SNAP Part Two – Hosea Helps

Understanding the Programs

Would you like to read the definitions for these programs?

(SNAP) Supplemental Nutrition Assistance Program

The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally funded program that provides monthly benefits to low-income households to help pay for the cost of food. The program also provides nutrition education to families to meet their food and nutritional needs and provides employment and training opportunities to help families gain employment that leads to less dependence on SNAP.

(TANF) Temporary Assistance for Needy Families

Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash payments, or other support services, to strengthen eligible families with children or pregnant individuals. If you are the child’s parent, the caretaker, or pregnant individual who would like to be included in the grant, we will require you to participate in a work program.

If you apply for TANF you may be eligible for GRG funds. (Grandparents Raising Grandchildren)

Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be cared for in the homes of their grandparents.

(CAPS) Childcare and Parent Services

The Childcare and Parent Services (CAPS) program is designed to assist low-income families with the cost of childcare. It provides financial assistance to help parents access childcare so they can attend work, school, or training programs.

Medicaid

Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash payments, or other support services, to strengthen eligible families with children or pregnant individuals. If you are the child’s parent, the caretaker, or pregnant individual who would like to be included in the grant, we will require you to participate in a work program.

Refugee Cash Assistance

The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible for the TANF program. The term refugee includes refugees, Cuban/ Haitian Entrants, victims of human trafficking, Amerasians, Asylees, Afghanis or Iraqis with Special Immigrant Visa (SIV) or eligible Afghan parolees.

Apply for Benefits

Select any programs that interest you.

SNAP (Food Stamps)

WIC (Women, Infants and Children)

CAPS (Childcare and Parent Services)

TANF (Temporary Assistance for Needy Families)

Medicaid (For Medical Expenses)

Refugee Cash Assistance

I would like to apply for GRG (Grandparents Raising Grandchildren).

Your Information

First Name

Middle

Last Name

Suffix

Street Address (Where You Live)

Apartment Number

City

State

Zip Code

Type in your complete mailing address.

Main Telephone Number

Other Phone Number

Email

Use the same email you used on the previous authorization form.

Would you need an interpreter during your interview?

Americans with Disabilities Act

Do you have a disability that will require a Reasonable Modification or Communication Assistance?

Will you need assistance one time or ongoing?

Briefly explain when and how long you will need this assistance.

For All SNAP, TANF and Medicaid Applicants

Declaration of Lawful Presence in the United States.

I declare under penalty of perjury to the best of my knowledge and belief that the person(s) for whom I am applying for benefits is/are U.S. citizen(s) or are noncitizen(s) lawfully present in the United States. I further certify that all of the information provided on this application is true and correct to the best of my knowledge. I understand and agree that DHS-DFCS, DCH and authorized Federal Agencies may verify the information I give on this application. Information may be obtained from past or present employers. I understand that my information will be used to track wage information and my participation in work activities.

I will report any change in my situation according to SNAP and/or TANF program requirements. I will also report if anyone in my 
household receives lottery or gambling winnings, in the gross amount of $4500 or more (before taxes or other amounts are withheld). I will report these winnings no later than 10 days from the end of the month in which my household receives the winnings. I understand if any information is incorrect, my benefits may be reduced or denied, and I may be subject to criminal prosecution or disqualified from DHS DFCS programs for knowingly providing incorrect information. I understand that I can be prosecuted if I provide false information or hide information. I understand that if I fail to tell DHS-DFCS about some of my expenses during my application or renewal process and/or fail to verify them, DHS-DFCS will not budget that expense in calculating the amount of my SNAP benefits.

The Georgia Department of Human Services (“DHS”) collects Personally Identifiable Information (PII), such as names, addresses, telephone numbers, email addresses, and dates of birth, etc., during your application for benefits. By submitting any personal information to us, you agree that we may collect, use, and disclose any such personal information in accordance with DHS policies, procedures, and as permitted or required by law and/or regulations.

Add your electronic signature here.

Type your first and last name.

Select a Date

Witnesses' Electronic Signature

Type witnesses' first and last name.

Select a Date

Do I qualify to get SNAP faster?

If "Yes", who?

Total gross earned income that will be received for this month.

Dollars

Amount in dollars.

Employer's Business Name

Employment Begin Date

Employment End Date

Rate of Pay Per Hour

Dollars

Amount in dollars.

Hours Worked Weekly

How often are you paid?

Total Gross unearned income that will be received for this month.

Dollars

Amount in dollars.

1st Type of Unearned Income

Amount of 1st Unearned Income

Dollars

Amount in dollars.

