FACTS YOU SHOULD KNOW ABOUT APPLYING FOR TEMPORARY CASH ASSISTANCE, FOOD SUPPLEMENT PROGRAM (FORMERLY FOOD

STAMPS) AND MEDICAL ASSISTANCE Social Security Numbers

You must give us a social security number for each family member who wants benefits. If a person who wants benefits does not have a social security number, that person must apply for
a number. We can help applicants get their numbers. If a family member has applied for a social security number, we will not delay your application while you wait for the number. We use social security numbers to prove income. We do not give numbers to other agencies like Immigration and Naturalization. Citizenship and Immigration Status You must tell us about the citizenship and immigration status for each family member who wants benefits. Information If a family member will not tell us about citizenship, immigration status or social security number, that person will not get benefits. They must still give us proof of income, expenses and other things. The other family members who give us their information will get benefits if they meet the rules. Emergency Medical Assistance Immigrants who are not eligible for other kinds of medical assistance and apply only for emergency medical assistance do not have to tell us their social security number, immigration or citizenship status. Time Limits Temporary Cash Assistance has time limits. The Food Supplement Program (formerly Food Stamps) and Medical Assistance do not have a time limit. When Temporary Cash Assistance ends because of time limits, earnings or other reasons, you may still get Food Supplement benefits and Medical Assistance. Interviews You, a responsible family member or someone you choose to represent you must come into our office for an interview. If you have a serious problem, or if you are working, and you cannot come to our office for an interview, we can interview you by telephone. You must give or send us the proof we ask for at your interview. If you need help:
Applying for benefits, or Have questions about information you must give us Want to know what will happen to your benefits Do not speak English and need free translation services

Call your case manager or call 1-800-332-6347

Si necesita ayuda para llenar el formulario favor de llamar al 1-800-332-6347.
DHR/FIA CARES 9701 Revised 8/10

MARYLAND DEPARTMENT OF HUMAN RESOURCES FAMILY INVESTMENT ADMINISTRATION APPLICATION FOR ASSISTANCE
Your Name (Last, First, Middle) Where do you live? (Number and Street) Mailing Address (If different from home) Home Telephone Apt. # City State

Date Received (Agency use only)

Work Telephone Zip Code

Cell Telephone

What language do you speak? English Spanish Other ___________________________________ If you do not speak English and need free translation services, call your case manager or call 1-800-332-6347. What type of assistance do you need now? (Check all that you need) Cash Assistance Child Care Services Food Supplement Program (Food Stamps) Medical Assistance - Do you have any unpaid medical bills from the past 3 months? Yes No Do you have any of these problems? Utility shut off Eviction or foreclosure No place to stay No heat No food Cannot afford child care other:_____________ Are you or anyone in your household pregnant? Yes No If yes, who?________________________ Due Date___________ Are you or anyone in your household disabled? Yes No If yes, who? ________________________ Disability?___________ What type of assistance do you or any household members receive now or in the past? (Check Now if you are currently receiving this assistance) Under what name? Now 1. 1. Now Now 2. 3. 2. 3.

If you are applying for the Food Supplement Program (FSP) you can complete all of the form and give it to us now. You may also fill in your name, address, sign this page and give the page to us. You can then finish the rest of the application at home and bring or mail it back to the office. You will not get any benefits until we receive the entire form and interview you. Your Food Supplement benefit is based on the date you sign this application and give it to the department of social services. You may get Food Supplement benefits right away if you meet one of the following conditions: Your households monthly rent or mortgage and utilities are more than your households income and resources. Your households gross monthly income is less than $150, and your resources, such as bank accounts, are $100 or less. Your household is a migrant or seasonal farm worker household. If you qualify to get Food Supplement benefits right away, you will receive them within 7 days from the date you sign the form; however, you will not get expedited Food Supplement benefits, if eligible, until we get a completed application form and interview you. YOUR SIGNATURE DATE

Go to page 2
LDSS Office Case Managers Name Application/Redetermination Date MA #s FOR AGENCY USE ONLY Programs applied for or receiving AU ID #s

