The food stamp certification handbook /

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The
Food Stamp
CERTIFICATION
Handbook
PROPERlY OF THE
LIBRARY
FEB G 1976
UNIVERSITY OF NORTH CAROLINA
AT GREENSBORO
0447A
AUGUST 5, 1974
REPRINTED -AUGUST 1975
(/nclucles Change Numbers 1 through 5)
732-1 : ••• ••• i .••. •.. :• :• :• :• •• •• •** •• •• •• •• :• ••• • ••* •• ••• •• ••• • i• :• •• : • ** ~ FOOD 8c NUTRITION SERVICE, U.S. DEPARTMENT OF AGRICULTURE , WASH!NGTON, D.C., 20250 **
(732-1)
RECORD OF CHANGES
CHANGE DATE CHANGE DATE
NUMBER DATED FILED NUMBER DATED FILED
10-10-74 (Change 1') i
(732-1)
CHANGE DATE CHANGE DATE
NUMBER DATED FILED NUMBER DATED FILED
.
'
• 10-10-74 (Change 1) ii
2000
2010
2011
2020
2021
2022
2023
2030
2040
2041
2042
2050
2051
2052
2060
2070
2100
2101
2102
2103
2104
2110
2115
2116
2117
2118
2120
2121
2122
2123
2130
2131
2132
2133
2134
2135
2136
2200
2201
2205
2206
TABLE OP CONTENTS
GENERAL PROVISIONS
PURPOSE
PRUDENT PERSON CONCEPT
PROMPT ACTION
PERSONNEL REQUIREMENTS
VOLUNTEERS
PERSONNEL AND FACILITIES OF PARTIES TO A STRIKE
RECORDS AND REPORTS
NONDISCRIMINATION
DISCLOSURE OF INFORMATION
AVAILABILITY OF PUBLIC INFORMATION
RECIPIENT CLAIMS
REFUNDS FOR OVERCHARGES
CREDITS FOR LOST BENEFITS
QUALITY CONTROL
DISASTER CERTIFICATION
APPLICATION PROCESSING
HOUSEHOLD CONCEPT
Nonhousehold Members
Economic Unit
Head of Household
APPLICATION PROCESS
PUBLIC ASSISTANCE (PA) APPLICATION PROCESS
PA Affidavit
PA Interviews
PA Verification and Documentation
NONASSISTANCE (NA) APPLICATION PROCESS
NA Application
NA Interview
NA Verification and Documentation
AUTHORIZED REPRESENTATIVE
Application
Coupon Purchasing
Addict/Alcoholic Representative
Restrictions on Appointment
Multihousehold Representatives
Documentation and Control
ELIGIBILITY STANDARDS
RESIDENCY
CITIZENSHIP AND PERMANENT ALIEN STATUS
Citizens and Eligible Aliens
2-14-75 (Change 3) i
2207
2208
2210
2211
2212
2215
2216
2220
2221
2222
2223
2224
2225
2226
2227
2228
2229
2230
~·: 2240
~·: 2241
~·: 2242
~·: 2243
~·: 2244
2250
2251
2252
2253
2254
2255
2256
2257
2260
2261
2262
2263
2264
2265
2300
2301
2302
2303
2304
2310
2311
2312
2313
2-14-75
Ineligible Aliens
Verification of Citizenship or Alien Status
COOKING FACILITIES
Households Exempt From Cooking Facilities Requirement
Eligibility to Use Coupons for Prepared Meals
RESIDENTS OF BOARDING HOUSES
RESIDENTS OF INSTITUTIONS
WORK REGISTRATION
Registration Procedure
Exemptions to Work Registration
Determinations of Exemption Status
Additional Registration Requirements
Suitability of Work
Failure to Comply
Redetermination of Eligibility
Registrant Reporting Requirements
State Agency Reporting
UNLAWFUL STRIKES
TAX DEPENDENCY
Applicants Not Affected
Tax Dependency Defined
Determination and Verification of Tax Dependency
Ineligible Students as Nonhousehold Members
RESOURCES
Resource Eligibility Standards
Nonexempt Resources
Nonrecurring Lump Sum Payments
Exempt Resources
Verification of Nonexempt Resources
Verification of Liquid Resources
Verification of Nonliquid Resources
INCOME
Income Eligibility Standards ;
Nonexcluded Income
Income Exclusions
Income Deductions
Verification of Income
ELIGIBILITY DETERMINATIONS
DETERMINING ADJUSTED NET MONTHLY FOOD STAMP INCOME
Income and Deduction Factors
Averaging
Variable Basis of Issuance
CERTIFICATION PERIODS
PA Households
NA Households
Certification Pending Verification
(Change 3) ii
2320
2321
2322
2323
2324
2325
2326
2327
2328
2329
2330
2331
2332
2340
2341
2342
2350
2351
2352
ELIGIBILITY DETERMINATIONS FOR SPECIFIC HOUSEHOLDS
Earned Income
PA Recipients
s·si Recipients
Self-Employed Households
Resident Farm Labor
Migrant Farm Laborers
School Employees
Students
Strikers
Narcotics Addicts and Alcoholics
Ineligible Aliens
Zero Purchase Households
DETERMINING BASIS OF ISSUANCE
FREQUENCY OF ISSUANCE
IDENTIFICATION CARD
NOTIFICATION OF ELIGIBILITY
Notice of Certification
Notice of Denial
2400 ADDITIONAL CERTIFICATION FUNCTIONS
2401
2402
2403
2404
2405
2406
2407
2410
2411
2412
2413
2420
2421
2422
2423
2424
2425
2426
2427
2430
CHANGES DURING THE CERTIFICATION PERIOD
Desk Reviews
Recipient Responsibilities
State Agency Responsibiliies
Notice of Adverse Action
Changes Not Requiring Advance Notice
Continuation of Benefits
EXPIRATION OF THE CERTIFICATION PERIOD
Recipient Responsibilities
State Agency Responsibilities
Verification
60-DAY CONTINUATION OF CERTIFICATION
Certification of Household Transfer
Responsibilities of Losing Project Areas
Responsibilities of Gaining Project Areas
Moves Within Continued Certification
Expiration of Continued Certification
Security and Control of Form FNS-286
Reporting Requirement
NONUSE OF ATP CARDS
2500 FAIR HEARINGS
2501 Definitions
2510 HEARING REQUEST
2511 State Agency Assistance
2512 Denial or Dismissal
2-14-75 (Change 3) iii
2520 GROUP HEARINGS
2530 PARTICIPATION DURING APPEAL
2531 Reduction or Termination Prior to Hearing Decision
2532 Notification
2540 HEARING PROCEDURE
2541 Hearing Official
2542 Fact-Policy Distinction
2543 Claimant Rights
2544 State Agency Rights
2545 Hearing Record
2546 Hearing Recommendation
2550 HEARING DECISION
2551 Hearing Authority
2552 Decision Format
2553 Notification of Claimant
2554 Appeal Rights of Claimant
2560 FINAL ADMINISTRATIVE ACTION
2561 Agency Responsibilities
2562 Adjustments After Decision
2-14-75 (Change 3) iv
•
(732-1)
2000 GENERAL PROVISiONS
2010 PURPOSE
The purpose of the Food Stamp Program is to raise the nutritional
level among low-income households whose limited food purchasing
power contributes to hunger and malnutrition among members of such
households. The process of determining the need for and the level
of assistance is the certification procedure. The purpose of this
handbook is to provide the State agency with guidelines for
certification procedures.
2011 PRUDENT PERSON CONCEPT
The policies and procedures throughout this handbook are intended
to be a guide for food stamp certification and are broadly written
within the limits imposed by the Food Stamp Act and Regulations.
The policies contained in this handbook are intended to be suffi­ciently
flexible to allow the eligibility worker (EW) to exercise
reasonable judgment in executing his responsibilities. It is
impossible to write a procedure that will cover every possible
contingency that specific cases may present .to the EW.
In this regard, the concept of the "prudent person" can be helpful
to the EW. The term refers to the reasonableness of the judgments
made by an individual in a given situation. In a court case, a
person charged with negligence will try to show that his actions
were the actions that any reasonable person would take in the same
circumstances.
In making a certification decision, the EW should ask himself if
his judgment is reasonabl~ based on his experience and knowledge
of the program. For example, if the client '.s she 1 ter expenses as
he states them are out of line with rentals charged in the
community, the EW must ask for an explanation. Similarly, it is
the EW's responsibility to exercise reasonable judgment in deter­mining
if a given number of individuals who apply for food stamps
as a single household do in fact fit the Food Stamp Program's
concept of an economic unit .
If the EW encounters a problem in a specific case that he feels
may necessitate a change in policy or the creation of a new
policy, he should refer the matter to his supervisors. The
problem might then be referred by the local office to the State
agency and it might finally be referred to FNS for disposition.
Howeve.r, if the problem has application to only a specific case
1
(2011) (732-1)
or to a limited number of cases and is generally covered by
existing policy guidelines, the EW should make a judgment that
he can defend as reasonable and prudent .
2020 PROMPT ACTION
The State welfare agency is responsible for the certification of
applicant households. The term State agency will mean both the State
welfare agency and its local counterpart agencies. The State agency
must provide an application for participation in the Food Stamp
Program to any person upon request, aJ)d must accept an identifiable
application when submitted. An identifiable application is an appli­cation
or affidavit containing a legible name and address that has
been signed. The State agency must either approve or deny appli­cations
for participation within 30 days from the receipt of an
identifiable application. The person making application is responsi­ble
for cooperating with the State agency in providing the informa­tion
necessary for the State agency to make this determination.
2021 PERSONNEL REQUIREMENTS
The State agency will provide the qualified employees necessary to
assure that prompt action is taken on all applications and affidavits.
The State agency employees used to certify households for participa­tion
in the Food Stamp Program shall meet the personnel standards
used by the State agency in the certification of applicants for
benefits under the federally-aided public assistance programs. Only
such qualified State agency employees shall conduct the interview of
applicant households required by 2120 and determine the household's
eligibility or ineligibility and the level of assistance. In addi­tion,
only authorized employees of the State agency or a State
issuing agency shall have access to ,foo~ coupons, authorization to
purchase (ATP) cards or other issuance documents.
2022 VOLUNTEERS
Volunteers or other persons not employed by the State agency may
be used in certification related activities, but shall not be
permitted to conduct the interview required by 2120 or certify
as eligible applicant households. The activities in which volun­teers
and such other persons may be used include· outreach
activities such as locating potential participants, assisting in
program promotion, teaching nutrition education, and providing
transportation to the certification or issuance offices. In
addition, they may assist households who so desire in completing
the application and other forms and in securing the needed
verification of information reported on the application. In
2
(2022) (732-1)
certain situations volunteers may act as an authorized represen­tat~
ve for ·households which are unable to personally come to the
certification office.
2023 PERSONNEL AND FACILITIES OF PARTIES TO A STRIKE
The State agency may not ~se, in any certification related activity,
persons or organizations who are parties to a strike or lockout.
Such persons shall not be permitted to certify applicant .households,
to interview households, or to secure verification required of such
households. These individuals may, however, be used as a source of
verification for information provided by applicant households if
they would, under normal circumstances, be in the best position to
confirm a household's circumstances. The facilities of persons or
organizations who are parties to a strike or lockout may not be used
in the certification process or as a site for the interview required
by 2120.
2030 RECORDS AND REPORTS
The State agency shall keep such records and submit such reports
and other information as may from time to time be required by FNS.
Certification records will be available for review or audit by FNS
or the Department for a period of 3 years from the month of origin
of each such record. Certification records shall include appli­cations
for certification or subsequent certification, including
required FNS or State agency forms; worksheets used in the com­putation
of income. for ~ligibility and the basis of issuance;
documentation including verification techniques employed by the
caseworker; copies of forms sent to the issuance unit authorizing
or changing participation or basis of issuance; copies o~ notices
of adverse action and other notices sent to the client and responses
thereto; actions related to the fair hearing process; f1scal adjust­ments
including claims, refunds, and credits for lost benefits; and
any other data which affects a household's eligibility or basis of
issuance, such as Form FNS-286, Certification of Household Transfer.
2040 NONDISCRIMINATION
It is the policy of FNS that program benefits shall be extended
to all eligible households without regard to race, color, religious
· creed, national origin, or political beliefs .
To further this policy, State agencies shall initiate programs
to inform the public that the Food Stamp Program is administered
3
(2040) (732-1)
without discrimination. The State agency's Public Notification
Plan shall consist of the following elements:
2040.1 Minority Group Contacts
The State agency is responsible for assuring that local certifying
agencies advise local minority group organizations, in writing,
that the Food Stamp Program is available to all eligible house­holds
without regard to race, color, religious creed, national
origin, or political beliefs. Local agencies should contact
minority group organizat.ions once every Federal fiscal year. If
there are no minority group organizations in the project area~
the local agency should contact prominent minority leaders,
ministers, teachers, and other community spokesmen in the project
area.
2040.2 Nondiscrimination Poster
The State agency shall assure that the poster " ... And Justice for
All" is prominently displayed in all local food stamp certification
and issuance offices. If this poster is not currently being
displayed, the State agency should order additional copies from
the appropriate Regional Office and display the poster immediately.
2040.3 Nondiscrimination Statement
Applicants for program participation shall be advised that their
application will be processed without discrimination. This can
be accomplished in the statement on the application form that the
applicant has been advised of his rights. The statement should
include a sentence reading: "Standards for participation in the
Food Stamp Program are the same for everyone without regard to
race, color, religious creed, national origin, or political beliefs."
In addition all State agency publications informing the public
of program benefits should include the same statement: "Standards
for participation in the Food Stamp Program are the same for
everyone without regard to race, color, religious creed, national
origin, or political beliefs." State agencies may exhaust
present supplies of forms and publications; however, any new
issues shall include the nondiscrimination statement.
