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UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES (DHS) DIVISION OF FAMILY ASSISTANCE – Certification Unit SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) (aka FOOD STAMP) & CASH APPLICATION COVER PAGE FOR CLIENT PACKET DO NOT RETURN THE FOLLOWING DOCUMENTS ATTACHED TO THIS PACKET. THESE ARE FOR YOUR RECORDS!!! 1. Something You Should Know 2. Simplified Reporting Requirements 3. Your Rights/Responsibilities 4. Privacy Act Statement 5. The Smart Family Brochure Rev. 10/2022 SOMETHING YOU SHOULD KNOW s part of the SNAP/CASH process you need to verify information about you and your household. The more verification you submit with your application, the sooner we can determine if you are eligible. Items listed below are the most common examples of verification but there are other acceptable documents to complete the SNAP/CASH application process. Your eligibility worker will advise you of any additional verification or information that is needed. IDENTITY – The identity of the applicant and the authorized representative, if any, must be verified. These are some common examples but not limited to: driver’s license; work or a school identification card; voter’s registration card; birth certificate; permanent resident card; passport; or collateral contact can be used to verify identity. SOCIAL SECURITY NUMBER – You must provide proof of social security number for yourself and everyone in your household. RESIDENCY – Your place of residency will normally be verified. These are common examples but not limited to: identification card with physical address; lease; rent or mortgage statements/receipts; utility bills; or collateral contact may be used to verify residency. INCOME – All income whether earned or unearned. RESOURCES (applicable for CASH and for any member of your SNAP household, who has been disqualified, because of an intentional program violation or noncompliance with the SNAP work requirement) – you must provide verifications of all resources such as: • Checking and savings accounts • Stocks & Bonds • Savings certificates • Certificates of Deposit (CDs) • Vehicles, Boats, Motorcycles, etc. • Land • Additional homes when not income producing A Earned Income – common examples but not limited to: • All wages or salaries • Contract income • Self-employment income Unearned Income – common examples but not limited to: • Social Security benefits • Alimony • Child support • Unemployment benefits • Veterans’ benefits • Retirement/Pensions • Financial contributions from relatives/friends Acceptable verification documents but not limited to benefit or award letter, check stub, check or record of payment Acceptable verification documents but not limited to benefit, check stub, contractual agreements, payment record, Income Tax 1040 form OPTIONAL SNAP VERIFICATION Things you may show us that may make you eligible for more SNAP benefits. SHELTER AND UTILITY EXPENSES – These are common examples of acceptable verification but not limited to. Housing costs: • Rent receipt • Lease or letter from your landlord or roommate • Mortgage statement • Property tax • Condominium fees • Home insurance bill • Other documents showing how much you pay Utility costs: • Bill for water • Electricity • Gas or phone • Lease showing you pay for utilities • letter from your landlord or roommate MEDICAL EXPENSES – This is applicable to members of your household 60 years or older, or members who have a certified disability. Below are some examples of medical expenses but not limited to: • Medical costs not covered by insurance such as co-payments • Medical supplies/equipment • Prescription medication • Dental care • Prescription eyeglasses • Over-the-counter medical items prescribed by licensed practitioner • Cost for attendant, homemakers, home health aides • Transportation costs to and from health appointments DEPENDENT CARE COST – Actual cost of care for children or other dependents when necessary for household members to accept or continue employment. Statement or letter from provider. CHILD SUPPORT PAYMENTS – Documents showing a legal obligation to pay child support like a court order to someone outside of your household and verification of payment. Contact information: ST. CROIX ST. THOMAS ST. JOHN 4102 Mars Hill Frederiksted, VI 00840-3376 Ph: (340) 772-7100 Fax (340) 772-9591 Email: certoffice.stx@dhs.vi.gov 1303 Hospital Ground, Ste. 1 St. Thomas, VI 00802-6722 Ph: (340) 774-0930 or (340) 774-2399 Fax (340) 777-5449 Email: certoffice.stt@dhs.vi.gov Multi-Purpose Building 307 Enighed, Contant Cruz Bay, VI 00830 Ph: (340) 776-6335 or (340) 776-6334 Fax (340) 777-5449 Email: certoffice.stt@dhs.vi.gov In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: mail: (1) U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410;(2) fax: (202) 690-7442; (3) email: program.intake@usda.gov. This institution is an equal opportunity provider. Rev. 10/2022 Acceptable verification documents but not limited to bills from providers of health insurance, services, etc., health