EXPEDITED SERVICE FOR FSP BENEFITS (CUSTOMERS SHOULD NOT WRITE IN THIS AREA FOR AGENCY USE ONLY) Applicants who meet the standards below are eligible to receive Food Supplement benefits within 7 days. The customer must be interviewed, either in person or by telephone, in order to determine eligibility for expedited service. The application must be complete, signed, and identity verified before expedited benefits can be issued. 1. Is the total household income this month, before deductions, less than $150 AND household cash/savings $100 or less? Yes No Estimated self-reported income for this month = $__________ Households monthly rent or mortgage amount = $___________ Household cash and savings for all members = $__________ Appropriate utility standard (SUA, LUA or actual) = $___________ A. Total income and liquid resources = $__________ B. Total shelter costs = $___________ 2. Is the total amount for B. (Total shelter costs) greater than the total for A. (Total income and liquid resources)? Yes No 3. Are the household members destitute migrant or seasonal farm workers whose cash and savings are $100 or less? Yes No If the answer to any of the above questions is yes, this household is potentially eligible for Expedited FSP. 4. If there is another reason why this household should NOT be expedited, list it here: _______________________________________ I certify that I screened this applicant for expedited Food Supplement benefits and determined that the household was was not eligible for expedited issuance at this time.
Signature of Case Manager Date

DHR/FIA CARES 9701 Revised 8/10

A. HOUSEHOLD MEMBERS Fill in the blanks for everyone that lives with you. List your own name first. Social Security number and Citizenship are optional for members not applying for benefits. Use the codes below to complete the Citizenship, Race and Ethnicity columns. Enter each code that applies, using at least one code for each person.
Ethnicity Codes: 1= Hispanic or Latino, 2=Not Hispanic/Latino Race Codes: you can choose one or more race code - 1=American Indian/Alaskan Native, 2=Asian, 3=Black/African American, 4=Native Hawaiian/Pacific Islander, 5=White Citizenship/Immigration Code: 1=United States Citizen, 2=Permanent Resident, 3=Asylee, 4=Alien granted conditional entry, 5=Parolee 1 year or more, 6=Alien whose deportation is withheld, 7=Refugee, 8=Battered alien spouse, child, or parent of child(ren) Note: You do not have to give information about your race or ethnicity. If you do, it will help show how we obey the Federal Civil Rights Law. We will not use this information to decide if you are eligible. If you do not give us your race, it will not affect your application. The case manager will enter a race code for statistical purposes only. Title VI of the Civil Rights Act of 1964 allows us to ask for this information.

Only Answer the questions below for each person who wants benefits

U.S. CITIZEN (Yes or No)

ETHNICITY

NAME (Last, First, Middle)

How are they related to you?

Self

Are any of the household members a roomer or boarder? Yes No

If yes, who?_____________________________________

B. CITIZENSHIP/ IMMIGRATION STATUS If anyone for whom you are applying is not a United States citizen, fill in this section. ONLY ANSWER THESE QUESTIONS FOR EACH PERSON WHO WANTS BENEFITS. If you are not eligible for other kinds of Medical Assistance and you are applying only for Emergency Medicaid, you do not have to fill-in this section.
Household member INS Status US Entry date: INS Status US Entry date: INS Status US Entry date: INS Status US Entry date: INS Status US Entry date: Sponsored Immigrant? Yes No INS Number: Sponsored Immigrant? Yes No INS Number: Sponsored Immigrant? Yes No INS Number: Sponsored Immigrant? Yes No INS Number: Sponsored Immigrant? Yes No INS Number: Country of origin

Household member

RACE

DATE OF BIRTH SEX

LAST GRADE COMPLETED

IN SCHOOL (Yes or No)

APPLYING FOR (Yes or No)