2040.4 Records
The State agency shall issue written instructions to insure that
local agencies maintain all file copies of correspondence con­cerning
public notification of nondiscrimination. These documents
4
•
(2040.4) (732-1)
shall be made available for inspection during compliance reviews
and audits of the Food Stamp Program.
2041 DISCLOSURE OF INFORMATION
In accordance with Section 10(e)(3) of the Food S~amp Act, the
State agency shall restrict the use or disclosure of information
obtained from applicant households to persons directly connected
with the administration and enforcement of the Food Stamp Program.
Names and addresses of participating households may be made
available to persons directly connected with nutrition education
and outreach efforts. The State agency may cooperate in furnishing
needed information to the Federal Bureau of Investigation or other
law enforcement agencies if the investigation concerns a household
fraudulently obtaining coupons or otherwise violating the Food
Stamp Act or Regulations.
2042 AVAILABILITY OF PUBLIC INFORMATION
Regulations, Plans of Operations, Federal procedures, and State
agency certification manuals and supplemental instructions issued
for use in certifying households shall be maintained in the State
office and at least one local office of the State agency in each
project area for examination by members of the public on regular
workdays during regular office hours. Copies of audits or inves­tigations
conducted by the Department which are for official use
only shall not be made available for public examination.
2050 RECIPIENT CLAIMS
2051
The State agency will handle cases where a participating household
received an overissuance of free coupons in accordance with FNS(FS)
Instruction 736-1, Recipient Claim Instructions for State Agencies.
Any intentional misrepresentation on the part of the household may
subject the household to prosecution in accordance with 270.4(d)
of the Regulations. ·
REFUNDS FOR OVERCHARGES
The State agency will handle cases in which a household has been
overcharged for its coupon allotment because of an administrative
error on the part of the State agency personnel in accordance with
FNS(FS) Instruction 736-2, Refunds to Households Which Have Been
Overcharged for Their Food Coupon Allotment.
5
(732-1)
2052 CREDITS FOR LOST BENEFITS
The State agency will handle cases of households which have had
their food coupon allotment wrongfully denied, delayed, or
terminated by providing credit for lost benefits in accordance
with applicable Food Stamp Regulations and procedures.
2060 QUALITY CONTROL
The State agency will establish and maintain a quality control
system in accordance with FNS(FS) Instruction 732-2, Quality
Control of Eligibility and Coupon Basis of Issuance Determination.
Quality control is an administrative ' system for documenting the
extent of and reasons for errors in the eligibility and basis of
issuance of participating households. Based on this documentation,
action must be taken to reduce the incidence of these errors
below preestablished tolerance limits.
2070 DISASTER CERTIFICATION
When authorized by FNS, the State agency may certify households
affected by a natural disaster in accordance with FNS(FS)
Instruction 732-3, Emergency Food Stamp Assistance in Disasters,
or households affected by a mechanical disaster in accordance
with appropriate Food Stamp Regulations and procedures. When
FNS does not authorize a disaster declaration, households shall
be certified in accordance with procedures detailed in this
handbook. Such households may be eligible for an unusual expense
deduction as prescribed in 2264.7.
6
•
•
(732-1)
2100 APPLICATION PROCESSING
All applications shall be submitted on behalf of a household.
2101 HOUSEHOLD CONCEPT
A household is defined as any one of the following:
(1) A group of individuals who are living as one
economic unit sharing common cooking facilities.
(2) An individual living alone who purchases and prepares
food for home consumption.
(3) An individual who purchases and prepares food for
home consumption residing with any other person or
persons who is not a member of an economic unit.
(4) An elderly person (i.e., an individual age 60 or
older) who lives alone or only with spouse and who
need not have cooking facilities if he participates
in a delivered meals program or a communal dining
program.
(5) A narcotics addict o~ alcoholic who is a resident of
a drug addiction or alcoholic treatment and rehabili­tation
program and who receives meals through such
program.
2102 Nonhousehold Members
2102.1
2102.2
The following individuals residing with a household will not be
considered household members for determining the household's
eligibility or basis of issuance.
Roomer
An individual to whom a household furnishes lodging, but not
meals, for compensation .
Boarder
An individual to whom a household furnishes meals, or lodging
and meals, for payment at a monthly rate at least equal to the
coupon allotment for a one-person household.
(1) An individual furnished both meals and lodging by
the household, but contributing less than a one­person
coupon allotment, will be considered a part
of the household. By failing to meet the basic
2-14-75 (Change 3) 7
;'(
;':
'i':
;':
"k
-!:
··k
(2102.2)
2102.3
2102.4
2102.5
2102.6
2102.7
payment, the individual's basic needs are being
provided by the household and he will therefore be
treated as any other household member.
(732-1)
(2) An individual furnished only meals but not residing
with the household and contributing less than a one­person
coupon allotment will not be considered a
member of that household and only his actual payment
to the household will be included as household income
(See 2262 .13).
Attendant or Housekeeper
An individual necessary for medical or child care reasons who
is not a part of the household economic unit.
Ineligible Alien
An individual who does not meet the citizenship or permanent
alien status as defined in 2205. However, the income and
resources of such individual, if he is not otherwise excluded
from the household as a roomer, boarder, or attendant, will be
considered available to the household for the purpose of
determining eligibi.lity and basis of issuance for the remaining
household members (See 2331).
SSI Recipients in "Cash-Out" States
Recipients of Supplemental Security Income (SSI) who reside in
a State designated by the Department of Health, Education and
Welfare (DHEW) to have specifically included the food stamp
bonus in its State supplemental payment (See 2323).
Student Tax Dependents
A student who is (1) 18 years of age or older, (2) enrolled in
an institution of higher education, and (3) properly claimed as
a tax dependent for Federal income tax purposes by a parent or
guardian who is a member of another household which is not
eligible to participate in the Food Stamp Program (See 2240).
Others
Other individuals who are not a part of the household's
economic unit and do not normally purchase food with the
household.
2103 Economic Unit
2-14-75
An economic unit is a group of individuals for whom food is
customarily purchased and stored in common for use by all
(Change 3) 8
•
(2103)
2104
(732-1)
members of the group and for whom common living costs (such as,
but not limited to, shelter costs) are customarily being met
from the income and/or resources available to any individual
within the group.
It is possible for more than one household to share common
living quarters and even common shelter costs. In such
situations, it is the responsibility of each person or group
of persons to establish that they are in fact separate economic
units and may apply as separate households.
Head of Household
The head of household is the person in whose name application
is made for participation in the program. Such individual must
be a household member except that, if the only adult member of
an economic unit is an ineligible alien or an SSI recipient in
a cash-out State, such individual may make application on behalf
of the household of minors as the head of household.
2110 APPLICATION PROCESS
2-14-75
Households wishing to participate in the program must make this
desire known and provide the State agency with enough informa­tion
regarding household income and circumstances to make a
determination of eligibility. Failure by the household to
cooperate with the State agency in providing the information
necessary for an eligibility determination can result in denial
of the application. The application process consists of an
application for participation made by or in the name of the
household head, an interview, and required verification and
documentation. For purposes of applying for program benefits,
households fall into two categories--public assistance (PA)
households and nonassistance (NA) households. SSI households,
although eligible for food stamps without regard to their
income or resources as are PA households (See 2200), are
treated as NA households for all other aspects of the program,
including application processing.
(Change 3) 9
2110.1
2110.2
2110.3
(732-1)
PA Households
The following households will be classified as PA households
for food stamp purposes:
(1) Households in which all members are rece1v1ng
directly or on their behalf a federally aided public
assistance grant such as Aid to Families with Dependent
Children (AFDC) or Old Age Assistance (OAA), Aid to
the Blind (AB), and Aid to the Permanently and Totally
Disabled (APTD) where still applicable.
(2) Households in which all members are receiving
directly or on their behalf a general assistance (GA)
grant from a State or local public assistance program
which has been determined by FNS to meet the criteria
for inclusion as PA households. (The presence in any
household of an individual receiving a grant from a
GA program which has not received FNS approval shall
result in the classification of the household as a NA
household).
(3) Households in which all members are rece1v1ng either
a federally aided PA grant or a GA grant as ·defined
above.
(4) Households in which all members are PA or GA
recipients as defined above and SSI recipients.
The classification of a PA household will not be affected by the
presence of a legally assigned foster child.
SSI Households
An SSI household shall be only those in which all members are
SSI recipients or SSI recipients and an essential person as
determined in 2323.
NA Households
All other households shall be classified as NA households.
2-14-75 (Change 3) 10
•
•
2115
2116
PA APPLICATION PROCESS
PA households who apply for food stamp benefits are certified
on the basis of an affidavit and information contained in the
PA case file. Households which are currently recipients of
public assistance may mail in the.affidavit. There should be
no need for the PA recipient to make a special visit to the
office to execute the affidavit. A new affidavit will be
executed at each subsequent certification. (See 2311 for PA
certification periods.)
PA Affidavit
{732~1)
The application form for a PA household is an affidavit which
provides the PA household with a legal request for certifica­tion,
and requests certain information which might not be
available in the case file. The use of the affidavit will not
necessitate a separate application process for PA households
as most of the information necessary for certification is
known through the PA case file. In most instances the affida­vit
will be an integral part of the application for public
assistance and should be executed at the same time the
application for public assistance is completed.
2116.1 Affidavit Form
·When information needed to establish household eligibility and
basis of coupon issuance is not available in the application
for public assistance, a separate food stamp affidavit must be
provided to ob~ain the necessary information. If the application
for public ass~tance does not include the following information,
it must appear on the affidavit:
(1) The applicant's desire to participate in the program.
(2) Residence in the project area.
(3) The availability of cooking facilities.
(4) The availability of household members for employment.
Household members registered in the Work Incentive
Program (WIN) will be considered to have met the food
stamp work registration requirement.
11
(2116.1) (732-1)
(5) Income, exclusions, and deductions, including the
value of housing provided by an emproyer in lieu of
or supplemental to household income.
(6) Public assistance withholding (PAW) option, when it
becomes available.
(7) Delivered meals and communal dining option.
(8) Penalties, civil and criminal, for fraudulent acqui­sition
and use of food coupons. Requirement to
report within 10 dars changes in income or deductions
of $25 or more.
(9) Right to a fair hearing.
(10) Nondiscrimination assurance.
(11) Signature of the head of the household, the spouse,
or the authorized representative.
The affidavit form must be approved by FNS prior to use.
2117 PA Interviews
The interview of PA households shall be satisfied by the
interview conducted in connection with their certification for
public assistance.
2118 PA Verification and Documentation
The PA case file will serve as verification and documentation.
If, however, the EW has any reason to question information in
the file or provided in the affidavit, he should verif1 all such
information prioP to certification for food stamp benefits.
2120 NA APPLICATION PROCESS
To be certified for food stamp eligibility, anNA or SSI house­hold
must complete an application and cooperate in providing all
information necessary for an eligibility .determination. In
addition, each application must be followed by an interview.
Applications by NA or SSI households are also subject to verifi­cation
of facts stated by the applicant and documentation which
consists of a written record in the case file of the method used
to verify information received from the applicant.
12
2121
•
•
2121.1
(732-1)
NA Application
Applications for participation by NA and SSI households may be
completed by the applicant or anyone he chooses. The applica­tion
must be signed by either the head of the household, the
spouse, or the household's authorized representative. The
application may be completed in the certification office or may
be submitted by mail. Although the application form is designed
to be client-oriented, the EW should assist the applicant in
completing the form if requested to do so. All applicants must
he provided an application form at the time they request to
participate in the Food Stamp Program.
NA Application Form
The application must contain all information necessary to
determine a household's eligibility and basis of issuance. FNS
requires that the application form be client-oriented--that is,
easily read, adequate spacing for furnishing necessary and
complete information, and a clear stat~ment of the applicant's
understanding of his rights and responsibilities, including
penalties, which is to be signed by the head of the household
or his representative. Included in the responsibilities shall
be the requirement to cooperate with quality control personnel,
if choosen for a review. If the questions are not self-explanat
1
ory,
clear instructions regarding execution of the form must be
provided either on the form itself or as a separate piece of l
material to be made available with the application form. The
instructions must ·be approved by FNS concurrently with the State
agency's proposed1application form. Other considerations include
space for performing necessary administrative actions on the
information submitted, such as changes resulting from the
interview or verification or similar notations, and retrievability
of information. The format of the application also serves as a
useful tool in directing the course of the interview.
See the following pages for a format of anNA application and
worksheet. The purpose of the suggested worksheet is to provide
the eligibility worker with an effective tool for assuring the
correctness of computation. It is not a checklist. If additional
sheets are used for computations, besides the worksheet, those
additional sheets are to be preserved and filed in the case record.
The worksheet must be executed, although not necessarily completed,
since it reflects the disposition of the application and the docu­mented
reason for the determination of eligibiiity or ineligibility.
We have not provided a format for self-employment income which the
State agency may incorporate into the application or provide a
separate form.
13
(732-1)
THIS PAGE IS INTENDED TO BE VACANT.
•
14
2121.1 (732 -~
11. NAME OF HEAD OF HOUSEHOLD ( L as t, ,_.1rs l , MH1<1/e} APPLICATION FOR PARTICIPATION L DATE
IN FOOD STAMP PROGRAM
3 . CASE NUMBER (Worker completion only) 4 . IE NUMBER (Home and
-MAILING ADDRESS (Numbe r, Stree t, R oute Number C i t y, C ounty , Stait>, ·Zip Code)
6 . ADDRESS WHERE RESIDING {/1 diflerenl /rom above) (Number, Stree t, R oute Number- City, County, Slate, Zip Code)
(7. 01 RECTIONS TO HOME (Worker completion only)
•
(8. GIVE rHE FOLLOWING INFORMATION FOR ALL PERSONS LIVING IN YOUR .D EXCEPT ROOMERS BOARDERS, OR PERSONS
WHO PROVIDE NURSING CARE. HOUSEKEEPING SERVICE , OR CHILD CARE . LIST THESE EXCEPTIONS IN NO. 9 . (List any additional
• members on a separate sheet and attach)
Citizen [Form FNS-284
Relationship to Head of House- or Employment
Alien Statu• completed for
NAME (Lost, Fir•t, Middle) JBirthdate Age ,.~~d~:fn, IVi(e, mother-in-law, su.;~- A-B-C-D eaoh'"'!.m~,r
f,unreloted, enter 1-2 E-F-G-H marked H.
