longer needing special needs child care, or changes to marital status, family size or address.

  4. As a participant in Division of Social Services subsidized Child Care Program, I further understand:

    • That the information I give to qualify for child care will be subject to verification by federal, state and local officials. If it is found inaccurate, I can be subject to criminal prosecution for knowingly providing false information.

    • That if I do not have documents to verify needed information, I agree to give the name of a person or organization that Division of Social Services may contact to obtain verification and that I authorize Delaware Health and Social Services personnel to verify any statement I make regarding my application for child care.

    • That if I plan to change my child care provider within the authorization period indicated that I will notify my worker at least five days before moving my child so that a new authorization can be processed.

    • That I will notify my current provider of my intent to move my child at least five care days before moving my child(ren), and pay or make arrangements to pay any outstanding fees prior to approval of another provider.

    • That I may be responsible for payment to my child care provider at the provider’s private fee if my child attends when he/ she has not been approved for service by Division of Social Services.

    • That my provider may charge me a late pickup fee, late payment fee, field trip fees, and provider co-pay.

    • I will be required to reimburse Division of Social Services for payment made for my child(ren) if I continue to use child care when I was not eligible to receive the service.

    • That I may experience a disruption in my child care service if I fail to respond to Division of Social Services Attendance Quality Control inquires.

  5. That in consideration for payment made by Division of Social Services, I hereby release Division of Social Services from any claim or cause of action and agree that I will not hold Division of Social Services liable for any injury, illness or disease resulting to my child(ren) that may arise out of or during the course of service.

Delaware's Food First Electronic Benefits Transfer (EBT) Card

Food Benefits are issued on an EBT card. When your benefits are approved, you will receive an EBT card in the mail. You must call Conduent Customer Service at 1-800-526-9099 to select your Personal Identification Number (PIN). You must keep your PIN a secret. DO NOT write down your PIN on your card or in an unsafe place. DO NOT give anyone your PIN. If someone takes your EBT card and uses your PIN to get your benefits without permission, you will not get those benefits replaced.

If your EBT card is lost or stolen, you MUST CALL Conduent’s toll free Customer Service number at 1-800-526-9099 immediately. If you do not call this number immediately to freeze your account so no one can use your benefits, we will not replace those missing benefits. The number is operational 24 hours/7 days a week.

PENALTY WARNINGS (Food Stamps and Cash Assistance)

We will check the information you give us to make sure your household is eligible for Food Benefit and Cash Assistance. Federal, State, and Local officials will check the information you give us. We will check the State Income and Eligibility Verification System, other computer matching systems, program reviews and audits. Some information may also be sent to U.S. Citizenship and Immigration Services (USCIS) to see if the information you gave us is correct. We will not check non-lawful alien status. This will not affect any public charge determination or lead to deportation proceedings. Other federal aid programs and federally-aided state programs, such as School Lunch and Medicaid, may also check the information you gave us. If any information you give us is incorrect, you may be denied Food Benefits/Cash Assistance. If you give us false information on purpose, legal action may be taken against you. You may also have to pay back the amount of benefits that you should not have received.

Any member of your household who breaks any of the following rules ON PURPOSE will not be able to get Food Benefits or Cash Assistance:

For Food Benefits:

DO NOT give false information, or hide information, to get or continue to get Food Benefits.

DO NOT trade or sell Food Benefits or authorization cards or any authorization document.

DO NOT alter authorization cards to get Food Benefits you are not entitled to receive.

DO NOT use someone else’s Food Benefits or authorization cards for your household.

DO NOT use Food Benefits to buy ineligible items, such as alcoholic drinks and tobacco.

Any member of your household who breaks a Food Benefit rule on purpose will not be able to get Food Benefits for one year for the first violation, two years for the second violation, and permanently for the third violation.

The Court can also order an individual off the program for an additional 18 months. The individual can also be fined up to $250,000, sent to jail for up to 20 years, or both. Under other Federal laws, additional criminal or civil action may be taken against the individual.

If any member of your household is found guilty by a court (Federal, State, or local) of selling or purchasing controlled substances with Food Benefits, the individual will not be able to get Food Benefits for two years for the first time. The second time the individual is found guilty of selling or purchasing controlled substances with Food Benefits, he/she will NEVER get Food Benefits again.