SOCIAL SECURITY NUMBER

Country of origin

Household member

Country of origin

Household member

Country of origin

Household member

Country of origin

DHR/FIA CARES 9701 Revised 8/10

C. AUTHORIZED REPRESENTATIVE: You may choose a person to apply for you. You may also choose a person to get your benefits through your Independence Card. This person can use your benefits the same way you do. If you choose someone to help you, give us the following information about the person and check what you want this person to do.
Name (Last, First , Middle) Number, Street Relationship City Telephone Number State Zip Code

Check what you want the representative to do: Complete interview for you Use your Independence Card (cash) Sign your application Use your Food Supplement benefits

Receive your notices Receive your Medical Assistance card

D. STUDENTS Are any household members between ages 18-50 attending a school for higher education (college, vocational or technical school)? Yes No Name of student _______________________________________________ School__________________________________ Is the student employed? Yes No Is the student getting educational grants, scholarships, or loans? Yes No Amount $__________________ Amount of tuition $_________________ Books $_______________ Fees $________________ Transportation $______________ E. RESOURCES/ASSETS Does anyone in your household have any resources or assets such as a checking or savings account, stocks, bonds, cash on hand, property other than where you live, prepaid burial plan, trust fund, IRA or KEOGH account? Yes No If yes, list below:
NAME OF OWNER (Specify if self-employed) TYPE OF RESOURCE/ASSET BALANCE/VALUE LOCATION (Name of Bank, at home, etc.)

F. TRANSFER OF ASSETS Has anyone in your household sold, traded or given away any property, stocks, bonds, cash or other assets in the past 36 months? (60 months if a trust is involved)
Former Owner Fair Market Value $ Amount Received $ Transfer Date Who Received the Asset? Type of asset

Reason for Transfer

G. EARNED INCOME Dose anyone in your household receive any income from employment? Yes No If yes, list all gross income before deductions (such as full or part-time employment, self-employment, baby-sitting, odd jobs, day work, roomer/boarder payments, etc.)
NAME NAME OF EMPLOYER (INCLUDE ADDRESS AND PHONE NUMBER) RATE OF PAY NUMBER OF HOURS WORKED AMOUNT PER PAY PERIOD HOW OFTEN RECEIVED

DHR/FIA CARES 9701 Revised 8/10

H. DEPENDENT CARE If anyone in your household pays someone to care for a child or disabled adult, fill in this section:
Name of Care Provider Number City Household Member Receiving Care Who Pays? Household Member Receiving Care Who Pays? Street State Zip code Under 2 years old? Yes No Cost $ Under 2 years old? Yes No Cost $ Telephone Name of Care Provider Number City Household Member Receiving Care Who Pays? Household Member Receiving Care Who Pays? Street State Zip code Under 2 years old? Yes No Cost $ Under 2 years old? Yes No Cost $ Telephone

I. CHILD SUPPORT/ALIMONY EXPENSE Does any household member pay court ordered child support to a NON-HOUSEHOLD member? Yes No If yes, who? (Includes current payments, arrearages, health insurance)
DEPENDENTS NAME, ADDRESS AND PHONE NUMBER AMOUNT PAID PERSON OR AGENCY PAID HOW OFTEN PAID

J. OTHER INCOME AND BENEFITS If anyone in your household receives, applied for or was denied any benefit listed below, place a check in the box next to the benefit
Alimony Child Support Social Security SSI Railroad Retirement Veterans Pension/Benefit Unemployment Benefits Education Grants or Loans Workers Compensation Pension or Retirement Union Benefits Disability, Sick or Maternity Benefits Military Allotment Money from Rental Income Black Lung Benefits Money from Friends or Relatives Lump Sum Cash Amounts Civil Service Annuity Temporary Cash Assistance TDAP Social Security Disability Interest Dividends from Stocks, Bonds, Savings or Other Investments Other ______________________________________ Do you agree to apply for all benefits you may be entitled to receive? Yes No

If you checked yes to receiving, applying for or being denied any benefits, fill in below:
HOUSEHOLD MEMBER TYPE OF BENEFIT
Applied CLAIM NUMBER Received Amount

yes yes yes yes yes

no no no no no

yes yes yes yes yes

no no no no no

DHR/FIA CARES 9701 Revised 8/10

K. SHELTER COSTS Complete if you are applying for Food Supplement Program Benefits Is anyone in your household paying for any of the following? Check all those paid and answer the questions.
Expenses Rent Mortgage Electric Gas Oil Coop/Condo / Assoc. fees
Telephone

Amount

How Often?

