Phone: 735-7245 735-7274 Fax: 735-7092 PLEASE PRINT CLEARLY IN BLACK OR BLUE INK APPLICATION FOR PUBLIC BENEFITS - PART I DEPARTMENT OF PUBLIC HEALTH 8: SOCIAL SERVICES Division of Public Welfare Bureau of Economic Security 123 Chalan Kareta, Mangilao, Guam 96913-6304 1. PLEASE COMPLETE THE FOLLOWING INFORMATION MARK TYPE OF ASSISTANCE NEEDED - - . . . Medically edicaid Supplemental Nutrition Assistance Program (SNAP) Cas Indigent Program MARK TYPE OF APPLICATION New Application Reapplication/Reopening Renewal Medicaid SNAP Cash Assistance MIP Case No: Case No: Case No: Case No: Name of Applicant Email Address Last First MI Social Security Number Date of Birth Mailing Address City State Zip Code Home Address Village Home Phone Work Phone Do you need an interpreter? YES NO Cell Phone Alternate Phone 2. PLEASE COMPLETE THIS SECTION FOR EMERGENCY ASSISTANCE Are you or anyone in your household a victim of domestic violence? Is anyone in your household pregnant? Does anyone in your household need off?island health care? Is anyone in your household a boarder? (paying for room and meal) Is anyone in your household on strike from work? Have you refused any job within the last 60 days? How much is the total household?s income for this month (before deductions)? The amount of your rental/mortgage for this month (without arrears). The amount of your water/sewer bill for this month (without arrears). The amount of your power bill for this month (without arrears). The total amount of your gas, telephone, trash bill for this month (without arrears). applying for assistance? The total of your household?s cash, bank accounts, savings certificates, stocks or bonds. YES YES YES YES YES YES 69696969 How have you been able to pay for your housing, food, power, water, gas, telephone and medical bills before SIGNATURE: DATE: APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Please complete back page FIIGHTS: You have the right to immediately file an application. You can complete this first page and give it to us today. The rest of the application can be completed later and submitted at the time of your interview. If you wish to be considered for Expedited Service, complete the Emergency Assistance Section of this form. If you are eligible for Expedited Services, you may receive your SNAP benefits within seven (7) days. If you are eligible, you will receive SNAP benefits retroactively from today?s date. Welfare benefits do not begin until the month after your application is approved. You have the option of answering only those questions that are relevant to the programs for which you are applying for. Note: The sooner you submit this first page, the sooner you can be scheduled for your interview. The receptionist will give you a list of what to bring with you to your interview. PRIVACY ACT STATEMENT: The collection of 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 to participate in the SNAP, Cash and Medical Programs. 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 SNAP, cash, or a medical claim arises against your household, the information on your application including 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 SSN of each household member is voluntary. However, failure to provide an SSN will result in the denial of SNAP, Cash and Medical benefits to each individual failing to provide an SSN. Any SSN provided will be used and disclosed in the same manner as the SSN of eligible household member. USDA Nondiscrimination Statement: This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex, religious creed, political beliefs or reprisal or retaliation for prior civil rights activity. Persons with disabilities who require