insurance policies, pharmacy printouts, statement/receipt from provider, transportation bills, medical supply bills DEPARTMENT OF HUMAN SERVICES Division Family Assistance Program Supplemental Nutrition Assistance Program (SNAP) SIMPLIFIED REPORTING REQUIREMENTS All SNAP HOUSEHOLDS ARE ON SIMPLIFIED REPORTING You must report when your SNAP household’s total monthly gross income is greater than the amount listed on table below, However, if at time of certification your household’s gross income was greater than the amount listed in the table below you are not required to report. (Review the notice of decision your household received to verify the gross monthly income used to certify your household). OCTOBER 1, 2022 to SEPTEMBER 30, 2023 Number of persons you get SNAP for 130% Poverty Gross Income Limit 1 $1,473 2 $1,984 3 $2,495 4 $2,871 5 $3,007 6 $4,029 7 $4,541 8 $5,052 9 $5,564 10 $6,076 Each additional person add: $512 Here is how you calculate your household’s income and what your household needs to do: ▪ At the end of each month, add up all your pay stubs plus any other income you may have received. Do this for each household member over the age of 18. Then total the income for all household members and compare it to the table above for your household size. Use the household size that you had when you applied for benefits. ▪ If your household’s income has increased for your household size from what it was at the time of certification, you must report the increase. You must report it to the SNAP office within ten (10) days after the end of the month. ▪ You will need to provide pay stubs and/or proof of the income change(s). ▪ The ONLY other change your household is required to report is, if any member of the SNAP household received a single winning of $4,250.00 or greater from lottery or gambling winnings. Reporting other changes is optional, however households are encouraged to report any changes that the household believe would increase their household’s SNAP benefits. ▪ Your household will be notified via a notice of decision if the reported change(s) increased or decreased the household benefits. HOUSEHOLDS RECEIVING CASH ASSISTANCE ARE REQUIRED TO REPORT ALL CHANGES BY THE 10TH DAY OF THE FOLLOWING MONTH THAT THE CHANGE OCCURRED. Rev. 10/2022 UNITED STATES VIRGIN ISLANDS DEPARTMENT OF HUMAN SERVICES Page 5 | Rev. 10/2022 DIVISION OF FAMILY ASSISTANCE – CERTIFICATION UNIT SNAP /CASH APPLICATION YOUR RIGHTS 1. YOUR RIGHT TO APPLY. You have the right to request an application in person, by telephone, by fax or by mail. You have the right to file an application in person, by telephone, mail or by fax. The amount of benefits for the first month is based on the date the application was received by the certification office. You have the right to have your office interview waived and be interviewed by phone. You have the right to apply for food and cash benefits at the same time. The time limits and requirements for cash assistance have no bearing on the Supplemental Nutrition Assistance Program (SNAP). 2. YOUR RIGHT TO PRIVACY. You have the right to be treated in a way which does not invade one’s right to privacy. 3. YOUR RIGHT TO PROGRAM INFORMATION. You have the right to examine the SNAP/CASH rules and regulations. 4. YOUR RIGHT TO EXPEDITED SERVICE. You have the right to receive SNAP within a few days if you have little or no money or income. 5. YOUR RIGHT TO PROPER NOTICE. You have the right to be told in writing the specific reason for denial of SNAP/CASH and the policy on which the decision is based. You have the right in most instances, to 10 days advance notice of the program’s intention. You have the right to have the SNAP/CASH Office make a decision and provide an opportunity to participate if found eligible within 30 days after the filing of an application, provided you have supplied the necessary and adequate information (orally or in writing). 6. YOUR RIGHT NOT TO BE DISCRIMINATED AGAINST. You have the right to fair and equal treatment and freedom from discrimination. You have the right to considerate and respectful treatment from SNAP Staff. 7. IF YOU FEEL WE TREATED YOU DIFFERENTLY: This institution is prohibited from discrimination based on race, color, national origin, disability, age, sex and in some cases religion and political beliefs. USDA Non-discrimination Statement This institution is prohibited from discriminating based on race, color, national origin, disability, age, sex and in some cases religion or political beliefs. The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) Mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410 (2) Fax: (202) 690-7442; or (3) Email: program.intake@usda.gov For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201, or call (202) 619-0403 (voice) or (800) 537-7697 (TTY). This institution is an equal opportunity provider. ACCESS TO FREE LEGAL SERVICES. You may contact the Office of Legal Services for free legal service at: St. Thomas/ St. John/ Water Island District No. 1832 Kongens Grade Charlotte Amalie, VI 00802 Ph: (340) 774-6720 Fax: (340) 777-8686 No. 3017 Estate Orange Grove Christiansted, VI 00820-4375 Ph: (340) 773-2626 Fax: (340) 778-8593 St. Croix District (CLIENT’s COPY) Pp. 5-7 YOUR RESPONSIBILITIES NOTE: If you sign this application as an Authorized Representative of a person who is requesting or receiving assistance, you are agreeing to assume all the following responsibilities on behalf of that person. 