Who Pays?

Expenses Water Sewer Garbage Wood/Coal Property Tax Homeowners insurance

Other

Amount

How Often?

Who Pays?

Do you live in: Public Housing Section 8 Housing FMHA 515 Housing Private Housing Is heat included in your rent? Yes No Do you pay an electric bill for lights or cooking? Yes No If heat is not included in the rent, what is your source of heat? __________________ Do you pay for air conditioning? Yes No Does someone help you with your utility costs? Yes No If yes, who?_________________________ Are you sharing any of the shelter costs listed above? Yes No If yes, with whom? ___________________ Your share? ________ Have you received Energy Assistance at your current address within the past 12 months? Yes No L. MEDICAL EXPENSES Complete Appropriate Section if Applying for Medical Assistance or Food Supplement Benefits Medical Assistance Do you or any household members pay medical expenses? Yes No If yes, check the appropriate box Food Supplement Benefits Do you or any household members pay medical expenses for any person age 60 or over, or any person receiving disability benefits? Yes No If yes, check the appropriate box and list the monthly amount you pay. DISCUSS THESE EXPENSES WITH YOUR CASE MANAGER.
Health/Medicare Insurance Hospital Attendant Care $_______________ $_______________ $_______________ Medical/Dental Insurance Transportation Costs Nursing Pharmacy Expense $______________ $______________ $______________ $______________ Others ____________ ____________ ____________ ____________

Dentures/Glasses/Hearing Aids $_______________

M. HOUSEHOLDS DECLARATION INQUIRY Complete if you are applying for Temporary Cash Assistance or Food Supplement Benefits 1. Has anyone in your household ever been convicted of a felony committed on or after August 22, 1996 that involved drugs? YES NO If yes, who? ___________________________________________________________________ 2. Is anyone in your household currently violating parole or probation or fleeing from the police or the courts? YES NO If yes, who? ___________________________________________________________________ 3. Has anyone in your household been convicted since August 22, 1996 in a Federal or State Court for not telling the truth about where they lived or their identity in order to receive Food Supplement benefits or cash assistance from more than one place in the same month? YES NO If yes, who? ___________________________________________________________________ 4. Has a court convicted any member of your household for trafficking Food Supplement benefits of $500 or more? YES NO If yes, who?____________________________________________________________________ 5. Is anyone in your household receiving benefits under another identity or as a member of another household or in another State? YES NO If yes, who?___________________________________________________________________

DHR/FIA CARES 9701 Revised 8/10

N. MEDICAL INSURANCE Complete if you are applying for Medical Assistance or Temporary Cash Assistance 1. Has anyone applying dropped health insurance coverage in the past six months? YES NO 2. Does anyone applying have any health insurance? YES NO If you answered yes to question 2, fill in the section below.
HEALTH INSURANCE POLICY NUMBER 1
POLICY HOLDER NAME HOUSEHOLD MEMBER(S) COVERED BY POLICY POLICY NUMBER RELATIONSHIP OF MEMBER TO POLICY HOLDER GROUP NUMBER HOUSEHOLD MEMBER(S) COVERED BY POLICY RELATIONSHIP OF MEMBER TO POLICY HOLDER

Number

Street

POLICY HOLDER ADDRESS City State INSURANCE COMPANY/UNION

Zip Code

Telephone

Insurance Company Name Number Street City State Zip Code Telephone

HEALTH INSURANCE POLICY NUMBER 2

POLICY HOLDER NAME HOUSEHOLD MEMBER(S) COVERED BY POLICY POLICY NUMBER RELATIONSHIP OF MEMBER TO POLICY HOLDER GROUP NUMBER HOUSEHOLD MEMBER(S) COVERED BY POLICY RELATIONSHIP OF MEMBER TO POLICY HOLDER