alternative means of communication for program information Braille, large print, audiotape, American Sign Language, etc.) should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hearing impaired or have speech disabilities may contact USDA through the Federal Relay Service at 1(800) 877-8339. Additionally, program information may be made available in languages other than English. To file a complaint alleging discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: 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 1(866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: US. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, DC. 20250-9410 (2) Fax: (202) 690-7442; or (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 1(800) 221-5689 which is also in Spanish or call the State Information/Hotline number (click the link for a listing of hotline numbers by State); found online at: To file a complaint of discrimination regarding a program receiving Federal Financial assistance through the US. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, SW, Washington, DC. 20201 or call 1(202) 619-0403 (voice) or 1 (800) 537-7697 (TTY). This institution is an equal opportunity provider. PENALTY WARNING: The information you provide will be subject to verification by Federal, State and local officials. Information available through Income Eligibility Verification System (IEVS) will be requested, used and may be verified through collateral contacts. The alien status of household members may be subject to verification with Immigration and Naturalization Service (INS). Information obtained through IEVS or from INS may affect your eligibility and level of benefits. Benefits may be denied if any information is incorrect. You may be criminally prosecuted and fined up to $10,000.00 and imprisoned up to five (5) years for knowingly providing incorrect information. If you intentionally break any program rules, you may be disqualified for one (1) year for the first violation, two (2) years for the second violation and permanently for the third violation. Intentional violations of program rules may disqualify you from both SNAP and cash assistance programs. I understand the penalties for providing false or incorrect information and certify under penalty or perjury the truth of the information contained in this application. SIGNATURE DATE DEPARTMENT OF PUBLIC HEALTH 8: SOCIAL SERVICES Division of Public Welfare 0 Bureau of Economic Security 123 Chalan Kareta, Mangilao, Guam 96913-6304 Phone: 735-7245 735-7274 Fax: 735-7092 PLEASE PRINT CLEARLY IN BLACK OR BLUE INK APPLICATION FOR PUBLIC BENEFITS - PART II MARK TYPE OF ASSISTANCE NEEDED 1. PLEASE COMPLETE THE FOLLOWING INFORMATION - - Supplemental Nutrition Assistance Medically MBd'Ca'd Program (SNAP) Gas? Indigent Program (MIP) MARK TYPE OF APPLICATION New Application Reapplication/Reopening Renewal Medicaid Case SNAP Case Cash Assistance Case MIP Case No: No: No: No: Name of Applicant Last First MI Social Security Number Date of Birth Mailing Address City State Zip Code Home Address Home Phone Work Phone Email Address Cell Phone Alternate Phone APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 1 of 14 CERTIFICATION THAT NO MEMBERS ARE FLEEING FELONS OR HAVE BEEN CONVICTED OF A DRUG FELONY IF YOU ANSWER YES TO THESE QUESTIONS, COMPLETE THE NAME OF APPLICANT SOCIAL SECURITY INFORMATION TO THE RIGHT. (Last, First, M.I.) NUMBER Have you or any member of your household been convicted of a felony involving the possession, use or distribution of illegal drugs after August 22, 1996? YES N0 Are you or any member of your household fleeing to avoid prosecution or custody for a crime, or attempting