If any member of your household is ever found guilty by a court of selling or purchasing firearms, ammunition, or explosives with Food Benefits, even for the first time, he/she will NEVER get Food Benefits again.

If any member of your household is found guilty by a court (Federal, State or local) of having trafficked Food Benefits in the amount of $500 or more, even for the first time, he/she will NEVER get Food Benefits again.

If any member of your household is found guilty of misrepresenting their identity or place of residence in order to get multiple Food Benefits for the same month, the individual will not be able to get Food Benefits for a 10 year period.

Individuals are ineligible to receive food benefits during any period of time in which the individual is:

  • Fleeing to avoid prosecution for a crime, or attempt to commit a crime, that is a felony (or in the case of New Jersey a high misdemeanor) under the law of that State; or

  • Fleeing to avoid custody or confinement after conviction for a crime, or attempt to commit a crime, that is a felony (or in the case of New Jersey a high misdemeanor) under the law of that State; or

  • Violating a condition of probation or parole imposed under a Federal or State law.

For Cash Assistance:

DO NOT give false information, or hide information, to get or continue to get Cash Assistance.

Any member of your household who breaks a Temporary Assistance for Needy Families (TANF) rule on purpose will not be able to get Cash Assistance for one year for the first violation, two years for the second violation, and permanently for the third violation.

Any applicant or recipient who gives false information in order to obtain benefits is subject to penalties that include a fine of up to $500 and imprisonment up to 6 months.

If any member of your household is found guilty of misrepresenting their place of residence in order to get multiple benefits in two or more States for the same month from programs funded under TANF, Title XIX Medicaid, the Food Stamp Act of 1977, and Title XVI Supplemental Security Income Program, the individual will not be able to get Cash Assistance for a 10 year period.

Individuals are ineligible to receive Cash Assistance during any period in which the individual is:

  • Fleeing to avoid prosecution for a crime, or attempt to commit a crime, that is a felony (or in the case of New Jersey a high misdemeanor) under the law of that State; or

  • Fleeing to avoid custody or confinement after conviction for a crime, or attempt to commit a crime, that is a felony (or in the case of New Jersey a high misdemeanor) under the law of that State; or

  • Violating a condition of probation or parole imposed under a Federal or State law.

If any member of your household is convicted of a felony for having, using, or selling controlled substances, the individual will NEVER get Cash Assistance again.

DELAWARE’S TEMPORARY ASSISTANCE FOR NEEDY FAMILIES PROGRAM (TANF) FAMILY CAP

Family cap children are included in the standard of need when determining eligibility but not in the payment standard to figure benefit amounts. This means that family cap children are considered TANF recipients. This includes assigning child support rights to the State and cooperating with the Contract of Mutual Responsibility.

TANF JOB QUIT

The penalty for individuals who quit their jobs without good cause and do not comply with subsequent job search requirements will be the closure of the TANF case for one month or until the individual obtains a job of equal or higher pay. If the individual participates for the required amount of hours in approved work related activities for four consecutive weeks the case can be reopened.

TANF SANCTIONS

The TANF case closes for at least one full month. For a TANF case to reopen, the TANF recipient must complete 4 consecutive weeks of full participation with the Employment and Training vendors.

Requirements

Sanctions

Employment and Training/work

The TANF case closes for at least one full month. For a TANF case to reopen, the TANF recipient must complete 4 consecutive weeks or full participation with the Employment and Training vendors.

Child under 16 not attending school

A $50.00 successive sanction for the teen not attending school when the parent does not work with the school to ensure school attendance.

Child 16 and over not attending school

The removal of the teen from the grant and the reduction in household size.

CMR requirements

An initial $50.00 reduction in the TANF grant if the participant has not complied, an additional reduction each month until compliance occurs.

APPLICATIONS FOR OTHER BENEFITS (For TANF and Medical Assistance)

I understand that I must apply for and accept other benefits that I may be eligible to get such as Unemployment Compensation or Social Security.

FOOD BENEFIT EMPLOYMENT AND TRAINING

Delaware administers a statewide voluntary Employment and Training Program for Food Benefit only recipients. If you receive Food Benefits and Do Not Receive TANF you are not mandatory to participate with employment and training but you can volunteer to participate.