14 below below right)
left) YES NO
HEAD OF HOUSEHOLD
-------- - - ·-
!CITIZEN & ALIEN STATUS EMPLOYMENT STATUS CODES
A. Mother or other household mtmber with rest~nsibilitv
1
E. Persons self-employed on a full-time basis
1. U.S. Citizen lor care of sick or disabled or dependent c ddren under 8 F. Under 18 years of age
2. Permanent Alien B. Students enrolled at least half time in o school or G. Over 65 years of age
3. Temporary Alien training program H. Available lor employment (Such person mus,:li~~;r,:~:· 4. Hone of the Above c. Persons wor~ing at least 30 hours per weelc Form FNS-284, Work Registration,. before lily
D. Persons unable to work for mental or physical J,eolth for Food Stamps can be established)
reasons
• 9A. Do any of the persons living in the home pay for board, room or both? 0 Y. . 0 No If yes, give this information:
Check Box Amount Paid How
NAME (Lost, First, Middle) .. .. .. E 1! ..r:. :; 1 Other 0 Cl 0 • ar0: 0 e 0 Ill Ill • :a
$
$
I • I
15
2121.1
B .t!oes any member live in0t~:, ~~':'id::n"rov_i,de, no~rsin_g care, houoe II 0 Do au~ havjj~~e to prepare cooked meals where you live?
lceeplnf services, or core 10 that you or other mem-bers
0 the houoehold can work? 0 Yeo 0 No Yes _llo
If "Yes," give this persOns name IIA Are. you or your opouu_unobl.e to prepare meals becouo• of health
problems? 0 y O N If "Y ., · es o .••, do you receive meals from either:
C Do any other persons live _in the home? If so, give names o.nd A. Meals on wheels program? 0 Yeo 0 No
status--for example, do they share the home or rent? Do they B. A communal dini~g facility? 0 Yes 0 No live as a separate household unit? Explain fully.
liB Are you, or any member of the household, a member of o drug addict or
alcholic rehabilitation treatment center? O Yea O No
If 11Yea," give the name
Do you participate on a 0 resident or 0 non-resident basis?
112. SCHOOL OR TRAINING PROGRAM. Give the following I·'· ..... ,_,for peroono listed under item 8~
Muft)ber
NAME OF HOUSEHOLD MEMBER of houro
(Last, First, Middle) Nome of School or Training Program attending • each
week
'..
3A. RESOURCES Resources include cosh on hand, money in cheCking or savings accounts, (includinQ cred/t unions) stocks, bonds and other itema
which can be easily changed into caeh, 01 well 01 real property, buildings, and.peraonol property (such aa campers, sn•wmobiles, lxults,
motors, etc.). Do not Include your home, peraonel ltema (clothing, book&, etc .) houaehold gooda, or one licensed automobile .
If none, write "NONE."
HAM E of person who owns the resource.
TYPE OF RESOURCE Va!ue Amount you owe
(Last, First, Middle) on resource
s s
s ~
'
IS p
s ~
s s
•
s s
13B. MON.EY -MAKING_ RESOURCEs.: List all resources used to produce income such as rented property, real estate or personal property, etc.
If none, write "NONE, •
NAME o~ person who owns the resource.
TYPE OF RESOURCE Yolue
Amount you owe Monthly
(Last, First, Middle) on resource
Income
jS IS Is
s IS Is
~ I• s s IS s -
16
2121.1 (732-1)
INCOME fLiat all income ttOm all aou!!'ea>: ln_come ln~lucl~1 but Ia not llmltocl to: _public or gonorol a11l1tanco
1
(~-.!i.';':. ..:..u_-:;._ ••
~~c~~~ 1ocial .. curlty or rallroo~n~~::~~ vacation :·.-;;;i~ln~:",', 1trlko ";,-;,'~j; glft1,~;~!'rd~
=~:i:;~~~ f;l~ carea n-cul -o.do :_~::t iaonnno•l • .'t':::l· I DOn1i 1-;.;.,-~~I a~ 11;;;;~~-··r,In ln one wr Ito ··r.-oH"e' or · provided
Deductions
How often (from earned income)
SOURCE OF INCOME
NAME (La s t, First, Middle) Gross I! [ Ago T., • .,. (Name of agency, firm, Other
employer)
Amount I Sep~!::.1 Soc ial
(Union It 11 Security I .... Dues,
f ~~: Federal ;;;,)"'' I! li: ~t~~:·
II
Is 12 Is s
13
Is
11
~- • s
13
II
Is 12 ~ s
13
~OTJ: : ~~II_~ stubs or other_ w tich can be_ used to verity the amount of income from an• • dedu ctlons or inc >me rrom
other source, must be attached or mode oval I able upon request.
~·If any member of the hou1_ehold ha1 Income from 1el!-employment or farm oporot1on1, a lupplo_mentcil form mull be flied. The food 1tamp office will,
:upon requo~t, provide you with a form to be u1ed to reportthl1 Income.
,5, EXPENSES HOW .OFTF .. FVDI .,.,,, ..t.RF P..t.ll
Give the following Information about your household expenses. ..•... ...
~ Number of
These expenses ore only those that you actually pay. Expenaea •• c paid by another person or source are to be included. • 0 ... months to be
AMOUNT ~ ... E ~ paid (if less
IMPORTANT: This will enable u1 to give full credit for all ... f • i• " allowable expenses •
I than 12) A. ~~~le ntE Ror mortaoao aovment on home Is
2' (a) Heating ~~d ~~-;;k,-;,_gdf~:rentJ I$
(b) Electricity s
(c) ,._ (basic charlie for one) s
ldl ...... s
(e) S.wa11• diseosal fe01 s
3. Taxes and asee11ment1 - (Yearly parments)
(a) Real estate tax01 on ho.;;; IS
Special aueuments (if required by law)
B. ME~~~~ 1. 1ician and dental services s
2. _H_oSJtitol or nursing care s
3. Health Insurance and medicare $
4, Proscriotion drugs Is
5, Other. (specify) Is
.. c. UNUSUAL I, Replacement or repair of property damaged or loat'
through vandalism, fire, theft, flood, storm, etc. ·
Explain:
Is
• 2. :~ .. ~ .. ~~: old by nber of the household
Is
D. OTHER
1. ro~y:hnt1 for the. care of a child or another ~er1on when neces•ory
• a ... ~.;.b.; to w~rk outside of t • homo s
2
' _;:~~·::::~teria/~1 · feo1 for education (Do not include cost of
S·
,(o) When poid?
(b) For whom poid?
(c) To whom paid?
(d) 'Period covered by paymonto:
From To
17
2121.1 (732-1)
--income, re1ourcea,
I certify that this application hoo been examined by me (or read to me) and that the .informolion given is true and correct to the b .. t of my knowl­edge
and belief. I agree to provide the county food atomp office Information neceaaary to verLfy any atatemente given in thla application 011d
hereby give permi11lon to obtain 1uch verification. I will alao cooperate fully with •tate and federal peraonnel in a quality control review.
I agrH to inform the county food stomp office promptly (within 10 daya) of changes in income and/or deductions of more than $25.00 per
month, resources, living orron .. mento or other Information which I hove given since auch changes may affect eligibility to purcha ..
food coupons or the amount to be paid for them. ·
I underatand that when I plan to move to another county participating In the food atomp program, it may be poaaible for me to purcho1e food
coupons in tha other county without making application immediately, PROVIDED that I report the..,ove to the food stomp office in the county
from which I om moving.
N.ONDIS\::Ifi""HATIQ.N: rhlo application will be considered without regard to race, color, religious creed, national origin, or politlcol
beliefs.
I understand that I have a right to a hearing if I om not satisfied with the action token on my application by the food stomp office.
BEFORE YOU SIGN YOUR NAME GO BACK AND CHECK TO SEE THAT EACH ITEM THAT APPLIES TO YOUR HOUSEHOLD
HAS BEEN ANSWERED ACCURATELY
PENAL TIES FOR FRAUD: The state ond federal low provides r,•nohl .. including a line, imprioonment or bath for pe;oono found guilty of
obtaining food stamps for which they are not eligible by making alee statements; or
FAILING TO REPORT PROMPTLY any chongeo in their circumstances. If evidence lndicot .. that euch individuals have willfully violated
the law, they will be referred lathe proper law enforcement authority for investigation and pouible prosecution·.
ANYONE WHO AIDS another penon to obtain food stomps fraudulently is subject to the same penalties.
l
SIGNATURE (Head of Houeho/d or Spouae)
..
If Signed by
2. Signature of Witneu
SIGNA PERSON (It eny, he/pi"' to complete form) ESS
U•you would like to hove oomeono elae purchaae your coupons for you, give hie noiM and addrou
18
•
2121.1
I.
1. Liquid Resources:
2. Non-Liquid Resources:
(Do not list excludable resourc es)
3. Total Resources for FS:
INCOME
4. Allowable Resources for Household Size and "--------i Composition (consider age of members):
•--------i S. Eligible boaed on resources? 0 Yea 0 No
VERIFICATION
A. Monthly Earned Income from Employment
B
c.
D.
E.
1. Gross Salaries, Wages, Training Allowance:
(Monthly. Do not include earnings of child
attending school, or other excludsble income.)
2. less 10 'ercent of line 1:
(Not to ex~ecd $30 per month)
3. Total earned income(Line 1 minus Line 2):
4. less Mandatory Deductions:
5. Adjusted Earned Income:
Other Monthly Income
1. Boarder Payments: $
2. Less Coupon Allowance
(Monthly one-person
allotme nt. ) -$
3. Total Boarder Income (Line 1 - 2)
4. Roomer Payments: • .._ _____ --i
5. Self-employment Income (Monthly as
pro~~!. ted.) Includes Form. ·~--------1
6. Student Loons, Grants, Scholarships
(Prorated Monthly)
7. PA Grant, Social Security, SSI, Roilrood
Retirement, Pens ion +.._ _____ -i
8. Other Income:
9. Total Other Income:
Toto I Food Stomp Income (Line AS plus Line 89):
Deductions from Income
1. Live-in Attendont (child
care or medical)
2. Plus Coupon Allowance
(Monthly one-person
allotment): $
3. Medical (only i£ over $10 per month)
4. Child core:
5. Mandatory Education Expenses +
6, Support or Alimony +
7, Unusual Expenses (requires supervisory
apnrova I below) +
8. Total Deductions Other Than Shelter
Shelter Adjustment
I. Food Stomp Income before Shelter
Adjustment(!rom Line C) S
2. Deductions (from Line DB> $
3. Net Food Stamp Income =
4. Total Shelter Cost(indude
utilities. etc. )
5. Less shelter standard (use
table OJ 3()17o of Line E J) -
6. Shelter Deduction, if any .. $
7. Net Food Stomp Income (from Line E3)
8. Less Shelter Adjustment ( frnm LinC' E6)
9. ADJUSTED NET FOOD STAMP INCOME
19
(732-1)
2121.1
A. All-olole looc-e lor Ho.,oehelol Slae
8. Aolj,o,.ol Met F-" St-p lnc­(
from Line II £9)
CerllllcetiOfl perlool: p,.,. to
(732-1)
.._ ______ -!C. E!.!!ibila for food stamps on the basis of resources ond income?
U Yu 0 No
D. Frequanca of i•suance 0 Monthly 0 Semimonthly ·------1 E. PAW option QYeo nHo
Purchase Requirement Total Coupons------
CIRTIFIED BY:
Slgnot~------------------------------------------- Dote: ______________________________ ~
APPROVAL FOR UNUSUAL I!XPIMSIS BY:
Svper•l•••-------------------------------------------------- Dote
'
20
•
2122
•
•
(732-1)
NA Inte'rview
It is necessary to interview all NA and SSI applicants including
those whose applications are submitted by mail. Only qualified
EW (See 2021) shall interview the applicant who may be the head
of the household, the spouse, or the household's authorized
representative. Applicants who are unable to come into the
office for a face-to-face interview may be interviewed in a
home visit or by telephone. When it is necessary to interview
the applicant by telephone, the justification for such action
must be fully documented in the case file. Inconvenience
to the applicant is not considered sufficient justification.
No household shall be interviewed by telephone for any two
successive certifications without a face-to-face interview in
the office or at home.
The purpose of the interview is to establish, to the satisfaction
of the EW, that the actual facts of the case are consistent with
the statements on the applicat_ion concerning household income
and circumstances and to establish, subject to subsequent
verification, whether or not the household is eligible for food
stamp assistance. The only successful method of making such a
determination is the use of investigative interview techniques
to conduct a thorough and searching inquiry into household
circumstances. Merely reviewing the application for completeness
ts no substitute for the investigative interview.
The State agency must impress upon EWs that the interview is an
official and confidential discussion of household circumstances
with the applicant. The applicant should be made to feel at
ease during the interview and in all instances the household's
right to privacy must be respected. The scope of the interview
may not extend beyond the examination of household circumstances
which directly relate to the determination of household
eligibility and basis of issuance.
During the interview, the EW should be sure that the applicant
understands his obligations as a recipient and has a basic
understanding of program procedures and aims. The applicant
must be advised of his right to appeal the EW's determination
if he is not satisfied -with the results (See 2500 for Fair
Hearings). In addition, the applicant must be advised that
eligibility will be determined without discrimination.