to commit a crime that is a felony in the place you or the household member is fleeing from, or violating a condition of probation or parole? YES NO I certify under penalty of perjury that I have completed the above information truthfully and the information provided may be compared to court records. Applicant?s Signature Date 3 FOR OFFICIAL USE ONLY ETHNIC CODES African American AF Chamorro - Guam CG German GE Palauan PA American Indian/Alaskan Native - - - - AA Chamorro - Rota CR Hawaiian HN Pohnpeian PO American Samoan AS Chamorro - Saipan - - - - CS Hispanic HI Portuguese PE Asian Indian Al Chamorro - Tinian CT Japanese JP Soviet Jew SJ Australian AU Chinese Cl Korean KO Thai TH Cambodian CB Chuukese TR Kosraean KS Vietnamese VI Canadian CN Cuban CU Marshallese MA Yapese YP Caucasian CA Filipino FO Mexican ME Other OT CITIZENSHIP MARITAL STATUS RELATIONSHIP CODES CODES CODES Alien AL Divorced DI Separated - - - - SE Head of Household - - - HH Son SO FAS citizen FS Married MA Widowed WI Daughter DA Spouse SP Permanent Resident - - PR Single SI Other OT Granddaughter GD Other OT United States citizen - - US Grandson GS APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 2 0f 14 HOUSEHOLD MEMBERS i CURRENTLY 0 LIST YOURSELF AND ALL PERSONS WHO LIVE WITH YOU. THE PARTICIPATING IN: ELIGIBILITY SPECIALIST WILL DETERMINE WHO QUALIFIES FOR a. 0 Lu ASSISTANCE. DO NOT LIST PERSON INCLUDED IN SECTION 2 a; a; FEE OFPAGE2. FE 5% 3% I 2 GumsmBEQEonmEoom 1. Your Name (Last, First, MI.) SEX ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 2. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 3. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 4. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 5. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 6. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 7. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 3. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 9. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) 10. Name (Last, First, MI.) ALIEN NUMBER SOCIAL SECURITY NUMBER DATE OF BIRTH MARITAL STATUS DATE OF ENTRY ABSENT PARENT NAME (Last, First, MI.) APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 3 of 14 STUDENT INFORMATION LIST ALL STUDENTS IN YOUR HOUSEHOLD. HOUSEHOLD NAME (Last, First, MI.) NAME OF SCHOOL TYPE OF TRAINING PROGRAM CLASS HOURS PER WEEK LIQUID ASSETS CODES Cash Held by Others CO Cash on Hand CH Checking Account CA Health Insurance with Cash Value - - - HI Individual Retirement IR USE THESE CODES TO COMPLETE SECTION 7 BELOW Life Insurance with Cash Value Savings Bonds SB Money Market Certificates (Shares) - - - - MM Stocks and Bonds ST MF Time Certificate TC Pension Plan PN Trust Funds TR Savings Account SA Other OT LIQUID ASSETS LIST THE LIQUID RESOURCES OF EACH MEMBER OF YOUR HOUSEHOLD. USE THE CODES LISTED IN SECTION 6 ABOVE TO INDICATE EACH TYPE OF RESOURCE. INCLUDE ALL JOINTLY OWNED RESOURCES. DESCRIBE ANY RESOURCES LISTED AS (OTHER). LIQUID ASSET TYPE CODE DESCRIBE OTHER HOUSEHOLD MEMBER BELONGS TO WHERE IT IS LOCATED VAL UE APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 4 of 14 NON-LIQUID ASSETS CODES USE THESE CODES T0 COMPLETE SECTION 9 BELOW Buildings Land, No House Rental Property Burial Plot BP Land With House LH Vacation and Recreational Property House Other Than Home Off-Island Property Other OT NON-LIQUID ASSETS LIST THE NON-LIQUID RESOURCES OF EACH MEMBER OF YOUR HOUSEHOLD. USE THE CODES LISTED IN SECTION 3 ABOVE TO INDICATE EACH TYPE OF RESOURCE. INCLUDE ALL JOINTLY OWNED RESOURCES, DESCRIBE ANY RESOURCES LISTED AS (OTHER). NON- LIQUID TYPE HOUSEHOLD MEMBER WHERE IT IS LOCATED VALUE CODE DESCRIBE OTHER IT BELONGS