APPLICATION FOR FOOD STAMP BENEFITS

PURPOSE: Food Stamp applications are entered in FAMIS without an FS-1 when the applicant applies in person. Use the FS-1 as the Food Stamp application form in the following situations:

NOTE: An FS-1 will not be used for all Food Stamp applications. If the applicant is available in person and can stay for the interview or the application is made through the Missouri Benefits Center online application system, do not require the applicant to complete the FS-1.

If an individual wants to download the FS-1 from the Internet or chooses to complete a web application, instruct the individual to go to http://dss.mo.gov. Both the English and Spanish translations are on the website to download or complete online.

NUMBER OF COPIES AND DISPOSITION: The original is completed and filed in the case record.

NOTE: An FS-1 is not needed to add an individual to an active Food Stamp case. Enter the add-a-person in FAMIS. See the User Guide Adding A Member To The Supercase And/Or Eligibility Unit for complete instructions.

MANUAL REFERENCE: FS MANUAL 1100.000.00 - 1160.000.00

INSTRUCTIONS FOR COMPLETION: Complete this form in ink. All entries are made by the applicant or his/her authorized representative. If an applicant has a physical or mental disability which prevents him/her from completing this form, staff may complete the application based on information given by the applicant. If FSD staff completes the application, explain on the FS-1 the reason the applicant was unable to make the necessary entries.

No changes or erasures are made after the form is signed by the applicant. If a change is made, the applicant must sign his/her name and the date by any correction(s).

If the applicant signs the FS-1 in the office because s/he cannot stay for the interview, the date filed is the date the applicant signs the form. If the FS-1 is mailed or faxed, the date the application is filed is the date the form containing name, address, and signature is received in the FSD office. If the FS-1 is faxed when the office is closed, the date of application is the next business day.

If the applicant cannot stay for an interview or to complete the FS-1, the applicant must at least write his/her name, address, and sign the form. Make a copy of the form and send the original form home with the applicant to complete. Schedule an interview with the applicant following current procedures. Enter the request in FAMIS if enough information is available. If there is not enough information, register the application when the completed form is received or when the interview is conducted. The date of application is the date the applicant signs the FS-1 at the FSD office.

INTERVIEW: An interview is required for ALL Food Stamp applications. Face-to-face interviews may be waived for EUs.  See Food Stamp Manual section 1120.045.15 Waiver of the Office Interview.

DATE RECEIVED/APPLICATION DATE/DCN: Enter the date the FS-1 is received in the office either in the mail, by fax, by web, or through an in-person contact.  Enter applicant's Departmental Client Number. Use the Social Services Clearing Menu (SCLR) screen to determine the individual's DCN or to assign a new DCN if one has not been previously assigned. Use the blank space located at the top, right side of page 1 to enter the application date and DCN.

Section 1-TELL US ABOUT YOURSELF

Applicant enters the full legal first, middle and last names. This is written as the name will appear on the EBT card for the head of the EU if the application is approved. Avoid the use of nicknames, aliases, diminutives, or initials for first name, unless said initials are the applicant's actual legal name.

Applicant enters the house number, street or rural route number, city, state and zip code where the applicant resides. If the EU does not have a residential address, the applicant must enter directions to the home or a description of where the EU lives. A ( ✓) box has been provided to indicate if the applicant is homeless.

Applicant enters the mailing address if it is different from resident address (the mailing address can be: the FSD office, in care of another residence, a post office box, or general delivery).

If the individual has a legal guardian, enter the address of the guardian as the applicant's mailing address. The complete address of the authorized representative is then entered.

TELEPHONE: Space is provided for the EU to list two possible numbers (home/cell/work/other) where they may be contacted.

E-MAIL: A space is provided for the applicant to list an e-mail address as a possible method of contact. It is not required that the applicant complete this section.

METHOD OF CONTACT: ( ✓) boxes are provided giving applicant the option to indicate if they prefer to be contacted via phone, e-mail, mail or text.