Number

Street

POLICY HOLDER ADDRESS City State INSURANCE COMPANY/UNION

Zip Code

Telephone

Insurance Company Name Number Street City State Zip Code Telephone

0. LIFE INSURANCE, FUNERAL PLANS or BURIAL FUNDS Complete if you are applying for Medical Assistance or Temporary Cash Assistance
NAME OF PERSON INSURED NAME OF PERSON WHO PAYS FACE VALUE OR VALUE OF PLAN CASH VALUE POLICY NUMBER OR ACCOUNT NUMBER COMPANY, FUNERAL HOME OR BANK NAME

PLEASE USE THIS SPACE IF YOU NEED TO GIVE US MORE INFORMATION ABOUT ANY APPLICATION QUESTION.

If you need more space, ask for the 9701- Application for Assistance Addendum.

DHR/FIA CARES 9701 Revised 8/10

P. CHILD SUPPORT INFORMATION Complete this section if you want TEMPORARY CASH ASSISTANCE OR MEDICAL ASSISTANCE for a child who has an absent or deceased parent. Fill in a separate section for each absent or deceased parent. #1 ABSENT PARENT (AP) INFORMATION Name of Absent Parent (First, Middle, Last) Relationship of absent parent to you. Check one: Absent Deceased CHILDS NAME MARITAL STATUS OF CHILDS PARENTS AT BIRTH Married Divorced Unknown Separated Never Married Married Divorced Unknown Separated Never Married Married Divorced Unknown Separated Never Married Married Divorced Unknown Separated Never Married Social Security Number Other Name Date of Birth Age Race Sex Male Female
APs Last Known Address APs Parent's Address Number Number Street Street City City State State Zip Code Zip Code Telephone Telephone

Drivers License State Current or Prior Military

Dates: From: Incarcerated To:

Birth Place (City, State) Paying Military Allotment? Yes No If yes, To whom?
Institution Name

Military Branch

Currently Previously Never ABSENT PARENT INCOME INFORMATION

Last Known Employer Second Employer Name, Address & Telephone Name, Address & Telephone

Other Income/Benefits: Social Security SSI Workers Compensation Pension/Retirement Union Benefits ABSENT PARENT COURT ORDER INFORMATION Paying Support? To Whom? YES NO Court Ordered? If yes, where was the court order issued? YES NO #2 ABSENT PARENT (AP) INFORMATION Name of Absent Parent (First, Middle, Last) CHILDS NAME Married Married Married Married Social Security Number
APs Last Known Address APs Parent's Address Number Number Street Street

Veterans Pension Unemployment Other, list__________________________________ Last Date Paid Payment Amount Can you give us a copy? YES NO

Relationship of absent parent to you.

Other Name

Check one: Absent Deceased MARITAL STATUS OF CHILDS PARENTS AT BIRTH Divorced Unknown Separated Never Married Divorced Unknown Separated Never Married Divorced Unknown Separated Never Married Divorced Unknown Separated Never Married Date of Birth Age Race Sex Male Female
City City State State Zip Code Zip Code Telephone Telephone

Drivers License State Current or Prior Military

Dates: From: Incarcerated To:

Birth Place (City, State) Paying Military Allotment? Yes No If yes, To whom?
Institution Name

Military Branch

Currently Previously Never ABSENT PARENT INCOME INFORMATION

Last Known Employer Second Employer Name & Address: Name & Address: Number Number Street Street City City State State Zip Code Zip Code Telephone Telephone

Other Income/Benefits: Social Security SSI Workers Compensation Pension/Retirement Union Benefit ABSENT PARENT COURT ORDER INFORMATION Paying Support? To Whom? YES NO Court Ordered? If yes, where was the court order issued? YES NO
DHR/FIA CARES 9701 Revised 8/10

Veterans Pension Unemployment Other, list___________________________________ Last Date Paid Payment Amount Can you give us a copy? YES NO