FOOD BENEFIT JOB QUIT

No individual who voluntarily quits his/her most recent job, or reduced work hours to less than 30 hours per week, without good cause will be not eligible to participate in the Food Supplement Program (FSP) as specified below.

Individuals receiving food benefits that voluntarily quit a job or reduce work hours to less than 30 hours per week without good cause will be ineligible for food benefits. The periods of ineligibility are as follows:

  • First violation, the individual will remain ineligible for a one month period.

  • Second violation, the individual will remain ineligible for a three month period.

  • Third violation, the individual will remain ineligible for a six month period.

For voluntary quit sanctions, the individual can receive Food Benefits again after the minimum sanction periods are served.

WORK REQUIREMENTS FOR ABLE-BODIED ADULTS WITHOUT DEPENDENTS

I understand that individuals 18 to 50 years of age are ineligible to receive Food Stamps if they received Food Stamps for at least three months in a 36 month period while they did not either work a monthly average of at least 80 hours in a 30-day period, participate in a work program at least 20 hours per week, participates in and complies in a work supplementation program; or participates in a workfare program, unless the individual is exempt from work requirements.

Riverside Rule

If you or a member of your family fails to perform an action required under an assistance program (TANF, Refugee Cash Assistance (RCA), or General Assistance (GA)), or commits fraud, that reduces or closes your grant, we will continue to count the amount you were getting in your food benefit case. You will not get an increase in food benefits when do not comply with Cash Assistance rules or commit fraud.

The following conditions apply:

  1. The rule applies to individuals who fail to perform a required action while receiving assistance.

  2. The rule does not apply to individuals who fail to perform a required action at the time the individual initially applies for assistance.

  3. The rule applies to individuals who fail to perform a required action during an application for continued benefits as long as there is no break in participation.

  4. The individual must be certified for food benefits at the time of the failure to perform a required action for this rule to apply.

  5. The rule applies for the duration of the reduction in the work program assistance and cannot continue beyond the sanction of the assistance program.

  6. When the TANF case closes, the food benefit sanction will remain in place for one year or until the individual is no longer eligible for TANF because the family makes too much money or meets one of the TANF E & T exemptions per 3006.1.

REPORTING AND DECLARING EXPENSES

Failure to report or declare any of the following expenses will be seen as a statement by your household that you do not want to receive a deduction for the unreported/undeclared expenses:

  • Shelter (rent/mortgage/lot) expenses

  • Homeowner’s insurance

  • Real estate taxes

  • Utility expenses (gas/electric/oil)

  • Water and sewage expenses

  • Garbage expenses

  • Phone expenses

  • Medical expenses

  • Dependent care expenses

  • Child support expenses paid to children who do not live in your home.

REPORTING REQUIREMENTS

For Food Benefits

SIMPLIFIED REPORTING REQUIREMENTS (For all households except elderly or disabled households with no earned income)

  • Households are required to only report income changes when the monthly income exceeds 130 percent of the poverty income guideline for the household size that existed at the time of certification or recertification.

  • When a household's monthly income exceeds the 130 percent of the poverty income guideline, the household is required to report that change within ten days after the end of the month that the household determines the income is over the 130 percent amount.

  • Additional reporting requirement for ABAWD individuals. Adults living in a home without any minor children, who are getting food stamps because they are working over 20 hours a week, must report when they start working less than 20 hours per week.

CHANGE REPORTING REQUIREMENTS (For elderly or disabled households with no earned income)

  • Changes in the amount of gross unearned income of more than $50, except changes in the cash assistance grants. Changes reported in person or by telephone are to be acted upon in the same manner as those reported on the change report form;

  • A change in the source of income, including starting or stopping a job or changing jobs, if the change in employment causes a change in income;

  • All changes in household composition, such as the addition or loss of a household member;

  • Changes in residence and the resulting changes in shelter costs;

  • The acquisition of a licensed vehicle not fully excludable under DSSM 9051 (for non-categorically eligible households);

  • When cash on hand, stocks, bonds, and money in a bank account or savings institution reach or exceed a total of $2,000 (for non-categorically eligible households); and

  • Changes in the legal obligation to pay child support.

Certified households must report changes within ten (10) days of the date the change becomes known to the household. For reportable changes of new employment/income, households must report the change within 10 days of the date the household receives its first paycheck/payment. An applying household must report all changes related to its food benefit eligibility and benefits at the certification interview. The household must report changes that occur after the interview but before the date of the notice of eligibility, within ten (10) days of the date of the notice.