 The applicant signs the application. If the signature is made by mark, the mark is identified as such and enclosed in parentheses with the applicant's name typed or handwritten as shown.

SIGNATURE OF APPLICANT: Space is provided for applicant to sign. Refer to Section 6 of these instructions for detailed information on obtaining the signature.

DATE: Enter the date applicant signs the FS-1.

Section 2-KEY QUESTIONS FOR FASTER SERVICE

Obtains necessary information in order to determine if  the EU qualifies for expedited service.

 This section includes fields to capture the name and phone number of an individual the agency may contact if FSD is unable to verify identity electronically.

Section 3- HOUSEHOLD MEMBERS

NAME: Applicant lists the full legal name of each person in the EU with the applicant's name entered on line one.

SEX (M/F): This field has been left blank for the applicant. Completion of this field is optional for other EU members. Providing gender information is not required in order to file for Food Stamp benefits.

RELATIONSHIP: Applicant enters the relationship of each EU member to herself/himself.

DATE OF BIRTH: Applicant enters the birth date for each EU member.

SOCIAL SECURITY NUMBER: Applicant enters the social security number for each EU member.

HISPANIC OR LATINO Y/N: Applicant enters "yes" or "no" if any EU member is Hispanic or Latino.

RACE: Applicant selects and enters the race code as shown at the bottom of the EU members section.

BUY & COOK TOGETHER: Applicant places a check ( ✓) if all EU members buy and eat (cook) meals together. Applicant then lists individuals who do not buy and eat (cook) together if applicable.

BOARDERS/FOSTER CHILD/ADULT: Applicant lists EU members who are boarders foster children or foster adults in the EU.

CITIZEN (Y/N): Applicant lists anyone in the EU who is not a U.S. citizen.EU

LANGUAGE: The applicant enters "yes" or "no" to indicate if English is their preferred language. Space is completed to indicate what language is spoken most often in the EU.

Section 4- HOUSEHOLD DECLARATIONS

Applicant checks ( ✓) "yes" or "no" if any EU member has been convicted of trafficking Food Stamp benefits of $500 or more after 9-22-96. If "yes", applicant lists the name of the EU member(s) who has been convicted.

Applicant checks ( ✓) "yes" or "no" if any EU member is hiding or running from the law to avoid prosecution, custody, or jail for a crime that is a felony. If "yes", applicant lists the name of the EU member(s).

Applicant checks ( ✓) "yes" or "no" if any EU member is violating a condition of probation or parole. If "yes", applicant lists the name of the EU member(s).

Applicant checks ( ✓) "yes" or "no" if any EU member has made false statements about their identity or address to receive Food Stamp benefits in two or more EUs at the same timeEU. If "yes", applicant lists the name of the EU member(s).

Applicant checks ( ✓) "yes" or "no" if any EU member has been convicted of a felony committed after 8-22-96 relating to illegal possession, use, or distribution of a controlled substance. If "yes", applicant lists the name of the EU member(s).

Applicant checks ( ✓) "yes" or "no" if any EU member has ever been convicted of fraudulently receiving duplicate Food Stamp benefits in any State after 9-22-96. If "yes", applicant lists the name of the EU member(s).

Applicant checks ( ✓) "yes" or "no" if any EU member has been convicted of trading Food Stamp benefits for guns, ammunitions, or explosives after 9-22-96. If "yes", applicant lists the name of the EU member(s).

Applicant check ( ✓) "yes" or "no" if any EU member has been convicted of trading Food Stamp benefits for drugs after 9-22-96. If "yes", applicant lists the name of the EU member(s).

Section 5- HOUSEHOLD INFORMATION

Applicant checks ( ✓) "yes" or "no" if any EU member(s) received benefits out of state in the last 30 days. If "yes", applicant lists the name of any EU member(s) and  state(s) where benefits were received.