How often do you receive this 1st unearned income.

2nd Type of Unearned Income

Amount of 2nd Unearned Income

Dollars

Amount in dollars.

How often do you receive this 2nd unearned income.

Total earned and unearned income for this month.

Dollars

Amount in dollars.

How much money do you and all household members have in cash or in the bank?

Dollars

Amount in dollars.

What is the monthly amount of your rent/mortgage, property taxes, and homeowner’s insurance?

Dollars

Amount in dollars.

What is the total amount of your electric, water, gas, and/or other utilities this month?

Dollars

Amount in dollars. (Exclude past due and late fee amounts in the total.)

What heating and cooling sources are used in your household?

Have you received energy assistance (LIHEAP) in the last 12 months?

What is the dollar amount of the assistance that you received?

Dollars

Amount in dollars.

The Applicant and Their Household

Would you like to read instructions for how to add household members?

Important Information

For Medical Assistance applicants: Please include yourself, your spouse, your children (including stepchildren) under 21 who live with you, your unmarried partner who needs health coverage, anyone you include on your tax return, even if they do not live with you, and anyone else under 21 who you take care of and lives with you. You do not have to include your unmarried partner who does not need health coverage, your unmarried partner’s children, your parents who live with you but file their own tax return (if you are over 21), or other adult relatives who file their own tax return. If you are applying for Emergency Medical Services (EMA) only, you do not have to provide your SSN or information about your immigration status. 
 
Please fill out the chart below about the applicant and all household members. The following federal laws and regulations: The Food and Nutrition Act of 2008, 7 U.S.C. § 2011-2036, 7. C.F.R. § 273.2, 45 C.F.R. § 205.52, 42 C.F.R. § 435.910, and 42 C.F.R. § 435.920, authorize DFCS to request you and your household members social security number(s). Anyone who is living in your household and is not applying for benefits may be treated as a non-applicant. Non-applicants do not have to give us information about their social security number, citizenship, or immigration status and are not eligible for benefits. Other household members may still be able to receive benefits if they are otherwise eligible. If you want us to decide whether any household members are eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their social security number (SSN). You will still need to tell us about their income and resources to determine the eligibility and benefit level of the household. We will not report any non-applicant household members to the United States Citizenship and Immigration Services (USCIS) Systematic Alien Verification for Entitlements (SAVE) system if they do not give us their citizenship or immigration status. However, if immigration status information has been submitted on your application, this information may be subject to verification through the SAVE system and may affect the household’s eligibility and benefit level. We will match your information with other Federal, state, and local agencies to verify your income and eligibility. This information may also be given to law enforcement officials to use to catch people who are running from the law. If your household has a SNAP claim, the information on this application, including SSN, may be given to Federal and State agencies and private claims collection agencies for them to use in collecting the claim. We will not deny benefits to applicant household members because other household members fail to provide their SSN, citizenship, or immigration status.

Are you and the members of your household U.S. Citizens or U.S. Nationals.

Important Notes

Complete the following section for YOURSELF first, and then members of your household.

Household Members (U.S. Citizens)

First Name

Middle Initial

Last Name

Relationship

Answer "Self" the first time you complete this section. Every time after that, click that person's relationship to you.

Is this person applying for benefits?

Does this person need health coverage?

Birth Month

Birth Date

Birth Year

Primary Applicant's Social Security Number

Other Household Member's Social Security Number

Gender

Hispanic or Latino

Race Codes (Select All That Apply)

AI (American Indian or Alaska Native)

AS (Asian)

BL (Black or African American)

HP (Native Hawaiian or Other Pacific Islander)

WH (White)

Is this person a U.S. Citizen or Qualified Immigrant?

Add Another Person Remove This Person

For Household Members who are NOT U.S. Citizens

First Name

Middle Initial

Last Name

Immigration Document Type

Alien, Certificate or Document ID Number

Lived in U.S. Since 1996?

Date of Entry Into U.S.?

Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military?

Add Another Person Remove This Person

More Information About Household Members

Has anyone received any benefits in another county or state? (For SNAP and TANF Only)

Who?

Where?

When?

Has anyone been convicted of giving false information about where they live and who they are to get multiple SNAP benefits in more than one area after 8/22/1996? (For SNAP only)

Who?

Where?

When?

Did anyone in your household voluntarily quit a job or voluntarily reduce his/her work hours below 30 hours per week within 30 days of the date of application? (For SNAP and TANF only)

Who quit?

Why did they quit?

Is anyone pregnant? (This question does not apply to SNAP applicants)

Name of the pregnant woman.

What is the estimated due date?