21
2122.1
(732-1)
Interview Management
State agencies are required to assure that all applicants are
promptly interviewed in order to take action on the apRlication
within the 30-day period. The State agency should prdiide
adequate staffing and efficient practices to avoid long waits
for interviews or rigid appointment systems which are not
structured to accommodate households whose need for food
assistance is obvious and immediate. In addition, adequate
supervision at both the State ~d local level shall be
provided to assure proper certification procedures and prudent
management controls are being followed. Facilities should
be of an adequate size and layout to assure the privacy neces­sary
to preserve the confidentiality of the interview and also
to allow workers to conduct the interview and perform other
office duties without undue distraction.
2123 NA Verification and Documentation
2123.1
Prior to determining eligibility for applicant households,
sufficient information concerning the applicant's situation
must be obtained in order for the EW to make an informed judg­ment
as to the household's eligibility. Verification and
documentation are tools for making this judgment and recording
the decision-making process in the case file.
Verification
Verification means that information has been secured which will
establish the accuracy, or lack thereof, of information
provided by the applicant. G~oss nonexempt income and mandatory
deductions are the minimum verification required at the initial
certification and at subsequent certifications when the amount
of this income has changed by more than $25 or the source has
changed. This does not preclude verification of other items
necessary to determine eligibility particularly when information
provided by the applicant is unclear, incomplete, or inconsistent.
The State agency should provide EWs with guidelines to determine
when additional verification is required.
Sources of verification include documentary evidence, collateral
contacts, or home visits. Applicants are primarily responsible
for furnishing documents sufficient for verification, or at
least information from which the verification may be made by the
EW. A refusal to cooperate in furnishing income information or
information necessary for verification must necessarily result
22
(2123.1)
2123.2
•
in a denial of benefits since no basis is provided from which
eligibility for program participation or basis of coupon
issuance may be determined.
(732-1)
While the applicant household does have primary responsibility
for providing verification, the EW is expected to aid the
applicant. Collateral contacts by means of telephone calls,
letters, or personal visits may suffice in some instances. In
other cases, the applicant should be informed that certain docu­ments
will be necessary and provided a reasonable opportunity to
comply with such requests. In cases of extreme emergency,
especially when the employer refuses to provide documentation or
information concerning income, the household should not be denied
solely on that basis, but the EW shall, in consultation with the
applicant or other sources, arrive at a figure to be used for
certification purposes.
Documentation
Case files must contain· documentation to support the determina­tion
to grant or deny program benefits. Documentation means that
a written statement regarding the type of verification and a
summary of the information obtained has been entered in the
case file. Such statement must be in sufficient detail so that
a reviewer would be able to determine the reasonableness of the
determination.
EXAMPLE
When income is verified by the presentation of
pay stubs ur wage statements, the EW shall record
on the application or worksheet the following
information:
The date of each pay stub or wage statement
used.
The name and address of the payer.
The gross amount of income on each stub
or statement •
The frequency of receipt of income (i.e;,
weekly, bimonthly, monthly, etc.).
The specific items and amounts of mandatory
deductions.
23
(2123.2)
The calculations made to arrive at a monthly
income; for instance, if pay is received weekly
and four pay stubs are seen, the income from
each should be added; then divided by 4 for
a weekly average. The weekly average will be
multiplied by 4.3 or 4 1/3 to ·provide the monthly
average. Deductions would be handled similarly.
(732-1)
2130 AUTHORIZED REPRESENTATIVE
An authorized representative is a person designated by the head
of the household or the spouse to act on behalf of the household
in applying for program bene:fi ts and in purchasing coupons. An
authorized representative is also a private nonprofit organiza­tion
or institution conducting a drug addiction or alcoholic
treatment and rehabilitation center which will act on behalf of
households who reside at such centers in applying for and
purchasing food stamps.
2131 Application
Where it is impossible for the head of the household or the
spouse to make application for participation, a responsible
household member may be designated as the authorized represen­tative.
If household members are unable to make application
because of employment, or health or transportation problems,
etc., a responsible adult outside the household -may be designated
under ~ the fo~lowing conditions:
1) The head of the household, the Epouse, or other
responsible household members cannot be interviewed.
(2) The authorized representative has been designated in
writing by the head of the household or the spouse.
(3) The authorized representative is adequately aware of
pertinent household circumstances.
It is important that the head of the household or the spouse
prepare or review the application whenever possible, even
though the authorized representative will actually be inter­viewed.
It should be emphasized that the head of the household
will be held liable for any overissuance which results from
erroneous information given by the authorized representative.
24
•
•
2132
2133
(732-1)
Coupon Purchasing
If the head of the household wishes to name an authorized
representative for purposes of purchasing coupons, such desig­nations
should be made at the time the application is completed.
Any authorized representative should be named on the identifi­cation
card. The authorized representative for coupon purchases
may be the same individual designated to make application for
the household or may be another individual. Even if the head
of the household is able to make application and purchase
coupons, he should be encouraged to name an authorized repre­sentative
for purchasing coupons in case of illness or other
c1rcumstances which might result in inability to purchase
coupons. State agencies may, at their discretion, provide for
a system that permits the head of the household or spouse to
designate in writing an emergency authorized representative to
purchase coupons with a particular ATP card. A separate written
designation is needed each time an emergency authorized
representative is used.
The authorized representative, whether he be a household member
or a person outside the household, may use coupons to purchase
food for consumption on behalf of the household provided he has
the household's identification card with the full knowledge and
consent of the head of the household or the spouse.
Addict/Alcoholic Representative
Residents of drug addiction or alcoholic treatment and rehabi­litation
centers must voluntarily elect to participate in the
Food Stamp Program. However, those that wish to participate
shall be required to apply for food stamps and purchase and use
coupons throu~h the nonprofit private organization or institu­tion
which runs the center as their authorized representative.
The resident household shall assist in completing the applica­tion
and shall sign the application along with the authorized
representative prior to certification. The organization or
institution which acts as the authorized representative for
resident households shall be responsible for ·notifying the
State agency of any changes in resident household income or
circumstances, as required by 2403, including notifying the
State agency when a certified addict or alcoholic leaves the
center. In addition, the organization or institution shall
be responsible for any overissuances which are caused by
misrepresentation or fraud committed in the certification of
center residents and shall assume the total liability for food
coupons held on behalf of resident households.
25
I I
2134 Restrictions on Appointment
Retailers who are authorized to accept food coupons or
employees of public welfare departments may not act in any
capacity as an authorized representative without the specific
approval and determination of the local welfare director that
no one else is available to serve.
2135 Multihousehold Representatives
(732-1)
An authorized representative m~y act on behalf of more than one
household, but such an arrangement should be approved only if
there is a bona fide rteed. In determining such need, considera­tion
will be given to the proximity of the households to one
another, the distance of the certification or issuance office,
the availability of transportation, and the health of the
household members involved.
2136 Documentation and Control
The State agency will assure that authorized representatives
are properly designated, that is, the name of the authorized
representative. and the justification for appointing a person
outside the househoid (if any) shall be maintained as part of
the household's permanent case file. In addition.each certi­fication
office shall maintain a control system by file car~ or
other listing9 of .those authorized representatives who are not
members of the. household they represent. This system will
identify those authorized representatives who represent more
than one household and may be used to assure that authorized
representatives do not represent more households than is reason­able
and prudent. Periodicarly the listing should be reviewed
to assure that all information is current and should be consulted
whenever the validity of a designation is questioned.
\
\ •
..
(732-1)
2200 ELIGIBILITY STANDARDS
2200.1
2200.2
2200.3
2-14-75
In January 1971, Congress mandated national uniform standards
of eligibility for the Food Stamp Program.
Financial Criteria
The Food Stamp Act requires that at a rnan1mum the standards of
eligibility for the program prescribe "the amounts of household
income and other financial resources, including both liquid and
non liquid assets to be used as criteria of eligibility." The
standards established by the Secretary of Agriculture for NA
households define those households whose income and resources
are substantial limiting factors in permitting them to purchase
a nutritionally adequate diet.
The income and resource eligibility standards are not applied
to PA or SSI households because their "need" has already been
determined by their eligibility for such assistance. However,
in determining basis of issuance, the same income computation
is used for PA and SSI households as is used for NA households.
Ineligibility of Certain SSI Recipients
In addition to the financial criteria, the Act also specifies
that SSI recipients living in States which the Secretary of
Health, Education and Welfare has determined are providing
State supplementary payments which have been specifically
increased to include the value of bonus food coupons shall not
be eligible to participate in the Food Stamp Program.
Ineligible SSI recipients shall be treated as nonhousehold
members in accordance with 2102.
Nonfinancial Criteria
Nonfinancial eligibility standards apply equally to PA, SSI,
and NA households and consist of:
(1) Residency in the project area;
(2) Citizenship or permanent alien status;
(3) Availability of cooking facilities;
(4) Prohibition against residency in boarding
houses and institutions;
(S) Work registration;
(6) Tax dependency.
(Change 3) 27
(732-1)
2201 RESIDENCY
2201.1
2201.2
2201.3
All households must live in the project area in which they make
application for the program. No household may participate in
more than one project area in any month, except as provided for
in 2422.2 under the transfer of certification procedures.
Residency Limitations
When determining residency, the State agency shall:
(1) Not interpret residency to mean domicile which is
sometimes defined as the legal place of residence
or principle home;
(2) Not impose a durational residency requirement;
(3) Not interpret residency to mean the intent to
permanently .reside in the State or project area,
however, persons in the project area solely for
vacation purposes shall not be considered residents;
(4) Consider as residents all other applicants who are
living in the project area for any purpose othe-r
than vacation.
Reporting
The application contains spaces for both a physical address
and a mailing address. If the two are different, the EW should
require both addresses be given. A mailing address only, such
as post office box or a rural rou.te, wi 11 not be sufficient as
it does not indicate that the household resides in the project
area. If the address is a rural route, information should be
given which can identify the home, e.g., third house on the
right, north of Jones' Market.
Verification
Verification of residency is not required unless the information
provided by the applicant is unclear, inconsistent, or incomplete.
If questionable, the client may supply the verification in the
form of documentation such as a driver's license, rent receipt,
utility or other recently received bill, voter registration
28
(2201.3)
2205
..
• 2206
(732-1)
card, or similar means. This infonnation may be furthe·r sub­stantiated
by cross reference to an independent source such as
a telephone or city di~ectory, detailed area map, contact with
landlord or neighbor, or, if necessary, a home visit.
In addition to valid addresses, the State agency should be
alert for duplicate addresses. Each office should consider
establishing an address file to check for multiple households
reporting the same address. While it is possible for more
than one household to occupy a given residence, duplicate
addresses would constitute a questionable circumstance and
require verification. Any office which issues ATP cards
directly to the household, rather than through the mails,
needs to be particularly sensitive for invalid and duplicated
addresses.
CITIZENSHIP OR PERMANENT ALIEN STATUS
To receive program benefits, an individual mtist be either:
(1) A citizen of the United States; or
(2) An alien lawfully admitted for permanent residence
or otherwise pennanently residing in the United
States under color of law, including any alien
lawfully in. the United States as a refugee pursuant
to Section 203(a)(7) of the Immigration and
Nationality Act or as a parolee pursuant to
Section 212(d)(S) of that Act.
The presence in a household of an alien who does not meet the
above criteria shall not prevent the remainder of the house­hold
from appjying for and receiving food stamp benefits. The
eligibility of such households will be detennined in accordance
with procedures in 2332.
This same eligibility criteria has been established by law for
the SSI Program and subsequently adopted by the DHEW for the
AFDC program. The experience and contacts developed by the
agencies responsible for these programs may be useful in
implementing this criteria for the Food Stamp Program.
Citizens and Eligible Aliens
Individuals in the following classifications are eligible to
receive program benefits:
29
2206.1
2206.2
2206.3
(732-1)
U.S. Citizens
For the purposes of qualifying as a United States citizen, the
United States shall be defined as the 50 States and District
of Columbia, Puerto Rico, Guam, and the. Virgin Islands. In
addition, nationals from American Samoa or Swain's Island shall
be regarded as United States citizens for food stamp purposes.
Immigrants
Immigrants are those aliens lawfully admitted for permanent
residency in the United States who e~tered with the express
intention of residing permanently in the country. Visitors,
tourists, students, workers, diplomats, etc., who are lawfully
admitted for specific periods of time and with no intention
of establishing a permanent residence in the United States
would not qualify under this provision.
Permanent Residence Under Color of Law-Continuous Residence
A permanent resident under color of law is a person who entered
the United States before July 1948, has maintained continuous
residence since then, and who may be eligible for permanent
residence at the discretion of the Attorney General under
Section 1259 of Title 8 of the United States Code. This
definition was provided by Congress when establishing this
criteria for SSI.
2206.4 Other Permanent Residence Under Color of Law
2206.5
Any alien granted indefinite voluntary departure or an indefinite
stay of deportation is considered as permanently residing in
the United States under color of law. Included among these
aliens are Cuban refugees who did. not enter at a designated port
of entry and therefore were not legally paroled into this country.
These and other aliens, although found deportable, may be granted
"voluntary departure" for an indefinite period or indefinite
stays of deportation because of humanitarian considerations or
because of technical difficulties which cannot be overcome and
which prevent the Immigration and Naturalization Service (INS)
from effecting their deportation.
Refugees -Section 203(a)(7)
This section provides for the conditional entry of aliens who
because of persecution or fear of persecution on account of
30
,..
(2206.5)
2206.6
(732-1)
race, religion, or political op1n1on, have fled from a Communist
or Communist-dominated country or from the area of the Middle
East; or who are refugees from natural catastrophies.
Parolees -Section 212(d)(S)
This section provides for the parole into the United States
for an indefinite or temporary period, at the discretion of
the Attorney General, for emergent reasons in the public
interest, of any alien applying for admission. Only parolees
admitted for an indefinite period will be considered permanent
residents.