YOUR RIGHTS AND RESPONSIBILITIES

YOU HAVE THE FOLLOWING RIGHTS

RIGHT TO WRITTEN NOTICE We must always give you a written notice explaining your benefits when we approve your case. We must always give you written notice when we change your benefits, deny or close your case. You have 90 days from the notice date to ask for a hearing. If you ask for a hearing within 10 days, you may be able to keep getting benefits while you wait for the hearing. RIGHT TO APPEAL Ask for a hearing if you disagree with the Departments decision. Your case manager can help you write your appeal. At the hearing, you can speak for yourself or bring a lawyer, friend or relative to speak for you. EQUAL RIGHTS Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy state we cannot discriminate against you because of race, color, national origin, sex, age, or disability. Under the Food and Nutrition Act and USDA policy, we also cannot discriminate against you because of religion, political beliefs or retaliation. If you think we have discriminated against you contact USDA or HHS. To contact USDA write USDA, Director, Office of Civil Rights, 1400 Independence Avenue SW, Washington, DC 20250-9410. You may also call toll free, 1-866-632-9992 (voice). TDD users can contact USDA through local relay or the Federal Relay at 1-800-877-8339 (TDD) or 1-866-377-8642 (relay voice users). To contact HHS, write Office for Civil Rights, Health and Human Services, 150 S. Independence Mall West Suite 372, Philadelphia, PA 19106-3499. You may also call HHS toll free at 1-800-368-1019 (voice) or 1-800-537-7697 (TDD). You may also send an email to [email protected]. USDA and HHS are equal opportunity providers and employers. For the Food Supplement Program, if you need this information in a different format (Braille, large print, audiotape, etc.), contact the USDAs TARGET Center at 202-720-2600 (Voice or TDD). If you need information about this program, activity or facility in a language other than English, contact the USDA agency responsible for the program or activity, or any USDA office. RIGHT TO PRIVACY You are giving personal information in the application. We use the information to see if you are eligible for benefits. If you do not give the information, we may deny your application. You have a right to review, change, or correct any information. We will not show your information or give it to others unless you give us permission or federal and state law allows us to do so. RIGHT TO CLAIM GOOD CAUSE If you want Temporary Cash Assistance (TCA), you must help the Department get child support. You may not have to help if it puts your or your family in danger. RIGHT TO REFUSE HELP You do not have to accept help from a religious organization if it is against your religious beliefs. RIGHT TO TIMELY APPLICATION PROCESSING If you are eligible for expedited Food Supplement Program benefits we must give you your benefits within 7 days. For the regular Food Supplement Program and other programs, except for certain Medical Assistance programs, we must process your application within 30 days. There are times when there is a delay in processing. If there is a delay, we will send you a letter to tell you why there is delay in processing your application.

DHR/FIA CARES 9701 Revised 8/10

YOUR RIGHTS AND RESPONSIBILITIES Authorization to Receive Family Planning Information If you want information, you can ask your case manager for a Family Planning Guide. You may also contact: 1-800-546-8900 if you need help in finding a provider for birth control or arranging prenatal care, or The Center for Maternal and Child Health at 410-767-6713 www.fha.state.md.us/mch YOU HAVE THE FOLLOWING RESPONSIBILITIES PROVIDE INFORMATION You must give true and complete information. You may need to give us proof of this information. We will keep this information private. Any delay in providing proof may result in your case being delayed or denied. Collecting application information, including the social security number of each household member, is authorized under the Food and Nutrition Act of 2008, U.S.C.2011-2036, Social Security Act 1137(f) and 42 U.S.C. 1320b-7(d). We use the information to find out if your household is eligible. We check this information by matching computer programs. We also use the information to see if you meet program rules. We may contact your employer, bank or other party. We may also contact local, state or federal agencies to make sure the information is correct. We can give your information to other federal or State agencies for official use and to law enforcement officers who need it to find persons fleeing to avoid the law. If you get too much in benefits: You may have to repay the money for the benefits, and We may give the application information, including social security numbers, to federal or state agencies, as well as private claims collections agencies, for action. Giving information is voluntary. If you do not give us information such as social security numbers for everyone who wants help, we may deny benefits for each person who does not give a social security number. If you do not have a social security number, we will help you get one. REPORT CHANGES - You must report all changes within ten days unless you are part of the Food Supplement Program simplified reporting group and are not receiving Cash Assistance or Medical Assistance. If you want to know if you are part of this group, ask your case manager. You may tell us about any changes in person, by telephone, or by mail to the Department. Warning We may deny, lower or stop your benefits if you give us wrong information or do not report changes. A judge may fine and/or imprison you if you deliberately give wrong information or do not report changes. AUTHORIZED REPRESENTATIVES In most instances, if your authorized representative gives us wrong information, you will have to pay back any amount you are overpaid. If your authorized representative knowingly gives us the wrong information or does not use your benefits properly, we may disqualify the person from being an authorized representative. If a drug and alcohol treatment center or a group living arrangement acts as your authorized representative for your food benefits and they willfully give us wrong information about your situation, we may prosecute the person under applicable State or federal law.