How many babies are expected?

If no, did anyone in the household deliver or was a pregnancy terminated within the last 12 months?

Name of the pregnant woman.

What was the delivery/termination date?

How many babies were delivered/expected?

What is the unborn baby's father's name?

What is the unborn baby's father's address?

For Medicaid applicants, does anyone have any unpaid medical bills for the last 3 months?

Open Medicaid Cases

You may be required to submit your unpaid medical bills if you have an open Medicaid case.

Is anyone disqualified from the SNAP or TANF Program? (For SNAP And TANF Only)

Who?

Where?

Is anyone fleeing to avoid prosecution or jail for a felony? (For SNAP and TANF Only)

Who?

Is anyone violating conditions of probation or parole? (For SNAP and TANF Only)

Who?

Does anyone have a felony conviction because of behavior related to the possession, use or distribution of a controlled drug substance (i.e., drug felon) after 8/22/1996? (For SNAP and TANF Only)

Who?

When?

Are you in compliance with the terms of probation related to any sentence received as a result of a drug felony conviction? (For SNAP Only)

Are you in compliance with the terms of parole related to any sentence received as a result of a drug felony conviction? (For SNAP Only)

Have you successfully completed all the terms of probation or parole related to any drug related conviction? (For SNAP Only)

Have you or any household member been convicted of trading SNAP benefits for drugs after 8/22/1996? (For SNAP Only)

Who?

When?

Have you or any household member been convicted of buying or selling SNAP benefits over $500 after 8/22/1996? (For SNAP Only)

Who?

When?

Have you or any household member been convicted of trading SNAP benefits for guns, ammunition, or explosives after 8/22/1996? (For SNAP Only)

Who?

When?

Have you or any member of your household been convicted as an adult of aggravated sexual abuse, murder, sexual exploitation, and other abuse of children, a Federal or State offense involving sexual assault, or an offense under State law determined by the Attorney General to be substantially similar to such an offense, after 2/7/2014? (For SNAP Only)

Who?

When?

Are you in compliance with the terms of probation related to any sentence received as a result of a felony conviction?

Are you in compliance with the terms of parole related to any sentence received as a result of a felony conviction?

Have you successfully completed all the terms of probation or parole related to any felony related conviction?

Have you or any household member received lottery or gambling winnings?

Who?

When?

Amount Received

Dollars

Amount in dollars.

Has anyone used TANF funds or the Way2Go Card at the following establishments, liquor stores, casinos, poker rooms, adult entertainment business, bail bonds, night clubs, salons/taverns, bingo halls, racetracks, gun/ammunition stores, cruise ships, psychic readers, smoking shops, tattoo/piercing shops, and spa/massage salons? (For TANF Only)

Who?

When?

Is anyone who is applying for benefits, currently receiving alimony?

Who?

Monthly Amount Received

Dollars

Amount in dollars.

Date alimony agreement finalized or last modified.

Household Members' Income

First Name

Last Name

Type of Income

Employer Name or Source of Income

Monthly Amount Before Deductions

Dollars

Amount in dollars.

How Often is Payment Received

Pay Per Hour

Dollars

Amount in dollars.

Hours Per Week

Last Date Paid

Add Another Person Remove this Person

Additional Household Income Questions

Is anyone currently on strike?

If self-employed, please list your monthly business expenses amount.

Dollars

Amount in dollars.

Applicant and All Household Members Resources

Do you or anyone you are applying for own any resources?

Have you or your spouse given away any assets for less than its value?

Household Member Resource Details

First Name

Last Name

Type of Resource

Account or Policy Number

Monetary Value

Dollars

Amount in dollars.

Name of Bank, Insurance Company, etc.

Add Another Resource Remove this Resource

Do you or your spouse own a vehicle?

Household Vehicles

Full Name of the Owner of the Vehicle

Vehicle Make

Model

Year

Amount Owed

Dollars

Amount in dollars.

Add Another Vehicle Remove this Vehicle

Do you or your spouse have a life insurance policy?

Household Life Insurance Policies

Full Name of the Policy Owner

Insurance Company

Policy Number

Face Value

Dollars

Amount in dollars.

Cash Value

Amount in dollars.

Add Another Policy Remove this Policy

Do you pay for the care of a dependent child or a disabled adult household member?

Details on Payment for Care

Full name of the person who requires care.

Full name of the person who pays for care.

What is the reason for the care.

Care Provider's Name

Care Provider's Phone Number

Amount Paid to Provider

Dollars

Amount in dollars.

How Often are Payments

Add Another Person Remove this Person

Do you pay transportation expenses for a dependent child or disabled adult household member?