TO 10 MOTOR VEHICLES LIST ALL VEHICLES USED BY YOUR HOUSEHOLD. INCLUDE ALL JOINTLY OWNED VEHICLES. ITEM VEHICLE 1 VEHICLE 2 VEHICLE 3 REGISTERED OWNER OF VEHICLE NAME OF PERSON WHO USES VEHICLE YEAR, MAKE, MODEL LICENSE PLATE NUMBER PRINCIPAL BALANCE OWED APPRAISED MARKET VALUE IF YOU OR ANYONE IN YOUR HOUSEHOLD HAD GIVEN AWAY, SOLD, OR TRANSFERRED MONEY, VEHICLES, PROPERTY OR OTHER IN THE LAST THREE (3) MONTHS, COMPLETE THE FOLLOWING INFORMATION. DESCRIPTION OF PROPERTY DATE OF TRANSFER BALANCE APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 5 of 14 INCOME CODES USE THESE CODES TO COMPLETE SECTIONS 13 AND 14 EARNED INCOME CODES Civil Service (Federal) Employment FG Government of Guam Employment GG Military Earnings IVIA Private Enterprise Income PE Other OT UNEARNED INCOME CODES Alimony and Child Support AY Civil Service (Federal) Retirement FR Dividends and Interest DI Foster Care Payments F0 GHURA SUbSidy (Utilities) GH Government of Guam Retirement GR Life Insurance Benefits Lump Sum Payments LP Military Exchange Retirement IVIX Money From Friends, Relatives, Etc. M0 Payments For Property Sold pp Property Rent Payments PR Scholarship, Fellowship, Loan SC Social Security Benefits SS Striker?s Benefits ST Supplemental Security Income (SSI) SI Veteran?s Pension VA Welfare Payments (Including GA) PA EARNED INCOME OR PLEASE BRING TWO (2) RECENT EMPLOYMENT CHECK STUBS, USE THE CODES IN SECTION 12 ABOVE TO INDICATE THE TYPE OF EARNED INCOME. DESCRIBE ANY INCOME LISTED AS (OTHER). FOR HOW OFTEN PAID, SPECIFY IF DAILY, WEEKLY, BI-WEEKLY, NAME OF HOUSEHOLD MEMBER RECEIVING INCOME (Last, First, MI.) TYPE OF EARNED INCOME HOW OFTEN CODE PLACE OF EMPLOYMENT DATE EMPLOYED PAID GROSS AMOUNT SELF-EMPLOYMENT INCOME PLEASE BRING MOST RECENT 1040 TAX FORM AND 12 MOST RECENT GROSS RECEIPT TAX FORMS. NAME OF HOUSEHOLD MEMBER RECEIVING INCOME (Last, First, MI.) TYPE OF SELF-EMPLOYMENT HOW OFTEN DATE EMPLOYED PAID GROSS AMOUNT APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 6 of 14 15 UNEARNED INCOME USE THE CODES IN SECTION 12 (PAGE 6) TO INDICATE THE TYPE OF UNEARNED INCOME. DESCRIBE ANY INCOME LISTED AS (OTHER). FOR HOW OFTEN PAID, SPECIFY IF DAILY, WEEKLY, BI-WEEKLY, OR NAME OF HOUSEHOLD MEMBER TYPE OF UNEARNED INCOME HOW OFTEN GROSS RECEIVING INCOME . . PAID AMOUNT (Last, FWSI: M-I-I CODE DESCRIBE OTHER EMPLOYMENT HISTORY PLEASE REPORT THE LAST EMPLOYMENT FOR EACH MEMBER OF THE HOUSEHOLD. DATES EMPLOYED EMPLOYEE NAME EMPLOYER NAME REASON (Last, First, MI.) AND ADDRESS FROM To FOR LEAVING GROSS INCOME APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 7 0f 14 17 DEPENDENT CARE IF YOU OR ANYONE IN YOUR HOUSEHOLD PAYS FOR THE CARE OF A CHILD OR DISABLED ADULT SO SOMEONE CAN WORK, LOOK FOR WORK, ATTEND TRAINING, OR GO TO SCHOOL, COMPLETE THE FOLLOWING INFORMATION. NAME OF PERSON WHO PAYS FOR DEPENDENT CARE NAME OF PERSON WHO PROVIDES THIS CARE AMOUNT PAID HOW OFTEN PAID 18 CHILD SUPPORT IF YOU OR ANYONE IN YOUR HOUSEHOLD PAYS CHILD SUPPORT AS ORDERED BY THE COURT, COMPLETE THE FOLLOWING INFORMATION. NAME OF PERSON NAME OF PERSON How OFTEN WHO IS PAYING. CHILD SUPPORT WHO IS PAID CHILD SUPPORT NAME OF AMOUNT PAID 19 SHELTER AND UTILITIES LIST THE AMOUNT OF YOUR LAST BILL FOR EACH OF THE EXPENSES LISTED BELOW. ITEM AMOUNT ITEM AMOUNT SEWER Ufn?fiLiffdi?Ifimgage, mortgage) TELEPHONE POWER TRASH WATER OTHER 20 MEDICAL EXPENSE LIST CURRENT MEDICAL EXPENSES OVER $35.00 FOR ANY PERSON IN YOUR HOUSEHOLD WHO IS AGE 60 OR OVER, OR WHO IS RECEIVING FEDERAL OR LOCAL DISABILITY BENEFITS. NAME OF PERSON WITH THE MEDICAL BILLS EXPENSE AMOUNT WHAT THE EXPENSE WAS FOR IF YOU OR ANYONE IN YOUR HOUSEHOLD HAS UNPAID MEDICAL BILLS DURING THE LAST