DHR/FIA CARES 9701 Revised 8/10

YOUR RIGHTS AND RESPONSIBILITIES FOOD SUPPLEMENT PROGRAM PENALTIES

Do not: Give false information or withhold information to get or continue to get Food Supplement Program (FSP) benefits Trade or sell FSP benefits, or electronic benefit cards. Use FSP benefits to buy items not allowed, such as alcohol and tobacco. Use someone elses FSP benefits. Use someone elses Electronic Benefits Card without authorization. Your Food Supplement Program benefits will not increase if your cash assistance case is reduced or closed because you did not follow the rules. If a household member deliberately breaks the rules, we may bar the person from the Food Supplement Program.

We may bar this person for one year after the first violation. We may bar this person for two years: * After the second violation, or * After the first time a court finds this person guilty of buying illegal drugs with Food Supplement Program benefits. We may bar this person permanently: * After the third violation, or * After the second time a court finds a person guilty of buying illegal drugs with FSP benefits, or * After the first time a court finds this person guilty of buying guns, bullets, or explosives, with FSP benefits. * After a court finds this person guilty of trafficking FSP benefits of $500 or more. We may bar this person for ten years if found guilty of making a false statement about the persons identity in order to receive multiple benefits at the same time.

A judge can also fine this person up to $250,000, imprison the person for up to 20 years, or both. A judge can also bar this person for an additional 18 months. The person may also have to face further prosecution under other federal laws. TCA PENALTY If an assistance unit member is convicted of an Intentional Program Violation (IPV), everyone in your family will lose their benefits. The first time, you will lose benefits for 6 months or until you repay all of the money. The second time, you will lose benefits for 12 months or until you repay all of the money. The third time, you cannot get TCA benefits again.
MEDICAID WARNING AND PENALTY - Only use Medical Assistance cards if you are eligible.

Every person convicted of Medicaid Fraud with a value of $500 or more in money, services, or goods is guilty of a felony, and shall: 1. Pay back money, services or goods; or the value of those services or goods unlawfully received; 2. Be subject to a fine of no more than $10,000, imprisoned for no longer than five years, or both. Every person convicted of Medicaid Fraud with a value of less than $500 in money, services or goods is guilty of a misdemeanor, and shall: 1. Pay back money, services or goods; or the value of those services or goods unlawfully received; 2. Be fined no more than $1,000 and imprisoned for no longer than three years or both.