2207 Ineligible Aliens
Aliens not in one of the above categories will not be eligible
for food stamps. Some of these aliens may be lawfully admitted
but only for a temporary or specific period of time. Such
aliens may include visitors, tourists, students, some workers,
and diplomats. These aliens are not eligible for food stamps
because of the temporary nature of their admission status.
In addition, any alien who has entered or remains in the United
States unlawfully is not eligible for food stamp benefits.
2208 Verification of Citizenship or Alien Status
Verification of citizenship or alien status is not required
except in questionable cases. Documentation of status can
be more difficult for some citizens than for the legally
entered alien. The problem of participation by ineligible
aliens will als·o not be of the same magnitude in all States
and localities. To require verification for all cases would,
therefore,be an unreasonable imposition on the majority of
eligible households and administratively infeasible for the
State agency.
In questionable cases where verification is required and to
assist the EW in determining how to classify certain aliens,
the following examples of acceptable documentary evidence are
provided. For more detailed information, the INS district
office has available copies of a pamphlet "Documentary
Requirements for Aliens in the United States" upon request.
31
2208.1
2208.2
2208.3
2208.4
2208.5
U.S. Citizens
Citizenship may be verified by a birth certificate, religious
or similar proof of birth, United States passport, a certifi­cate
of citizenship or nationalization provided by INS or an
Identification Card for Use of Resident Citizen in the United
States (INS Form I-179 or INS Form I-197).
Immigrants
Acceptable proof of immigration status is INS Form I-151,
Alien Registration Receipt Card. ·csee Page 33 for example
of form.) Earlier versions of this form, INS Forms AR-3 and
AR-3a, are proof of permanent residency if specifically
endorsed as such. Also, a Reentry Permit is acceptable proof
inasmuch as permanent residency is a requirement for its
issuance.
Permanent Residence Under Color of Law-Continuous Residency
An individual shall be presumed to be permanently residing
under color of law upon satisfactory proof of his presence
in the United States before June 30, 1948, and his continuous
residence since sue~ entry. This presumption shall be made
unless negated by available information which indicates no
intent to petwanently remain in this country, such as the
individual's being an official of a foreign government, an
international organization representative, or a member of
the family or the staff of such an official.
Permanent Residence Under Color of Law
Aliens in this category must have their status verified, as
(732-1)
it is a highly questionable circumstance. Documentation may
consist of correspondence from INS stating the alien has been
granted indefinite voluntary departure or indefinite stay of
deportation. In the absence of such documentation, the INS
district office having jurisdiction over the alien's residence
may be contacted to ascertain his status. The alien's INS
file number should be included in all such correspondence if
known. .
Refugees- Section 203(a)(7)
Verification of this alien status may be po3session of INS
Form I-94, Arrival-Departure Record, bearing the stamped
legend "REFUGEE - CONDITIONAL ENTRY" and citing the section
of the Immigration and Nationality Act under which admitted.
32
(2208.2)
•
•
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........
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1--
FORM 1-151 (ALIEN REGISTRATION
RECEIPT CARD)
lh1s It tn rlftih lhtl
Jose-Gonzales,
1 fl(. . rt.; 111 OF HUllH
I ~~~ b.cn dull rttislerlf mordurc I Jilt 11111
adtnrllcd lo lhe United Statc1 111n rmmittllll
I 1~o~o.·o•' "' v
1
• 73 NYC 11-18-7
Front -Actual Size
ALIEN REGISTRATION RECEIPT CARD
FORM 1-151 IREV . 7 - 1 -72)N
Commissioner u{ Immigration and Natturaltzation
United States Department of Just ice
::~---/-.~~~-~-~~'-~-~~~-.. J~'•-J~~~~'-~~j------------------~
Reverse
33
(732-1)
2208.6
2208.7
(732-1)
Parolees - Section 212(d)(5)
Individuals in this category should have INS Form 1-94 (Parolee
Edition), Arrival-Departure Record, (see page 35 for example of
form) which will state that the alien has been paroled pursuant
to Section 212(d)(5) of the Immigration and Nationality Act.
Only individuals whose forms have been endorsed by the
immigration officer to show that parole is for an indefinite
period of time shall be eligible. A Form 1-94 endorsed to show
that parole is for a specific period of time does not constitute
evidence of permanent residency.
Ineligible Aliens - Temporary Statu~
Aliens admitted for specific periods of time should possess
one of the following documents: 1-94, Arrival-Departure
Record (see example of form on Page 36) for other than parolees
and refugees; 1-185, Canadian Border Crossing Card; 1-186
Mexican Border Crossing Card and SW-434, Mexican Border Visitors
Permit; I-9SA, Crewman's Landing Permit; or 1-184, Crewman
Landing Permit and Identification Card.
2208.8 Absence of Documentation
2208.9
If the above documentation is not available, the applicant
may state the reason for such absence and submit other evidence
of probative value acceptable to the State agency. For instance~
since the same criteria exists for SSI and AFDC programs, receipt
of such aid would constitute proof of status. In the absence of
acceptable verification, the member or members in question
cannot be certified for program benefits. The INS district
office covering the jurisdiction in which the alien resides may
be .contacted for confirmation of al,ien status. Such referrals
shall not be a matter of general policy for all aliens, but
shall be restricted to those cases in which the EW has reason
to doubt the status reported by the applicant or in the absence
of acceptable documentation.
Reporting Illegal Aliens
If in the application process, it becomes known to the State
agency that an alien has entered or remained in the United
States illegally and INS has not declined deportation action,
such alien shall be promptly brought to the attention of the
INS district office for appropriate action.
34
•
•
I
• •
IMPORTANT NOTICE
Your parole into the United States does not consti­tute
an aomission under the terms of the Immigra­tion
and Nationality Act. You must observe the
conditions of the parole and failure to comply with
any of those conditions may result in the revocation
of your parole. If, for any reason, you do not pro­ceed
to the address shown on the face of this form,
or if after arrival, you change your address, you
must immediatt>ly report to the nearest office of the
Immigration ancl Naturalization Service. You must
also report to the nearest office of the Immigration
and !'l:aturalization Service if your status is not
otheiwise changed or if you do not leave the United
States bdore the termination datt• shown.
UPON DEPARTURE FROM THE UNITED STATES e By sea or air surrender this permit to trans-portation
line. e Over Canadian horder, surn·nder this permit to
Canadian Immigration Officer. e Over Mexican border, surrender this permit to
United States Immigration Officer.
O~~ARTURE RECORD
Port;
Date:
Carrier:
To:
(C o1111try of dis£'mbarkation)
UNITED STATES DEPARTMENT OF Jl1STICE
lmmicratiun and Naturalizatiun St'r\"ice:
Form Appro•e<l Budt=f'l Burf'au Jli.,_ -l3-R311 .7
ARRIVAL - DEPARTURE RECORD
FORM l-1)4. (Rev. 4·1-67) (Parole Edition)
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IMPORTANT NOTICE
•A NONIMMIGRANT AUEN WHO ACCEPTS
UNAUTHORIZED EMPLOYMENT IS SUBJECT
TO DEPORTATION.
• Retain this permit in your possession except
when required to submit same to the lmmigra·
tion and Naturalization Service.
• You are permitted to remain in the U. S. for
the time indicated.
• To remain past this period, without permission
from immigration authorities, is a violation of
law.
WHEN YOU LEAVE THE UNITED STATES
• By sea or air, surrender this permit to transpor·
tation line. ·-· · --- - ·- •· •·
• Over Canadian border, surrender this permit to
Canadian Immigration Officer.
• Over Mexican border, surrender this permit to
United States Immigration Officer.
RECORD OF EXTENSIONS(.; ?"
To Office_-+\_-__0 _ _
~-. -,
__________ Office ____··_ ·-.·.. . _
_________ Office_ ~ -~::--~­DEPARTURE
RECORD ,_ ; -, ;
·'
G:·-~::~
i r u·u
Port:
Date:
Carrier:
To:
(C.a~ry ol ~--)
UNITED STATES DEPARTMENT OF JUSTICE
Immigration and Naturalization Service
ARRIVAL-DEPARTURE RECORD P"ORM l-ee (REV. ··1·71)Y
P"OIUI APPROVED OMB NO. C3•ROcee
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. 2210 COOKING FACILITIES
All households, with the exception of those listed in 2211,
must have access to cooking facilities where they reside for
use in the preparation of food for home consumption.
The household need not have a formal or conventional kitchen
(732-1)
to meet the cooking facilities requirement. EWs should exercise
prudent judgment in determining whether or not a household has
the means available to prepare simple cooked meals.
2211 Households Exempt from Cooking Facilities Requirement
The following households are eligible to purchase prepared meals
with their coupons and therefore may be exempt from the cooking
facilities requirement:
2211.1 Communal Dining
A person 60 years of age or over who is not a resident of an
institution or boarding house, who is living alone or only with
spouse, and who elects to use coupons to purchase meals especially
prepared for the elderly at a communal dining facility which has
been authorized by FNS to accept food coupons.
2211.2 Meal Delivery Service
A person 60 years of age or over who is not a resident of an
institution or boarding house, who is living alone or only with
spouse, and who qualifies for as provided in 2212.3 and elects
to use coupon~ tb purchase meals from a nonprofit meal delivery
service authotized by FNS to accept food coupons.
2211.3 Resident Addjcts or Alcoholics
2212
A narcotics addict or alcoholic who is certified as a resident
of a drug addiction or alcoholic treatment and rehabilitation
center which is authorized by FNS to accept food coupons, and
who elects to use coupons at such a center.
Eligibility to Use Coupons for Prepared Meals
In addition to the households in 2211, the following persons
as individuals may use their coupons to purchase prepared
meals, provided the household of which they are .a part meets
all other eligibility criteria, including cooking facilities:
37
2212.1
2212.2
(732-1)
Communal Dining
Any member of an eligible household who is 60 years of age or
older may use all or any part of his coupons to purchase meals
prepared at a communal dining facility authorized by FNS for
such purpose. In addition, if the household member lives only
with spouse, the spouse may also purchase meals from a communal
dining facility regardless of age.
Definition of Communal Dining Facility
A communal dining facility means any'· facility such as senior
citizens' centers, apartment buildings occupied primarily by
elderly persons, any public or nonprofit private school ~ax
exemp~which prepares meals especially for elderly persons
during special hours and certain other public or nonprofit
private establishments (tax exempt) which prepare and serve
meals for the elderly. It also means a private establishment
which is under contract with a State or local agency to offer,
at concessional prices, meals prepared especially for the
elderly. Such facilities may accept coupons only after
authorization by FNS.
2212.3 Meal Delivery Service
2212.4
Any member of an eligible household who is 60 years of age or
older may use all or any part of his coupons to purchase meals
from a nonprofit meal delivery service authorized by FNS for
such purpose prov~ded the individual is housebound, feeble,
physically handicapped or otherwise disabled to the extent that
he is unable to adequately prepare all his meals. In addition,
if the household member lives only with spouse, the spouse may
also purchase meals from a nonprofit meal delivery service
regardless of age or disability.
Definition of Nonprofit Meal Delivery Service
A nonprofit meal delivery service means a political subdivision
or a private nonprofit organization which prepares and delivers
meals, which is recognized as tax exempt by the Internal Revenu.e
Service (IRS), and which is not receiving federally donated foods
from USDA for use in the preparation of meals to be exchanged for
food coupons. Such organizations may accept food coupons only
after au~horization by FNS.
38
..
..
2212.5
2212.6
Drug or Alcoholic Treatment and Rehabilitation Program
Any member of an eligible household who is a narcotics addict
or alcoholic and who regularly participates in a drug or
alcoholic treatment and rehabilitation program on a .resident
or a nonresident basis may use all or any part of his coupons
(732-1)
to purchase food prepared for or served to him during the course
of such program provided the program has been authorized by FNS
for such purpose. In the case of resident households, the use
of coupons shall be through an authorized representative
designated by the drug or alcoholic treatment and rehabilitation
program in accordance with 2133.
Definition of a Drug or Alcoholic Treatment and Rehabilitation
Program
A drug or alcoholic treatment and rehabilitation program means
a program conducted by a private nonprofit organization or
institution which is certified by the State agency or agencies
responsible for administration of the State's programs for
drug addicts and alcoholics as providing, treatment that can
lead to their rehabilitation. The Governor of each State shall
designate the certifying agency or agencies pursuant to Public
Law (P.L.) 91-616, "Comprehensive Alcohol Abuse and Alcoholism
Prevention, Treatment and Rehabilitation Act of 1970," and
P.L. 92-255, "Drug Abuse Office and Treatment Act of 1972."
Such programs must be recognized as tax exempt, must not receive
federally donated foods from USDA for use in the preparation of
meals to be exchanged for food coupons, and may accept coupons
only after authorization by FNS.
2215 RESIDENTS OF BOARDING HOUSES
Residents of boarding houses are ineligible to participate in
the program. A resident of a boarding house for food stamp
purposes is a resident of a place where three or more individ­uals
are furnished meals or meals and lodging for compensation.
Anyone residing in the boarding house, including the proprietor,
shall be ineligible for the program.
2216 RESIDENTS OF INSTITUTIONS
Residents of institutions are ineligible to participate in the
program. Except as provided in 2216.1, individuals will be
considered residents of an institution when the institution
39
(2216) (732-1)
provides them with the majority of their meals as a part of its
normal services, and the institution has not been authorized by
FNS to accept coupons.
Individuals who do not receive their meals from the institution
but have access to cooking facilities to prepare their own food
or are participating in a delivered meals program or a communal
dining program will be eligible for food stamps if they meet
all other eligibility requirements.
2216.1 Exemptions from the Institution ProQibition
Only the following households are exempt from this criteria:
(1) Any narcotics addict or alcoholic who resides at a
facility or treatment center under the supervision
of a drug or alcoholic treatment and rehabilitation
program as defined in 2212.6.