Are these expenses included in the dependent care expenses?

Total miles driven weekly.

Miles

Type a number.

Does anyone in the household pay child support to someone living outside of the home?

Child support outside of the home.

Household member who is obligated to pay.

Full name.

Name of child for whom support is paid.

Full name.

Obligated Amount to Pay

Dollars

Amount in dollars.

Actual Amount Paid

Dollars

Amount in dollars.

To whom is the child support paid?

Full name.

Add Another Person Remove this Person

Does anyone 60 years of age or older or disabled have medical expenses?

Individuals 60+ with medical expenses.

Household member who has the expense.

Full name.

Type of Expense

Amount Owed

Dollars

Amount in dollars.

Still Owed?

Date Paid

Will insurance pay?

Add Another Person Remove this Person

Does anyone 60 years of age or older or disabled have medical expenses for transportation?

Individuals 60+ or disabled with medical expenses for transportation.

Purpose of the Trip

Total Miles Driven

Type a number.

Cost of Transportation, Parking and Lodging.

Dollars

Amount in dollars.

Add Another Person Remove this Person

Do you or any household member have shelter and utility expenses?

Shelter and Utility Expenses

Expense Category

Amount

Dollars

Amount in dollars.

How Often?

Who pays?

Full name.

Add Another Person Remove this Person

Do you share monthly household expenses with anyone in the home?

Who do you share bills with?

The full name of the person you share a bill with.

Full name.

Comments

Who is this bill paid to?

Amount Paid

Dollars

Amount in dollars.

Paid How Often?

Add Another Person Remove this Person

Your Landlord

Landlord's Name

Landlord's Complete Street Address

Street Address, City, State, Zip Code

Does someone else pay any of these household bills for you?

Bills Paid For You

Who pays this bill?

What bill is this?

Amount Paid

Dollars

Amount in dollars.

Who is this bill paid to?

Add a Bill Remove this Bill

Applying for Medicaid

Does anyone in the household plan to file a federal income tax return NEXT YEAR?

List their full names. (Separated by a comma.)

Full names.

Will any of the tax filers listed file jointly with a spouse?

List the spouse's full name.

Full name.

Will any of the tax filers claim any dependents on their tax return?

List the dependents' full names. (Separated by a comma.)

Full names.

Will anyone be claimed as a dependent on someone else’s tax return?

Tax Filer and Dependent

Full name of the tax filer.

Full name.

Full name of the dependent.

Full name.

How is the dependent related to the filer.

Add Remove

Deductions

Alimony Payment

Amount Paid (Alimony)

Dollars

Amount in dollars.

How Often? (Alimony)

Student Loan Interest

Amount Paid (Student Loan Interest)

Dollars

Amount in dollars.

How Often? (Student Loan Interest)

Health Insurance Premiums, 401K, Other Pre-Tax Deductions (HIP401K)

Amount Paid (HIP401K)

Dollars

Amount in dollars.

How Often? (HIP401K)

Add "Other" Deduction

Name the "Other" Deduction

Amount Paid (Other)

Dollars

Amount in dollars.

How Often? (Other)

Does anyone have other health insurance that covers anyone in your household?

Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job, such as a parent or spouse.

Is this a state employee benefit plan?

Have you or anyone listed on this application lost any health coverage in the last 2 months?

Was anyone in Foster Care at age 18 applying for Medicaid?

Is anyone in your household American or Alaska Native?

Is anyone aged (65 or older), blind or disabled (permanent impairment that prevents you from working)?

Step Two: Complete the Form Below

1. A SNAP Case Manager will reach out to you by phone or email to get any supporting documents that are required to complete your application.

2. The more accurate information you type in, the faster we can process your application.

2. When you're finished, click "SEND".

Understanding the Programs

Apply for Benefits

Your Information

Americans with Disabilities Act

For All SNAP, TANF and Medicaid Applicants

Do I qualify to get SNAP faster?

The Applicant and Their Household

Household Members (U.S. Citizens)

For Household Members who are NOT U.S. Citizens

More Information About Household Members

Household Members' Income

Additional Household Income Questions

Applicant and All Household Members Resources

Household Member Resource Details

Household Vehicles

Household Life Insurance Policies

Details on Payment for Care

Child support outside of the home.

Individuals 60+ with medical expenses.

Individuals 60+ or disabled with medical expenses for transportation.

Shelter and Utility Expenses

Who do you share bills with?

Your Landlord

Bills Paid For You

Applying for Medicaid

Tax Filer and Dependent

Deductions

Thank you!