DHR/FIA CARES 9701 Revised 8/10

10

YOUR RIGHTS AND RESPONSIBILITIES

READ BEFORE SIGNING: I understand that it is important to give true information and if I do not, I am breaking the law. I understand that I can be fined, imprisoned or have my benefits reduced for making false statements or for pretending to be another person. I know I can be punished for not reporting changes that may affect my eligibility or benefit amount. I understand that if I get more Food Supplement benefits than I should, all adult members of my household are liable for repaying the debt. I know the Department can use the application against me in a court of law for fraud prosecution. I know that failing to report or verify shelter, medical, or dependent care expenses or child support payments is the same as saying I do not want a deduction for the expenses I did not verify or report. I understand that the Department may check the information on this form to see if it is correct and may select my case for a spot check, such as for a Quality Control Review. I agree to allow someone from the Department to visit me at home. I will help them get all needed proofs from any source. I understand by signing this application: I accept cash assistance and/or medical assistance. I agree that Medicare Part B will make payments directly to doctors and medical suppliers. I give the Department the right to seek payment from private or public health insurance and any liable third party. I understand that I must cooperate with the department in securing such payments. The Department may seek payment without legal action, as long as it does not keep more than the amount Medical Assistance paid. I give the Department the right to inspect, review and copy all medical records for services received through the Medical Assistance Program. I understand that when a person is deceased who was at least 55 years old when receiving Medical Assistance the state may take money from the estate to repay payments made on behalf of that person. The program may take the money only if there is no surviving spouse, unmarried child younger than 21, or blind or disabled child (married or unmarried) of any age. SIGNATURE SECTION I understand that, as required by Maryland law, certain law enforcement agencies that investigate fraud can obtain information about my application, income, benefits and other documentation as part of their investigation. While access to my application and benefit information is normally limited (under Md. Code Ann. Human Resources Article 1-201), these limits do not apply to these investigative agencies. Such agencies include the Department of Human Resources Office of the Inspector General. I understand that I do not need to provide consent to these agencies in order for them to investigate any allegations of fraud against me. Any information found as a result of the investigation may be used against me if an allegation of fraud is prosecuted. I have read or someone has read and explained the entire application to me. I swear or affirm under penalty of perjury, that all the information I gave is true, correct, and complete to the best of my ability, belief and knowledge. I received a copy of my rights and responsibilities. I authorize any person, partnership, corporation, association, or governmental agency that knows the facts about my eligibility to give that information to the Department. I also authorize the Department to contact any person, partnership, corporation, association, or governmental agency that has given proof of my eligibility for benefits. I certify, under penalty of perjury, that by signing my name below, all persons for whom I am applying are U.S. citizens, lawfully admitted immigrants or individuals in satisfactory immigration status.
Signature of Applicant I Recipient Signature of Witness (If you Signed an X) Signature of Spouse (If Applicable) Signature of Authorized Representative (If Applicable) Signature of Case Manager Date Date Date Date Date

I withdraw my application for: Cash Assistance

Signature of Applicant, Recipient, Authorized Representative

Food Supplement Program Medical Assistance

Date

DHR/FIA CARES 9701 Revised 8/10

11

YOUR RIGHTS AND RESPONSIBILITIES ASSIGNMENT OF SUPPORT RIGHTS FOR TEMPORARY CASH ASSISTANCE
I assign to the State of Maryland all rights, titles, and interest in support that I may have for myself or for any person receiving TCA. This includes any overdue support that has not been collected. I agree to have the child support agency collect any support owed to me and to keep up to the amount of TCA paid to me. I agree to send to the State of Maryland any support l receive. If l do not turn over this support, I will have to repay this amount to the State of Maryland. I may also be prosecuted for fraud.

When I am eligible for Medical Assistance: I assign all rights, title, and interest in medical support and health insurance payments I may have for myself or any person receiving Medical Assistance. This includes overdue medical support or health insurance payments that have not been collected. I agree to have the child support agency collect medical support payments owed to me and to keep up to the amount of Medical Assistance payments that were made for me. I agree to give the State of Maryland any medical support or health insurance payments I receive.

I will cooperate to the best of my ability and knowledge with the child support agency while I am receiving TCA and Medical Assistance If I do not cooperate with the child support agency, I may lose all my benefits and my case may be closed I HAVE READ THESE STATEMENTS OR SOMEONE READ THEM TO ME. I UNDERSTAND WHAT THEY MEAN. BY SIGNING MY NAME BELOW, I AGREE TO FOLLOW WHAT THEY SAY. Signature Date

DHR/FIA CARES 9701 Revised 8/10

12