For Cash Assistance and Medical Assistance

I agree to report IMMEDIATELY to the local Delaware Health and Social Services office any changes in circumstances, which may affect my continuing eligibility for assistance or the amount of assistance I am entitled to receive.

MEDICAL ASSISTANCE PROGRAMS

Understand and agree:

  • To give proof of your statement.

  • Other persons or organizations may be contacted to obtain necessary proof of your eligibility.

  • To allow us, directly or through our agents or the Diamond State Health Plan or the Delaware Healthy Children Program, access to all medical and school-based health and related services records of every member of your household who is eligible for Medical Assistance. This will allow us to administer the Medical Assistance program, coordinate care, determine medical necessity, and evaluate or pay for pending or incurred medical services.

  • To report, within 10 days, changes in your situation that could affect your eligibility, such as a change in how many people live with you, a new job, change in income, or if you move.

Understand:

  • You must apply for and accept other benefits that you may be eligible to get such as Unemployment Compensation or Social Security.

  • By law, as a condition of eligibility, you must assign all rights to medical support and to payment for medical care from any third party to Delaware Health and Social Services. You must cooperate with the Division of Child Support Services (DCSS) in establishing paternity and obtaining medical support for any child receiving Medical Assistance. You may claim to have good cause for refusing to cooperate in establishing paternity or in identifying and providing information about liable third parties. If you do not cooperate with Division of Child Support Services and do not have good cause, you will not be eligible for benefits but your child may still be eligible. Pregnant women are not required to cooperate in establishing paternity and obtaining medical support.

  • As a Medical Assistance recipient you will automatically receive full child support services from the Division of Child Support Services (DCSS), unless you state that you want to receive only child support services related to medical support.

  • If you are receiving services from Division of Child Support Services but you are not on cash assistance, Division of Child Support Services is authorized to deduct directly from your support payments, any and all monies owed to the Division of Social Services/Division of Medicaid & Medical Assistance including, but not limited to: fees, recovery of monies improperly paid to you, or paid in error, or any other reason deemed to correct your account.

  • You may be eligible for TRANSITIONAL MEDICAID for up to 12 months if your Medicaid case is closed due to increased earnings or hours and/or loss of earned income disregards due to time limitations.

  • Your children are eligible for preventative health care and you will be contacted.

  • You will allow Delaware Health and Social Services, or its representatives, to act as your agent in recovering money spent by the Medical Assistance programs when other money from insurance, etc., becomes available to pay your medical bills.

  • You may have to repay to Delaware Health and Social Services any Medical Assistance received for which you may not be entitled. You are responsible to repay such assistance both during your period of eligibility and after you are no longer receiving Medical Assistance.

  • An adult household member (age 18 or over), your Authorized Representative, or an emancipated minor must sign the application.

Right to a Written Notice

The Division will make an eligibility decision within 30 days of receiving your application for food benefits, within 45 days for Medicaid (including Qualified Medicare Beneficiary (QMB)/Specified Low Income Medicare Beneficiary(SLMB)), and within 90 days for Long Term Care Medicaid. If your benefits are changed, suspended, or stopped we will explain the reason in a notice within 10 days of taking the action.

Estate Recovery

If you are age 55 or older and receive Medicaid to pay for Long Term Care Services and any related hospital and prescription drug services, you will be required to repay the cost of these services from your probate estate.

Contribute to your cost of Long Term Care Services

It is the responsibility of the Medicaid recipient/representative to make the "patient pay" (the amount of monthly income the Medicaid recipient is required to pay for the cost of his/her care) each month.

Recipients residing in a nursing home should make the payment to the facility. If the "patient pay" amount is not paid promptly to the nursing home, the recipient's assets may accumulate to over $2,000 and the recipient would lose Medicaid eligibility. Moreover, if the nursing home is not paid the "patient pay" amount, the home may institute action to discharge or evict the recipient. Payments should be made to the facility during the Medicaid application process.