 Applicant checks ( ✓) "yes" or "no" if any EU member(s) has a disability. If "yes", applicant lists the name of the EU member(s) .

 Applicant checks ( ✓) "yes" or "no" if any EU member(s) age 18-49 is attending school. If "yes", applicant lists the name of the EU member(s), and states the name of the school.

RESOURCES:

Applicant checks ( ✓) "yes" or "no" if any EU member(s) have a bank account . If "yes", applicant lists the name of the EU member(s) who have a bank account, the balance and the name of the bank where the account is held .

Applicant checks ( ✓) "yes" or "no" if any EU member(s) have cash. If "yes" applicant lists who has the cash and the amount.

Applicant checks ( ✓) "yes" or "no" if any EU member(s) have stocks, bonds and/or retirement accounts. If "yes", applicant lists who has the account and the cash value.

INCOME:

Applicant checks ( ✓) "yes" or "no" if any EU member(s) are receiving income from employment. If "yes", the applicant lists the name of the EU member(s) who are employed, the employers' name(s), and monthly gross income before taxes and deductions. Applicant checks ( ✓) "yes" or "no" to indicate any income from other sources. If "yes" applicant checks ( ✓) the source and lists the EU member who has the income and lists the income amount.

 Applicant checks ( ✓) "yes" or "no" if any EU member(s) income has stopped or been reduced in the last 30 days. If "yes" is checked ( ✓) space is provided for the applicant to indicate whose income stopped and the date and amount of the last check.

EXPENSES:

Applicant checks ( ✓) "yes" or "no" if the EU has anyone who has rent or a house payment for the home they live in. If "yes" applicant is to list the total monthly amount and who pays the expense. EU.

Applicant checks ( ✓) "yes" or "no" if any EU member(s) incur utility expenses including gas, electric, other fuel, phone trash, water and sewer. If "yes", applicant lists the name of the EU member(s) who incur the expenses and whether gas, electric or other fuel is used to heat/cool the home.  

Applicant checks ( ✓) "yes" or "no" if any EU member(s) pays court-ordered child support and/or alimony. If yes, applicant lists the monthly amount owed.

Applicant checks ( ✓) "yes" or "no" if any EU member(s) who is either disabled or age 60 or over have medical expenses. The applicant then lists the total monthly amount of medical expenses.

Section 6- NOTICES OF NON-DISCRIMINATION AND FAIR HEARING RIGHTS / NOTIFICATION AND ACKNOWLEDGMENT OF FRAUD PROVISIONS

 Before the form is signed, the applicant must read the statements under each category. These statements are important in prosecution of individuals suspected of fraud and misrepresentation.

SIGNATURE OF APPLICANT: Applicant signs his/her name (in ink) in the same way it is entered on page one of the form.

If someone else (including the ES) helped the applicant complete the form or completed it for the applicant, that person must sign his/her name and enter the date.

If the signature is made by mark, the mark is identified as such and enclosed in parentheses with the applicant's name typed or handwritten as shown. The signature and address of a witness is entered in the blank space below the applicant's mark. The correct procedure for making the mark is illustrated below:

Signature of Applicant: Robert T. (X) (his mark) Cummins

Witnesses: Jane Harris, 716 Bird Ave., Joplin, MO 64804

Ralph Owen, 3201 Iowa Ave., Joplin, MO 64804

If the applicant has a legal guardian, the signature should be that of the guardian. For example, Ralph Owen, Guardian for Ruth Otis.

If the application is made for the EU by an authorized representative, the signature should be that of the authorized representative. For example: Ralph Owen, Authorized Representative for Ruth Otis.

NOTE: If the applicant is a resident of a drug or alcohol treatment center, the center is the authorized representative. A representative of the center must sign the application.

If someone else (including the ES) helped the applicant complete the form or completed it for the applicant, that person must sign his/her name and enter the date.

DATE: Enter the date applicant signs the FS-1.

11.08.2016