THREE (3) MONTHS, PLEASE COMPLETE THE FOLLOWING INFORMATION. YOU MAY BE ELIGIBLE FOR MEDICAL COVERAGE FOR THOSE UNPAID BILLS. DATES 0F TREATMENT APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 8 of 14 21 MEDICAL INSURANCE COVERAGE IF YOU OR ANYONE IN YOUR HOUSEHOLD HAS MEDICAL INSURANCE COVERAGE, COMPLETE THE FOLLOWING INFORMATION. NAME OF INSURANCE SUBSCRIBER COVERED UNDER THE INSURANCE NAME OF PERSON NAME OF INSURANCE COMPANY PREMIUM 22 DISQUALIFICATION HISTORY IF YOU OR ANYONE IN YOUR HOUSEHOLD HAS EVER BEEN DISQUALIFIED FROM THE SNAP PUBLIC ASSISTANCE PROGRAM, COMPLETE THE FOLLOWING INFORMATION. NAME OF PERSON DISQUALIFIED PROGRAM (Last, First, MI.) SNAP PA TYPE OF DISQUALIFICATION WHERE HAPPENED (Country, State) DATE DISQUALIFIED DISQUALIFIED FOR HOW LONG DRAW A MAP TO YOUR HOUSE APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 9 of 14 24 YOUR RIGHTS AND RESPONSIBILITIES The Department of Public Health and Social Services is responsible for informing all applicants applying for Public Welfare of their Civil Rights under the Federal law as provided by Title VI of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, Americans with Disabilities Act of 1990 (ADA) and the Public Welfare Rules and Regulations. Federal and local laws prohibit discrimination against Public Welfare applicants or participants because of race, color, national origin, disability, age, sex, religious creed, political beliefs or reprisal or retaliation for prior civil rights activity. This Department supports the policy of providing equal opportunity to all Public Welfare applicants and participants under all titles of Public Welfare. This means that: YOU HAVE THE RIGHT TO: 1. Receive an application when you ask for it. 6. Discuss any action regarding your case with your Eligibility Specialist or his/her supervisor if you are dissatisfied. 2. Turn in an application the same day you receive it. 7. To request for a Fair Hearing if you disagree with any action taken on 3- RECEIVG YOUT SNAP 0f Indigent Program your case. You may ask anyone to help you get a fair hearing, and your (IVIIP) PBHEIITS 0i be ?Otlfled YOU are NOT for the case may be presented at the hearing by any person of your choice. program within 30 calendar days after you turn in your application. 8. Be notified 10 calendar days in advance before your assistance is discontinued or reduced. 4. Be notified if you are eligible or not eligible for Cash Assistance or Medicaid within 45 calendar days after you 9. Have your records kept confidential. turn in your application. 10. Be served without regard to race, color, national origin, disability, age, 5. Receive SNAP benefits within seven (7) calendar days if you sex, religious creed, political beliefs or reprisal or retaliation for prior are eligible for Expedited Services. civil rights activity. ACKNOWLEDGEMENT OF RESPONSIBILITIES READ EACH SENTENCE CAREFULLY. PLACE YOUR INITIALS TO THE LEFT OF EACH STATEMENT TO SHOW THAT YOU UNDERSTAND YOUR RESPONSIBILITIES. I know I must let the know when my income exceeds 130% of the Federal Poverty level by the 10th day of the following month in which the change occured for the SNAP and Public Welfare Programs. I know I must let the know of any change within 10 days after the change happens for the MIR I know my child(ren) must go to school. If my child(ren) do not go to school, I know my Cash Assistance will stop. I know I have to get child support for my child(ren). If I do not cooperate to get child support for my child(ren), I know my Cash Assistance will stop. I know if I am an able-bodied adult aged 18-50, without dependent children and not pregnant, I can only receive a maximum of three (3) months of cash benefits under the General Assistance and SNAP in a three (3) year period. I know if I am a teen parent, I must live at home and attend school, sign an Individual Responsibility Plan with the JOBS Program, and comply with this Individual Responsibility Plan. If I don?t, my benefits and my benefits may be terminated. I know I will have to take part in a work or training program so I can get a job. If I do not take part in the work or training program, I know I my Cash Assistance will not be released. I know I must not exchange my SNAP benefits for cash. I know I must not use my SNAP benefits to establish credit for cash or non-food items. If I gave false information so I can get Cash Assistance, lVledicaid, AMP and SNAP, I know I can be taken to court and charged with a crime. I know I will assign my rights and eligible household member?s rights to lVledicaid/IVIIP for the support and payment received from a responsible third party (example, insurance company, court, etc.) as a result of any medical care initially paid by Medicaid/MIR I ACKNOWLEDGE I HAVE BEEN INFORMED, READ AND UNDERSTAND MY RIGHTS AND RESPONSIBILITIES FOR THE RESPECTIVE FOR WHICH I AM APPLYING. SIGNATURE DATE APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 10 0f14 25 PENALTY WARNING An Intentional Program Violation (IPV) consist of having intentionally made a false or misleading statement, or misrepresented or concealed facts; or having intentionally committed any act that constitutes a violation of the SNAP/Welfare Program Regulations or any local statute relating to the use, presentation, transfer, acquisition, receipt, or possession of SNAP or other Public Welfare benefits. Anyone found guilty of an Intentional Program Violation will be disqualified as follows: INTENTIONAL PROGRAM VIOLATION (IPV) DISQUALIFICATION PERIODS ONE or TWO YEARS if it involves TRADING COUPONS FOR ILLEGAL SUBSTANCES FIRST OFFENSE or PERMANENTLY if it involves TRADING COUPONS FOR GUNS, AIVIIVIUNITIONS, OR EXPLOSIVES, or if it involves TRAFFICKING IN COUPONS OF $500 OR MORE TWO or PERMANENTLY if it involves TRADING COUPONS FOR ILLEGAL SUBSTANCES or SECOND OFFENSE THIRD OFFENSE PERMANENTLY ALSO: - If the Head of Household is disqualified under Cash Assistance due to NON-COMPLIANCE or FRAUD, the entire household may also be disqualified under SNAP for the same duration; and I If a household member is disqualified under Cash Assistance due to NON-COMPLIANCE or FRAUD, the same household member may be disqualified under SNAP for the same duration; and I Anyone misrepresenting his/her IDENTITY or RESIDENCE in order to receive multiple benefits will be disqualified for 10 and I Anyone convicted of a DRUG FELONY or FLEEING to avoid prosecution, custody, confinement, or violating probation or a parole is INELIGIBLE. Any individual receiving assistance under the IVIedically Indigent Program for which he/she was not eligible on the basis of false declarations Shall be liable for repayment and shall be guilty of misdemeanor or felony as specified in the Criminal and Correctional Code. Such individual shall be ineligible for program services for a period of one (1) year or more as ordered by the court. Any individual who voluntarily discontinues medical insurance shall be disqualified from the Medically Indigent Program for six (6) months starting from the date when the discontinuance of health coverage was discovered/reported. I HAVE READ THE ABOVE PENALTY WARNING AND UNDERSTAND THE PENALTIES FOR PROGRAM VIOLATIONS. SIGNATURE DATE APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 11 0f14 DESIGNATION AND CERTIFICATION OF AUTHORIZED REPRESENTATIVE IF YOU ARE UNABLE TO