Nursing Home Responsibilities

Each nursing home must protect and promote the rights of each resident. Residents must be informed verbally and in writing what their rights are at the time of admission to the nursing home. State law requires that any abuse, neglect or mistreatment of a nursing home resident be reported. For more information contact the Division of Services for Aging and Adults with Physical Disabilities:

New Castle County - (302) 453-3820 or 1-800-223-9074

Kent/Sussex Counties - (302) 424-7310 or 1-800-223-9074

Federal law prohibits nursing homes from charging Medicaid recipients or their families for items and services covered by Medicaid. Nursing homes must provide a list of what items and services are included in the basic Medicaid rate and what items or services will be billed directly to the recipient. Federal laws prohibit nursing homes that accept Medicaid from requiring Medicaid eligible recipients to supplement Medicaid coverage as a condition of admission. A Medicaid enrolled nursing home cannot refuse to continue to care for a resident when the resident converts to Medicaid coverage if the home has an available Medicaid-certified bed.

REQUIREMENTS FOR ALIEN REGISTRATION CARD

For each applicant who is not a U.S. citizen you will need to show either documentation from the U.S. Citizenship and Immigration Services (USCIS) or other documents Delaware Health and Social Services determines are proof of your immigration status. Alien status may be subject to verification with USCIS, which may require submission of certain information from this application form to USCIS. Information received from USCIS may affect your household’s eligibility and level of benefits. Non-lawful alien status will not be checked.

CERTIFICATION OF CITIZENSHIP AND ALIEN STATUS

I certify, under penalty of perjury, that I, and any other members of my household, are U.S. citizens or aliens in lawful immigration status. Non-lawful aliens may be eligible for emergency services and labor and delivery only.

HEAD OF HOUSEHOLD DESIGNATION (For Food Stamps only)

Households with an adult parent of children, or an adult who has parental control over children, have the option of designating their head of household. Please read the following:

  • I understand the person selected must be the parent of a child, regardless of age, or have parental control over children under 18 years of age.

  • I understand that all adult household members must agree to the designation.

  • I understand that failure to designate or agree on a head of household will not delay my certification or have my benefits denied.

  • I understand that Division of Social Services/Division of Medicaid & Medical Assistance will designate a head of household if I choose not to or the adults do not agree on a designation.

  • I understand I can choose the designated head of household at each certification and whenever the household composition changes.

  • I understand if Division of Social Services/Division of Medicaid & Medical Assistance must designate a head of household, the designee will be the principal wage earner.

  • I understand that if a household member does not comply with the voluntary quit provisions, that individual will be sanctioned and ineligible for benefits.

  • I understand I can select a head of household and that all adult members in my household must agree to this selection (selection of head of household can be made at the interview).

NONDISCRIMINATION STATEMENT

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex, sexual orientation and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

  1. (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

  2. (2) fax: (202) 690-7442; or

  3. (3) email: program.intake@usda.gov.

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

AUTHORIZATION FOR RECEIPT OF PREGNANCY PREVENTION INFORMATION

You are authorized to receive pregnancy prevention information. If you wish to receive this information you can call Planned Parenthood at 1-800-230-PLAN (7526). If you wish to get teen pregnancy prevention information, you may also call the Alliance for Adolescent Pregnancy Prevention at 1-800-499-WAIT (9248). You can also call the Delaware Helpline at 211 for the Public Health Family Planning clinic in your area.

CERTIFICATION OF UNDERSTANDING AND ACCURACY OF APPLICATION ANSWERS

I understand the questions on this application and the penalty for hiding or giving false information. I certify, under penalty of perjury, that all my answers are correct and complete to the best of my knowledge. I understand and agree to provide documents to prove what I have said. I understand and agree that Delaware Health and Social Services may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits.

Electronic Signature Statements Of Understanding

  • I have agreed to submit an application by electronic means.

  • I understand the questions on this application and the penalty for giving false or misleading information or breaking any of the rules listed in the penalty warning below.

  • I understand that I can be prosecuted if I provide false or misleading information or documentation or hide or omit information or documentation.

  • I understand and agree to provide information and documentation to prove what I have said as a condition of program eligibility.

  • I understand and agree that Delaware Health and Social Services may contact other persons, employers, financial institutions or organizations to obtain the necessary proof of my eligibility and to determine my level of benefits.

  • I certify, under penalty of perjury, that all my answers are true, correct and complete to the best of my knowledge, including information about the citizenship or alien status of each household member applying for benefits.

  • I understand that an electronic signature has the same legal effect and enforceability as a written signature on an application.