(2) Residents of federally subsidized housing for the
elderly under either Section 202 of the Housing Act
of 1959 or Section 236 of the National Housing Act.
Section 202 of the Housing Act of 1959 provides for
the establishment of housing for the elderly (age
62 or older) or han.dicapped. Section 236 of the
National Housing Act provides for housing for lower
income families including, but not limited to, the
elderly and handicapped. Only in those instances
where 202 or 236 housing is built for the elderly
shall such residents be categorically exempt from
classification as residents of an institution.
2220 WORK REGISTRATION
The Food Stamp Act requires that all able-bodied adults who are
members of eligible households, with few exceptions, register
for work and accept suitable employment. The requirement is
multipurpose.
It assures that all members of eligible households who are in
need of and available for suitable employment have access to
those services which are provided by federally funded Employment
Service (ES) offices, and which are available to participants
without charge. It prevents participation by those persons who
would refuse to pursue gainful employment in order to obtain
program benefits, and it enables potentially employable persons
to improve their financial situations, minimizing their present
or future need for assistance.
40
..
•
)
•
..
(2220) (732-1)
Compliance with the requirement is a prerequisite to certification.
The requirement is not one which can be waived, and benefits may
not be granted conditionally prior to registration by all members
of the household who are required to do so. Effective adminis­tration
of this provision necessitates the closest cooperation
between State agencies, local certifying offices, and ES offices
in the areas where registrants reside so that all facilities
and services may be made available as required to effect the
intent of the Food Stamp Act.
2221 Registration Procedure
Except as provided in 2222, all able-bodied adults who have
attained the age of 18 and have not yet reached their 65th
birthday, including a person not working because of a strike
or lockout at his usual place of employment, must register
for work.
2221.1 Completing Form FNS-284
Registration shall be accomplished through the execution of
Form FNS-284, Work Registration, or an alternate form developed
by the State agency and approved in writing by FNS. Registration
is deemed to be completed when the Form FNS-284 or approved
alternate form has been completed by or for each person in the
household not otherwise exempt, reviewed for completeness and
accepted by the EW. One copy is provided for the case file,
and the remaining copies shall be promptly forwarded to the
ES office having jurisdiction over the area in which the
registrant resides. (See Page 42 for an example of Form
FNS-284.)
2221.2 Frequency of Registration
2221.3
Each person required to register shall do so at the time of
application, and at least once every 6 months thereafter. The
6 month I'egistration requirement may not be waived under any
circumstances .
. WIN Participants
The household situation of AFDC recipients must be examined to
determine the applicability of the food stamp work registration
requirement. Registration for participation in the Work
Incentive Program (WIN) by signing the WIN Registration Record
shall be considered to be equivalent to registration for work
under the food stamp work requirement, and such registration
shall continue to be effective ·until WIN participation is
41
2221.1 (732-1)
US OC'.-AIUMC'HT 0" AQitiCULTUitl
"0 0 D NO NUT II T ON SC'It._, Cl . '' ' V 0 0,... HO <IIIO·ItS71 •
Please PRINT atllnforrnotion · 5•• Addilional/nstructions on R•~· eru DO NOT Write in "Boxed" Area
I NAME OF REGISTRANT (First, middl• and IGJI ru:Jm•) I FOOD ASSISTANCE CASE NAME
John H. Jones s Jones, John H.
2 . ADDRESS I No., Strut, City, Staltt and lip Code) E 2 FOOD STAMP OR FOOD J 3 . DATE c DISTRIBUTION CAS[ NO.
-~~ St., Smithville, AK 00001 T 4101 - 2 12-03-74
3 TELEPHONE NO. ,. COUNT't' , • . SEX 6 DATE OF BIRTH I ~ - EG
fil MAI.IE 0 ,I: MALI IMtl'-•6{~44 0
~I-194.6 Smith N ~"r D• D·~ Do ONI.C O•N.t. D ..
7 . SOCIAL SECURITY NO. , • . HIGHEST SCHOOL GRADE COMPLETED ICl'<l• one) A
5 CHANGE IN STATUS j"· INTAKE SOURCE
417-51-2106 I J ) • t t 7 t • 10 II IJI IJ 14 IS It " " " On• C:;t•o liCIWIU,.,,UU
0 . HEAD OF HDUSEHOL110. NO. OF PERSONS IN 11 NO OF WEEKS 12. VETERAN STATUS I . OCCUPATIONAL TITLE
'i UNEMPLOYED '1'1:& 0 NO HOUSEHOL4 5 fil us D NO
·-------
15 UNE,:;fp~NT INSUR · 2 OCCUPATIONAL CODE --- 13. MILITARY SERVICE OATES 14. EMPLOYMENT SEA' - s
2-67 VICE REGISTERED ANCE CLAIMANT E
rtllloN : 2-63 TO : !9 us D•o OTn [J..o c
16. LIST YOUR LAST THREE JOBS: T 3 ES LOCAL OFFICE NO. 4 . COUNTY CODE
I.M~I..OTI.JII : Smith:1d lle Ccnstru.ct:f.QD CQmRa.ny:
I
0
G) 6 . RECENTLY 01 scHA"RC"EQ •oo .. u•· Sm:f thll~ 1 l e, AK N ~ VETERAN STATUS
VERIFIED
~-Labar.ex.. IWAOU· ·I 2.15 ~'" hr B On• D NO 0 Til 0 NO
OATIS riftON · 10-l·Z~ TO· lf.!-21-74 7 FAMILY INCOME .. HANDICAPPED-
------·
I.M~I..OTI.IIt : Rnv r.nnat-t".nl't-i nn Comoanv Do• Do Ovn D•o 0 ADDJIII.IS : C:mi t-nui 1 1 <> AJ(
REMARKS
.Joe TITI..I T.ohnt"t:>t" I WAGI.S . • ? 15 ... hr
OATIS 'JIIOM · R-1 ?-71. TO· Q-1<.-71.
IMII'\.OTIJII . c:.- ... ., .... ·i 1 <> Tn,.
0AODIIIISS· c: .. i t-hui 1 1 <> AJ(
.J08 TITI..I :
T ,h, ·~· •~ !w••n· ' ,;o .00 ... Wt:>t:>lr
OATil . ,-JIIOM • 1 n_,_,~ TO· 7-1-71.
FORM FNS 284
12-HI WORK REGISTRATION Edttto" o/9-71 may b• us•d
amlil supply is •.tllaust•d.
OIIGINAL·PI CoM PoldoT
•oRM '"'-'" oREvERSE I INSTRUCTIONS
All items must be completed. Do not tear the form apart--ill three copies must be submitted to the Food Stamp Office or the Food
Distribution Program Office.
1. NAME OF REGISTRANT - Print your full name.
2. ADDRESS - Print your complete mailin& address, includins the
Zip Code.
3. ~ - Show the number of the telephone where you may
be reached.
't , ~ - Print the name of the county in which you live.
5. ill- Make an "X" in the block that applies to you.
6. pATE OF BIRTH - Print the month, day, and year you were born.
For example: Dec. 9, 1920, or 12-9-20.
7. SOCIAL SECURITY NO. - Be aure you 1how your correct number.
If you are nOt aure, copy it directly from your Social Security
card.
a, HIGHEST SCHOOL GRAPE COMPLEIEQ - Hake a circle around the
hi&heat arade you completed in act-:.ool. If you graduated from
high achool or pa11ed the te1t and received a General
Equivalency Diploma, circle the number 12. If you went to
college or graduate achool circle the number beyond 12 that
you completed.
9 . HEAD OF HOUSEHOLD - If you are the head of the houaehold where
you live, 11X11 the Yea block; if you are not, "X" the No block.
10 , NO. OF PERSONS IN HOUSEHOLD - Show the number of per1ona who
live in your houaehold.
11. NO. OF WEEKS UNfl1PLOYEQ ... Show how many weeka you have been
out of work.
42
12. ~TERAN STATUS - If you have been in the Armed Forces • "X11
the Yea block; if not, "X" the No block.
13. MILITARY SERVICE DATES - Print ttfe month and year you aerved
in the Armed Force1. For example, from Oct 42 to June 46.
If you did not eerve in the Armed Forces, print "NONE. 11
14. EMPLOYMENT SERVICE REGISTERED - If you have regietered for
work at the State Employment Office within the laat 1110nth,
"X" the Yes block. If you have not reaietered, "X" the No
block .
15 . UNEMPLOYMENT INSURANCE CLAIMANT - If you are drawing
benefits, or have filed a claim at the Employment Service
Office for unemployment benefita, "X" the Ye1 block; 1f
not, "X., the No block. ·
16 . LIST YOUR LAST THREE JOBS - Print the name and addreu of
your previoul employen, and the title or tYPe of job YOl'
held .
After the word ''Wagea" ahow the amount of aroa1 waaee (before
taxea and other deductiona) you received every payday. After
the word "Per" •how how often you got paid. If you aot paid
every week, print week; if you got paid every two week a 1
print 2 weeki; or if you -Jot paid on a monthly baaia • ahov
month.
In the "Datea: From - To - " entry ahow the JDOnth and year
you worked for each employer. For example, Fro•: July 46
To : April 48.
If you have not worked for three employera in• your life 1
complete the information for the onea you did work for and
in the other blank or blanka, print "NONE. u
(2221.3)
2222
•
2222.1
2222.2
2222.3
2222.4
2222.5
•
2222.6
•
(732-1)
terminated by the welfare income maintenance unit by dropping
the individual from welfare or by adjustment of the welfare
grant. The recipient's AFDC case file may be used to make such
a determination of applicability.
Exemptions to Work Registration
The following individuals, between the ages of 18 to 65, are not
required to register for employment .
Mothers
Mothers or other members of the household who have responsibility
for the care of dependent children under 18 years of age or of
incapacitated adults.
Students
Students who are enrolled at least halftime (as defined by the
institution or program in which they are enrolled) in any school
or training program which is recognized by any Federal, State,
or local government agency.
Incapacitated
P~rsons who are physically or mentally incapable of engaging in
gainful employment.
Employed
Persons who are working on jobs for at least 30 hours per week.
Self-Employed
Self-employed persons where the EW determines that the employment
constitutes a full-time job of at least 30 hours per week during
the period of certification or an average of 30 hours per week
on an annual basis .
Addicts or Alcoholics
Any narcotics addict or alcoholic who regularly participates as
a resident or nonresident in a drug or alcoholic treatment and
rehabilitation program.
43
(732-1)
2223 Determination of Exemption Status
2223.1
2223.2
2223.3
Determination as to which household members meet the exemption
to the registration requirement must be made by the EW at the
time of initial certification, subsequent certification, change
in employment status, or required 6-month registration period.
In determining whether or not one or more members of the house­hold
fall within the exemptions set out above, the following
guidelines shall be used:
Mothers
If a mother and another member of the household both claim to
be responsible for the care of the same dependent children or
of incapacitated adults, the actual responsibility should be
determined by discussion with the applicant .
Students
In the case of students between the ages of 18 and 65, inquiry
may be made as to the institution or place of training, whether
or not such a school or training program is recognized by a
Federal, State, or {ocal government agency, and the time of
participation in training in order to meet the halftime
requirement. This exemption is not altered due to temporary
interruptions in school attendance such as semester or summer
vacations, provided the attendance will be resumed immediately
following such breaks. However, persons enrolled in correspondence
courses where physical attendance is not regularly required shall
not be considered students for the purposes of this exemption by
virtue of such enrollment.
Incapacitated
Eligibility for and receipt of benefits from SSI is prima facie
evidence of unemployability. The same determination shall be
made in those areas which have retained OAA, APTD, or AB programs
for recipients of such programs. In the case of SSI or PA
households containing an "essential person," individual situations
must be examined to determine whether the essential person must
register. In addition, receipt of disability. payments under the
Social Security Program Disability, (Retirement, Survivors, and
Disability Insurance) shall be considered proof of disability
for purposes of this exemption.
44
.,
•
(2223.3) (732-1)
Other individuals claiming a disability exemption shall in the
absence of physical evidence, furnish the names of medically
qualified sources which can substantiate such disability or
documentary evidence which supports the claim. Adequate docu­mentation
shall appear in the case file to support the granting
of this exemption.
2223.4 Employed
2223.5
If a person claims to be exempt by reason of employment for at
least 30 hours per week, verification of the amount of income
received from such employment, as is elsewhere required for
certification, is sufficient to establish the exemption, provided
the amount of income appears to be consistent with a conclusion
of employment for 30 hours a week under the general conditions
prevailing in the community.
However, if the individual does not meet this test, but Still
claims to be employed, then, in cooperation with the EW, the
applicant shall be requested to supply documentary evidence of
the existence of an employee-employer relationship and that
the number of hours worked is equivalent to 30 hours a week.
Factors to be considered, while not all inclusive, are:
(1) Does the wage meet State, local, or Federal minimums.
(2) Have deductions of required mandatory amounts for
Federal and/or State income taxes, Social Security
tax, etc., been made by employer.
(3) Does the employer pay unemployment insurance premiums
on behalf of the employee.
Persons engaged in hobbies or volunteer work or any other
activity which cannot, because of the minimal amount of monies
received from such activity, be considered as gainful employment,
shall not be considered exempt from work registration regardless
of the amount of time spent in such activity.
Self-employment
If a person claims to be exempt by reason of self-employment,
verification of the amount of income received from self­employment
is sufficient to establish the exemption, provided
the amount of income appears to be consistent with a conclusion
of full-time (30 hours a week) employment.
45
(2223.5)
2223.6
2223.7
If the income is not sufficient, but the client still claims
to be self-employed, he must cooperate with the EW in
establishing the income received from the self-employment
enterprise is at least sufficient to be considered gainful
employment and that the volume of work claimed justifies a
determination that the self-employment enterprise is a full­time
job for the purposes of this exemption. The household
must cooperate in providing adequate documentation to sub­stantiate
the claim.