FILL OUT THE APPLICATION AND GO TO THE INTERVIEW, YOU CAN NAME AN ADULT OUTSIDE YOUR HOUSEHOLD TO FILL OUT YOUR APPLICATION FORM AND APPLY FOR YOU. FOR SNAP APPLICANT, EVEN IF YOU APPLY FOR SNAP YOURSELF, YOU MAY NAME SOMEONE TO PICK UP YOUR EBT QUEST CARD AND USE YOUR CARD TO BUY FOOD FOR YOU. TO DESIGNATE SOMEONE TO HELP YOU FILL OUT THIS FORM AND GO TO THE INTERVIEW FOR YOU, TO PICK UP YOUR EBT QUEST CARD FOR YOU, COMPLETE THE FOLLOWING INFORMATION. YOU SHOULD OUT AND SIGN THE APPLICATION FORM EVEN IF SOMEONE ELSE GOES TO THE INTERVIEW FOR YOU. DESIGNATION OF AUTHORIZED REPRESENTATIVE: designate to be my Authorized Representative. Name of Applicant Name of Authorized Representative Signature of Applicant Date AUTHORIZED REPRESENTATIVE: NAME (Last, First, MI.) HOMEADDRESS PHONE NUMBER SOCIAL SECURITY NUMBER CERTIFICATION BY AUTHORIZED REPRESENTATIVE: HELPED THE APPLICANT FILL OUT THIS FORM. UNDERSTAND ANYONE WHO HELPS ANOTHER PERSON IN DISHONESTLY GETTING HELP IS ALSO SUBJECT TO THE CRIMINAL PENALTIES. I ALSO UNDERSTAND IF I MISREPRESENT THE HOUSEHOLD, I AM SUBJECT TO DISQUALIFICATION AS AUTHORIZED REPRESENTATIVE FOR A PERIOD OF ONE (1) YEAR. CERTIFY THE INFORMATION ENTERED BY ME ON THIS FORM: Was furnished by the applicant or recipient; or Is what I personally know about him/her. Signature of Authorized Representative, Date Legal Guardian, Interpreter, or Other Person APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 12 0f14 27 YOUR CERTIFICATION BEFORE SIGNING THIS APPLICATION, GO BACK AND CHECK THAT YOU HAVE ANSWERED EACH QUESTION. MAKE SURE YOU UNDERSTAND YOUR RIGHTS AND RESPONSIBILITIES AND YOUR AUTHORIZATION. 1. l/We certify l/we have been informed of my/our rights and responsibilities. 2. l/We understand the questions on this application and the penalty for hiding or giving false information. 3. My/Our answers are correct and complete to the best of my/our knowledge. Signature (OR MARK) of Applicant Date Witness if Signature is Date Signature (OR MARK) of Spouse Date if Joint Declaration 28 CERTIFICATION BY ELIGIBILITY SPECIALIST CERTIFY THE HAS BEEN INFORMED OF RIGHTS AND RESPONSIBILITIES AND OF THE POSSIBILITY OF CRIMINAL CHARGE FOR MISREPRESENTING OR CONCEALING FACTS WHICH DETERMINE ELIGIBILITY. Eligibility Specialist (ES) Date REMARKS: APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 13 of 14 DEPARTMENT OF PUBLIC HEALTH 8: SOCIAL SERVICES Division of Public Welfare . Bureau of Economic Security 123 Chalan Kareta, Mangilao, Guam 96913-6304 Phone: 735-7245 735-7274 Fax: 735-7092 CONSENT TO DISCLOSURE OF INFORMATION I, residing at on hereby authorize the SNAP and Public Welfare Programs to verify my employment income, disability and retirement benefits, savings and checking accounts, real and personal property, Life and Medical Insurance coverage, school attendance records, and any other information relevant to my eligibility for participation and compliance in any of the above programs. I also authorize any person, partnership, corporation, association, or government agency possessing information of such matters, to release such information to the Department of Public Health Social Services. I understand this information is confidential and will be used by program staff only for the purpose of verifying my eligibility to participate in the SNAP/Public Welfare Programs. I further understand my refusal to sign this consent may result in termination or denial of benefits. This consent will expire three (3) years from the date of signature. ApplicanUGuardian/Parent Signature Date Authorized Staff?s Signature Date Witness Signature (if needed) Date APPLICATION FOR PUBLIC BENEFITS (REVISED 09/2018) Page 14 of 14