(732-1)
Persons engaged in hobbies or ~ny other activity which cannot,
because of the minimal amount of monies received from such
activity, be considered as gainful employment, shall not be
considered exempt from work registration regardless of the
time spent in such activity.
Addicts or Alcoholics
The regular participation of an addict or alcoholic in a drug
or alcoholic treatment and rehabilitation program may be verified
through the organization or institution operating such program
prior to granting the exemption.
Cooperation
In any case, where any question of the propriety of exemption
from the work requirement arises, the head of the household
and the household member must cooperate in furnishing evidence
to support the contention of exemption from the requirement
to register. Failure to cooperate in furnishing such evidence
will result in the member being required to register, or failing
such registration, the household shall be denied program benefits.
2224 Additional Registration Requirements
Each member required to register for employment will also be
required to:
(1) Report for an interview to the Federal or State ES
office where he is registered upon reasonable
request.
(2) Respond to a request from the Federal or State ES
office requiring supplemental information regarding
employment status or availability for work.
(3) Report to an employer to whom he has been referred
by such office.
46
(2224) (732-1)
(4) Accept a bona fide offer of suitable employment to
which he is referred by such office.
(5) Continue suitable employment to which he was referred
by such office. Such household member shall continue
suitable employment until the employment is no longer
considered suitable (by the criteria in 2225); the
household member becomes exempt; or he is terminated
from employment due to circumstances beyond his
control.
2225 Suitability of Work
No employment offered will be considered suitable for any
registrant if the following conditions exist:
2225.1 Earnings
The wages offered are less than the highest of:
(1) The applicable Federal minimum wage;
(2) The applicable State minimum wage;
(3) The applicable wage established by valid regulation
of the Federal Government authorized by existing law
to establish such regulations;
(4) $1.30 per hour; or
The employment offered is on a piece-rate basis, and the average
hourly yield the employee can reasonably be expected to earn is
less than the ap~licable hourly wages specified above.
2225.2 Union Membership
The registrant, as a condition of employment, is required to
join, resign from, or refrain from joining any legitimate labor
• organization.
2225.3 Strikes
The work offered is at a site subject to a strike or a lockout
at the time of the offer, except that, the term "strike" shall
not include a strike which has, pursuant to a court decision
currently in force,been determined to be unlawful.
47
2225.4 Registrant Proof of Unsuitability
Any employment offered a particular registrant shall be
considered suitable unless he can demonstrate that:
(1) The degree of risk to health and safety is
unreasonable.
(2) He is physically or mentally tmfit to perfom the
employment, as established by documentary medical
evidence or reliable information obtained from
other sources.
(3) The employment offered is not in his major field
of experience unless, after a period of 30 days
from registration, job opportunities in his major
field have not been offered.
(732-1)
(4) The distance of the employment from his residence is
unreasonable. Deteminations in this connection will
be based upon estimates of the time required for going
to and from work by means of transportation that is
available or expected _to be used, and whether or not
it would be reasonable for the registrant to expend
the time and cost involved for the expected remuneration
from the work. In no event will commuting time per
day represent more than 25 percent of the registrant's
total work time.
2226 Failure to Comply
In the event a registrant fails to comply with any of the
requirements in 2224, the ES, office will inform the EW of the
facts and circumstances of each such failure by means of an
infomation statement. If the State agency finds that the
failure to comply was without good cause, the household will
be detemined to be ineligible for participation in the program
until the member complies with those requirements as set out in
2227, has become exempt from the work requirement as specified
in 2222, or for 1 year, whichever is earlier.
2226.1 Good Cause
In determining whether good cause existed .for failure to comply,
the EW will consider all facts and circumstances, including those
submitted by the household and the ES office, existing at the
time of the alleged failure. Good cause includes circumstances
48
•
.. ..
(2226.1)
2227
(732-1)
beyond the member's control, such as, but not limited to, illness,
illness of another household member sufficiently serious to
require the presence of the member, unavailability of trans­portation,
and an unanticipated emergency.
Redetermination of Eligibility
When a household has been determined ineligible for participation
due to a refusal of a member to comply with the above require­ments,
eligibility may be reestablished (provided the household
is otherwise eligible) upon the expiration of the 1 year suspen­sion,
upon the member's becoming exempt from the work requirement,
or upon the member's compliance as follows:
(1) Refusal to register--registration by the household
member.
(2) Refusal to report for interview to the Federal or
State ES office where he is registered--reporting
for the required interview.
(3) Refusal to respond to a request from the Federal or
State ES office requiring supplemental information
regarding employment status or availability for work-­response
to the employment office correspondence.
(4) Refusal to report to an employer to whom he has been
referred by such office--reporting to such employer
or another employer to whom he is referred.
(5) Refusal to accept a bona fide offer of the suitable
emplqyment to which he was referred by such office-­acceptance
by the household member of such employment
or of any other employment of at least 30 hours per
week.
(6) Refusal to continue suitable employment to which he
was referred by such office--returning to such
employment or acceptance of any other employment of
at least 30 hours per week.
2228 Registrant Reporting Requirements
Although the ES office should notify the EW of placement actions,
this does not relieve a household of its responsibility to report
the accept~ce of employment or receipt of income from employment
from any source by any member of the household in accordance with
the reporting requirements for changes in household circumstances
specified in 2403.
49
(732-1)
2229 State Agency Reporting
Project area offices of State agencies shall report activities
in connection with administration of the work registration
requirement using Form FNS-285, Report of Reduction/Termination
of Food Stamp Benefits, which is furnished to State agencies
by FNS. (See Page 51 for an example of Form FNS-285.)
Entries to be made on the form are self-explanatory. Most of
the required information is a compilation of the effects of
certification actions taken as a result of receipt of informa­tion
statements, which are forwarded in duplicate by ES office,
when there has been .a referral, placement action, or refusal to
comply by the registrant. Other information, such as number of
registrations, reductions in benefits, or terminations for
refusal to register, may be acquired at the time of certifi­cation
action. State agencies should insure that this report
includes those recipients who are registered for WIN.
The dollar figures in those columns reflecting reductions in
amounts of or termination of benefits are intended to be the
total reductions in the monthly free coupon entitlement which
result from certification action, whether or not coupons were
already purchased during the month in which the action was
taken. Instructions for forwarding Form FNS-285 are shown on
the form. All reports should be mailed by the lOth workday
of the second month following the month for which information
is being reported. In exceptional circumstances, an extension
of this due d.ate may be made subject to approval by FNS.
2230 UNLAWFUL STRJ~ES
In any case df a strike which has been determined unlawful by
a court decis\ion currently in force ; ·all households, which
contain one or more members involved in the strike ancl. affected
by the court order, shall be denie~ or terminated participation
in the program. However, if the household can demonstrate that
the member or members involved in the illegal strike are not
required to register for work under the exemptions listed in
2222, the household may then be certified . for participation,
if otherwise eligible.
so
•
..
2229 (732-1)
,..--------------------------,---- -----···------·----------,
I'ORM FNS•211 U.S. DEPARTMENT OF AGRICULTURE
{ .. 7t) P'OOO AND NUTRITION SERVICE
REPORT OF REDUCTION/TERMINATION OF FOOD STAMP BENEFITS
FORM APPROVED
OMB NO. 40•RJ1l7
INSTRUCTIONS
LOCAL WELFARE OFFICE: Send the original and two copies of this report to your State Agency; send the fourth copy to your local
State or F~deral Employment Service Office; and retain the last copy for your records .
STATE AGENCY : Forward the oricinal and second copy to the Food and Nutrition Service Regionol OHi<-e; retain the third copy .
REGIONAL OFFICE: Forward the original to the Food Stamp Division and retain the second copy for your records .
t. STATE 3. NAME AND COMPLETE MAILING ADDRESS OF LOCAL OR STATE WELFARE
AGENCY
4. NO. OF HOUSEHOLD MEM•
BERS REGISTERED THIS MONTH
Alabama
2. REPORTING MONTH
Montgomery County Departlllent of Pensions
and Security
December, 1971
211 North Decatur Street
Montgomery, AL 36104
I . BENEFIT REDU ED OR TERMINATED THIS
MONTH AS A RESULT OF ACCEPTANCE OF
EMPLOYMENT
BE.NEP'I T I RIE.OUCEO BENEFITS TEAMINATEO
35 15
10 6
HO.OF
PERSOHS
HO. OF
HOUSEHOLDS
AMOUNT OF BENEFIT
•' , .
675 . 325. ~ REDUCTION FOR ~
ONE MONTH
982
5. NO. OF INFORMATION STATE•
MENTS RECEIVED THIS MONTH
15
7. BENEFITS TERMINATED THIS MONTH
BECAUSE OF F AlLURE TO COMPLY
WITH REGUIREMENTS
18
5
s 200.
I . REMARKS t. SIGNATURE OF INDIVIDUAL PREPARING REPORT
NONE JOHN DOE
51
(732-1)
THIS PAGE IS INTENDED TO BE VACANT.
2-14-75 (Change 3) Sla •
..
(732-1)
2240 TAX DEPENDENCY
A student who is (1) 18 years of age or older and (2) enrolled
in an institution of higher education is required to meet the
tax dependency criteria for eligibility, in addition to the
other financial and nonfinancial eligibility criteria established
for the Food Stamp Program. A student who possesses both of the
above characteristics and is a member of a household other than
that of his parent or guardian is ineligible for food stamps if
he is properly claimed as a tax dependent for Federal income tax
purposes by a parent or guardian who is not a member of an
eligible household. An institution of higher education is defined
as an institution providing post-high school education. Some
examples include colleges, universities, and vocational and
technical schools at the post-high school level. In order for
the tax dependency criteria to be applicable, a student must be
enrolled at least halftime (as defined by the institution in
which he is enrolled).
2241 Applicants Not Affected
If a student is under 18 years of age, or is not enrolled in an
institution of higher education, or is not a properly claimed
tax dependent of an ineligible household, then he should be
certified according to the procedures for student households in
2328. For example, the following individuals would not have to
meet the tax dependency eligibility criteria: any 17-year old
student, any high school student, married students who are
entirely self-supporting.
2242 Tax Dependency Defined
2242.1
2-14-75
In order to determine whether the applicant meets the tax
dependency criteria for eligibility, the EW should pay special
attention to the following items:
Year of Claim
The eligibility of the student is based upon an anticipated
claim of tax dependency, that is, will the student be claimed
as a tax dependent for the calendar year in which he is making
application. For example, the eligibility of a student applying
in September 1975 would depend on the student's tax status for
(Change 3) Slb
(2242.1)
2242.2
2242.3
2-14-75
(732-1)
the calendar year of January !-December 31, 1975. The parent
or guardian must intend to claim the student as a tax depen­dent
on their tax return to be filed in the early months of
1976. A claim of tax dependency made for the past year can
be used as a guide to the student's current tax status, but
is not a sufficient criterion to determine whether the parent
or guardian intends to claim the student as a tax dependent
for the current year.
Properly Claimed Tax Dependent
In order to be properly claimed\ as a tax dependent, a student
must receive over half of his support from the parent or
guardian during the calendar year in which he makes application.
A student applying for food stamps in September 1975 is properly
claimed if his parent or guardian will provide for over half of
of his support during the entire year of 1975. An increase or
decrease in the amount of support the parent or guardian intends
to provide during the calendar year in which a student applies
for food stamps may change the tax dependency status of the
student. However, normally the EW will not become involved in
determinations of the propriety of the tax dependency claim
unless the tax dependency status as reported on the application
is questionable or the applicant student challenges the informa­tion
provided by the taxpayer household.
Eligibility of the Parent or Guardian Household
A student who is a properly claimed tax dependent may still be
eligible for food stamps if the parent or guardian making the
tax claim is a member of an eligible household. The taxpayer
household will be considered an eligible household if it is:
(1) Currently certified to participate in the Food Stamp
Program or Food Distribution Program; AFDC or one of
the other federally-aided public assistance programs
where still applicable; SSI; or a general assistance
program; or
(2) Able to demonstrate that it meets the income and
resource standards applicable t~ nonassistance food
stamp households.
The financial eligibility test required for the household of
the parent or guardian is to indicate whether or not the tax­payer
household would generally qualify as a low-income house­hold
for food stamp purposes and is not meant to meet the strict
tests required for households directly applying for program
(Change 3) 51c •
•
(2242.3)
2243
2243.1
(732-1)
benefits. Nonfinancial food stamp eligibility criteria, such
as work registration, will not be applied to the eligibility
test for taxpayer households.
Determination and Verification of Tax Dependency
Households containing one or more students to whom the tax
dependency criteria are applicable (see 2240), must report
the tax status of such students as part of the application
process. Before certifying such households, the EW 'must
obtain verification of:
(1) The eligibility of the taxpayer household for all
students who are properly claimed tax dependents;
and
(2) The tax dependency status of students where the
statement on the application is questionable.
Tax Dependency Statement for Applicants
Questions to be included on the application are:
(1) Was the student a properly claimed tax dependent
for the past year?
(2) Does he expect to be a properly claimed tax dependent
for the current calendar year?
(3) For students answering yes to the tax dependency
question or whenever requested by the EW, the name
and address of the parent or guardian.
(4) Is the taxpayer household currently certified to
participate in either the Food Stamp Program; Food
Distribution Program; AFDC or one of the other
federally-aided public assistance programs where
still applicable; SSI; or a general assistance
program?
(5) If the taxpayer household is not currently certified
in any of the above programs, would the household be
eligible for the Food Stamp Program based on income
and resources?
2-14-75 (Change 3) Sld
(2243.1)
2243.2
2243.3
2-14-75
(732-1)
States which do not wish to revise their applications
immediately to incorporate these questions may devise a
separate form for tax dependency. However, such questions
shall be included as part of the application form once the
current stock is depleted.
The student's eligibility may be denied for failure to
cooperate if he does not provide correct and complete answers
to the tax dependency questions, including the name and address
of his parent or guardian.
Cases Not Requiring Verification
If the EW is able to determine from the student's answers to
the questions on tax dependency and his financial situation
as revealed on the application that the student is not properly
claimed as a tax dependent, and that the student is financially
independent from the parent or guardian, then the student
should be certified according to the procedures in 2328. No
additional verification of tax dependency is required.
Cases Requiring Verification
In most other cases, the EW must obtain verification from the
parent or guardian household before certifying the student.
The EW shall verify the following information for the following
cases:
(1) For students indic~ting on the application that they
are tax dependents of currently certified households,
the EW must verify that the taxpayer household is
currently certified for the program as indicated on
the application form. Verification shall be accomplished
I through direct contact with the taxpayer household as
specified in 2243.4 and the EW may also contact the
appropriate office in the taxpayer's home area for
confirmation of their certification if it will expedite
verification.
(2) For students indicating they are tax dependents of
households not currently certified but financially
eligible for food stamps, the EW must verify through
direct contact with the taxpayer household that the
household's income and resources are within the
standards for nonassistance food stamp households.
(Change 3) Sle
(2243.3)
2243.4
2-14-75
In both of the above cases, the EW may also
wish to verify the parent or guardian's intent
to claim the student as a tax dependent and the
amount .of income the taxpayer is providing.
(3) For students indicating they do not know their
tax dependency status or when the EW has cause
to question the student's statement that he is
not a tax dependent, the EW must verify the tax
dependency of the student through direct contact
with the taxpayer household. At the same time,
the EW shall verify the financial eligibility of
those taxpayer households which indicate they
intend to properly claim the student as a tax
dependent.
Students will have satisfied the tax dependency
criteria if the verification shows their parent
or guardian does not intend to claim them as a
(732-1)
tax dependent or, if they will be claimed, that
the household of the taxpayer is either certified
for one of the above-mentioned programs or is
financially eligible as a nonassistance food stamp
household.
Method of Verification of Tax Dependency and Parental
Eligibility
When verification is required for a tax dependent, the
EW shall use a Tax Dependency and Financial Eligibility
Statement (see format and sample cover letter on pages Sli
through Slo). The form includes verification of the parent
or guardian's intent to properly claim the student as a tax
dependent and their status as a certified household, the
contributions made by the parent or guardian to the student's
income and resources, and a statement which allows a household
not currently certified for food stamps or the other above-mentioned
public assistance programs the opportunity to demonstrate that it
meets the income and resource standards for a nonassistance
household. The financial eligibility statement for the parent
or guardian is not intended to provide as complete a picture of
the income and resources of the household as would a regular
food stamp application combined with a face-to-face interview.
It serves as a guide to whether the parent or guardian house-hold
can reasonably be expected to exceed food stamp income
and resource standards. The EW should use prudent judgment
(Change 3) Slf
(2243.4) (732-1)
to determine whether the parent or guardian's household would
qualify as a low-income household for food stamp purposes.
The Tax Dependency and Financial Eligibility Statement
shall be sent by the EW directly to the parent or guardian.
The EW shall inform the applicant when such statements will
be used to verify tax dependency information. Prompt action
by both the EW in sending the form and the parent or guardian
in completing and returning the form will be needed in order
to permit the student's application to be processed within
the required time period. Th~ failure of the parent or
guardian to return the forms heeded to verify whether the
student is eligible under the tax dependency criteria is
sufficient grounds for the EW to determine that the student
is ineligible. Other members of the household with which the
student is applying may still be eligible for food stamps.
The Tax Dependency and Financial Eligibility Statement used
for initial certification shall remain valid for the balance
of the calendar year for which tax dependency status was
reported, unless subsequent information received by the EW
indicates a change has occurred which would affect the
student's eligibility. The student is responsible for
reporting changes in his parent or guardian's circumstances,
as well as his own, which would have an impact on his eligibi­lity
under the tax dependency criteria.
2244 Ineligible Students as Nonhousehold Members
2-14-75
A student who is a properly claimed tax dependent of another
househo1d which is not eligible for food stamps shall be
treated as a nonhousehold member in accordance with 2102.
The income and resources of the ineligible student shall not
be considered available to the other household members for
determining their income, resources, and deductions. The
ineligible student shall not be counted in determining the
household coupon allotment. The other members of a house­hold
containing an ineligible student may be certified for
food stamps. The income and resources of a household con­taining
an ineligible student shall be treated according to
the procedures in 2328.4.
(Change 3) Slg
\ \
•
..
•
2244.1
2-14-75
(732-1)
Right of an Ineligible Student to Appeal
An ineligible student shall have an opportunity to demonstrate
that he is not a properly claimed tax dependent in accordance
with the Fair Hearing procedure in 2500. The student may
prove that he is not properly claimed as a tax dependent by
demonstrating that the parent or guardian is not providing
and does not intend to provide over half of his support during
the calendar year in which the food stamp application is made.
Support is defined as income received to pay basic living
expenses. These would include food, shelter, clothing, medical
and dental care, and the like. Support payments can also cover
child care, board, lodging, entertainment, recreation, and
transportation. If the student can demonstrate through the
fair hearing process that he is not a properly claimed tax
dependent, then he shall be eligible for certification according
to the procedures in 2328.
The income tax return of the parent cannot be demanded in
either the certification or hearing process as proof of tax
dependency status as in most cases the relevant form will
not be filed until some future date. Likewise, the past
year's tax return cannot be demanded as it can be used as
nothing more than a guide to the current tax status in
question.
(Change 3) Slh
(2243.4) (732-1)
Cover Letter Address of Parent
County ----------------------------
Address
Telephone No.
Dear ------------------------------
--~--~----~~~--~----~----~~has applied for food stamps, a program
designed to aid low-income households to purchase food items for a
nutritionally adequate diet, in the certification pffice nearest his/her
college or university.
The law requires that we verify whether the appljcant is a properly claimed
tax dependent of another household (i.e., the huusehold mu st be providing
and intend to continue providing over half the applicant :s support during
the current calendar year, January !-December 31). In addition, the house­hold
claiming the applicant as a tax dependent must be able to meet the
income and resource criteria for eligibility in the Food Stamp Program.
In view of the above, please complete the attached form, signed by the
taxpayer or spouse, and return it by mail in the enclosed self-addressed
envelope.
Part I of the Tax Dependency and Financial Eligibility Statement verifies
whether you have claimed the applicant as a tax dependent in the past
and if you intend to claim him/her again for the current tax year. Part II
includes a statement on the amount and sources of the support you are
providing to the applicant during this calendar year. PART III provides
information concerning your potential eligibility for food stamps based upon
your income and resour·ces .
Please complete the attached form and return it to the food stamp office
promptly so that we may proceed with the processing of the application
without delay.
Thank you for your cooperation.
Sincerely,
THIS FORM IS TO BE USED IN DETERMINING ELIGIBILITY FOR THE APPLICANT ONLY.
THIS DOES NOT ENTITLE YOUR HOUSEHOLD TO FOOD STAMP BENEFITS. SHOULD YOU
DESIRE TO APPLY, YOU MUST CONTACT YOUR LOCAL FOOD STAMP OFFICE.
2-14-75 (Change 3) Sli,
A
..
(2243.4) (732-1)
TAX DEPENDENCY AND FINANCIAL ELIGIBILITY STATEMENT
Name (Taxpayer or Spouse) Street
City State Zip
PART I TAX DEPENDENCY
1. Have you properly claimed the applicant as a tax dependent for Federal
income tax purposes for the past tax year? (In order to have properly
claimed the applicant as a tax dependent, you must have provided over
half his/her support during the past calendar year, Jan. 1-Dec. 31).
---YES ---NO ---SPECIFY TAX YEAR
2. Do you expect to properly claim the applicant as a tax dependent for the
current tax year? (In order to properly claim the applicant as a tax
dependent, you must be providing and expect to continue providing over
half his/her support during the current calendar year, Jan. 1-Dec. 31).
3.
---YES ---NO ---SPECIFY TAX YEAR
If you have answered "YES" to Question 2, go on to Question 3.
If you have answered "NO" to Question 2, do not answer Question 3.
Complete only PART II. You should not complete PART III.
Is the head of your household (primary taxpayer) currently certified to
participate in:
CASE
NO.
a. The Food Stamp Program? YES NO
b. The Food Distribution Program? YES NO
c. Aid to Families with Dependent
Children (AFDC)? YES NO
d. Supplemental Security Income
(SSI)? YES NO
e. General Assistance? YES NO
2-14-75 (Change 3) Slj
(2243.4) (732-1)
If you have answered "YES" to any Section of Question 3, complete only
PART II. You should not complete PART III.
If you have answered "NO" to all Sections of Question 3, complete both
PART II and PART III.
PART II SUPPORT PROVIDED TO THE APPLICANT
List all items of support you provide to the applicant during the current
calendar year (Jan. 1-Dec. 31).
1. CASH PAYMENT
How much money do you give the applicant? $
--~----------------------
(Circle one: weekly, monthly, other-specify ________ )
2. DIRECT OR VENDOR PAYMENTS
Do you pay any of the applicant's expenses directly?
----YES ----NO
Specify the expense (i.e., tuition, rent, car payment, car insurance)
and the period your payment is intended to cover (i.e., monthly payment
entire school term).
Expense Paid for Applicant Amount Period Payment Covers
$ __ _
$ __ _
$ __ _
3. Do you know of any other items of support available to the applicant?
(For each of the items you have checked, specify source and amount.)
______ Scholarships, Fellowships
Student Loans, Other
Financial Aid
_____ Social Security Benefits
--- G.I. Loans
--- V.A. Benefits
2-14-75 (Change 3)
Source Amount
$ __
$ __ _
$ __ _
$ __ _
Slk
..
(2243.4)
--- Earnings
--- Resources of Applicant's Own (Savings Account,
Stocks, Bonds, etc.)
--- Access to Parents' Resources (i.e., Credit
Cards)
--- Other
PART III FINANCIAL ELIGIBILITY STATEMENT
1. NUMBER OF PERSONS IN YOUR HOUSEHOLD
Include all persons currently living in your household.
roomers (shelter for compensation), boarders (meals, or
meals for compensation), or persons who provide nursing
housekeeping service, or child care.
2. RESOURCES
(732-1)
$ __ _
$ __ _
$ __ _
$ __ _
Do not include
shelter and
care,
Resources include cash on hand, money in checking or savings accounts
(including credit unions), stocks, bonds, and other items which can
be changed easily into cash.
Also included are real property, buildings, and personal property
(such as snowmobiles, boats, motors, etc.).
Do not include your home, personal items (clothing, books, etc.),
household goods, or one licensed vehicle and one additional licensed
vehicle per employed person.
Type of Resource Present Market Value Amount Owed
$ $
$ $
$ $
$ $
MONEY-MAKING RESOURCES
List all resources used to produce income, such as rented property, real
estate, or personal property, etc.
2-14-75 (Change 3) Sl.t
(2243.4)
Trpe of Resource Present Market Value
$ ______________ _
$ ______________ __
$ ______________ _
3. INCOME
(a) MONTHLY EARNED INCOME FROM EMPLOYMENT
Amount Owed
$ ___ _
$ ___ _
$ ___ _
Monthly
Income
$ __ _
$ __ _
$ __ _
(732-1)
List each source of earned income in your household. Do not include
self-employment income or income from farm operation. Be sure to
include tips or commissions, where applicable, with earned income.
Indicate the frequency each source of income .is received. Use one
of the frequencies listed (weekly, biweekly, twice monthly, monthly,
yearly) or any other period of time which applies.
Firm or
Employer Gross
$ __ _
$ __ _
$ __ _
(b) SELF-EMPLOYMENT .INCOME AND FARM INCOME
Net
$ __
$__.__
$ __ _
Frequency
Include net income (gross income minus all major business-related
expenses~ Do not include salary paid to owner-operator as an
expense.
Amount $ ------ (Circle one: monthly, yearly)
(c) OTHER HOUSEHOLD INCOME
Check all items which apply and indicate amount and frequency (weekly,
biweekly, twice monthly, monthly, yearly) income is received.
Income Source Amount Frequency
_______ Boarder payment (meals or
room and meals for compensation $ __ _
2-14-75 (Change 3) Slm
.. ,
(2243. 4) (732-1)
--~
Roomer (shelter for compensation) $ __ _
--- Social Security $ __ _
--- Railroad Retirement $_ __
--- Other pensions or annuities $ __ _
--- Foster child care $-~-
--~
Alimony and/or child support $ _ _
Other $_ __
::..-~-
4. EXPENSES
(a) SHELTER
(1) Rent or home mortgage $ (Circle one: weekly, monthly,
yearly) (Do not include security deposits and downpayments on
home or mobile units.)
(2) Utilities $ (Circle one: weekly, monthly, yearly)
(Include heat, cooking fuel, basic cost for~ telephone, water,
sewage disposal fees.)
(3) Taxes and fire insurance on home paid on annual or biannual
basis $ ----
(4) Other special assessments required by law $~~---
(b) MEDICAL $ (List average amount paid monthly for medical
expenses if over $10. Include physician or dental service,
hospital or nursing care, health insurance, prescription drugs,
prosthetic devices. Do not include life insurance payments.)
(c) OTHER (i.e., payments for child care, court-ordered alimony and/or
child support, tuition or mandatory educational fees paid for
students living at home--DO NOT INCLUD~ TUITION PAID FOR
APPLICANT) $ ----
I certify that this statement has been examined by me (or read to me) and
that the information given is true and correct to the best of my knowledge
and belief. I understand the penalties for making a false statement.
Penalties for Fraud: The State and Federal law provides penalties including
a fine, imprisonment or both for persons found guilty of obtainin