1. When you apply for SNAP/CASH benefits, you sign an application that states: “I understand the questions on this application and the penalty for hiding or giving false information or breaking any of the rules listed in the penalty warning. The information given on the application is true, complete, and correct to the best of my knowledge. 2. I understand that I may have to provide documents to prove what I have said. I agree to do this. If documents are not available, I agree to give the name of a person or organization the Division of Family Assistance Office may contact to obtain the necessary proof.” 3. This means that you are aware that the State’s attorney can prosecute you if you or your authorized representative has given false information to get SNAP/CASH benefits. It is therefore IMPORTANT for you to answer each question TRUTHFULLY and CORRECTLY. 4. If your household is assigned to Simplified Reporting, you must let the SNAP Certification Office know when your SNAP household’s monthly income exceeds the monthly income allowed for your household size. You must report this change by the 10th day of the following month the household income exceed. 5. You must report all changes associated to your cash case by the 10th day of the following month when the change occurred 6. You must report if your household received lottery or gambling winnings of $4,250.00 or more, won in a single game before taxes or other withholding, this change must be reported by the 10th day of the following month the winnings occurred. 7. I understand that if my application is for SNAP, failure to report or verify any of my expenses will be seen as a statement by my household that I do not want to receive a deduction for unreported expenses. 8. You are authorized to receive “The Smart Family Brochure.” This brochure provides information on families making good decisions. 9. The State or Federal Quality Control Agency may randomly choose your case for review. They will review statements you have made on your application. They will check to see if we determined your eligibility correct. The state agency may seek information from other sources. The State or Federal Quality Control agency will tell you about any contact they intend to make. IF YOU DO NOT COOPERATE, YOUR BENEFITS MAY STOP. 10. CONTACT YOUR WORKER IF YOU HAVE ANY QUESTIONS OR ARE UNSURE ABOUT ANY REPORTING RULES. PENALTY WARNING If any information you give is found to be incorrect, you may be denied SNAP/Cash benefits. If you give us false information on purpose legal action may be taken against you. You may also have to pay back the amount of benefits that you should not have received. If you get SNAP/CASH, you must follow the rules listed below. Any member of your household who is found guilty by a court or an administrative disqualification hearing of breaking any of the following rules or who signs a voluntary disqualification consent agreement or waiver of an administration disqualification hearing will be barred from getting SNAP benefits for: one year for the first violation, two years for the second violation, and permanently for the third violation. • DO NOT give false incorrect or incomplete information or hide information to get or continue to get SNAP or CASH Assistance • DO NOT trade, sell, or alter your EBT card. • DO NOT use SNAP benefits to buy ineligible items, such as alcohol drinks and tobacco. • DO NOT use someone else’s EBT card for your household. • DO NOT use your EBT card to purchase food on credit. • DO NOT attempt to buy or sell your SNAP benefit. Any household member found guilty by a court of using SNAP benefits to buy controlled substances will be disqualified for: 24 months for the first violation; and permanently for the second violation. Any member who is found guilty by a court of using SNAP benefits to buy firearms, ammunition, or explosives will be permanently disqualified from SNAP on the first instance. Any household member convicted by a court of having trafficked SNAP benefits for an aggregate amount of $500 or more shall be permanently disqualified from SNAP upon the first occasion of such violation. Any household member found to have made a fraudulent statement or representation with respect to the identity or place of residence of the individual in order to receive multiple SNAP benefits simultaneously shall be ineligible to participate in SNAP for a period of 10 years. Any household member fleeing to avoid prosecution, custody, or confinement after conviction for a felony, or attempted felony, or violating a condition of probation or parole will be ineligible until the situation is rectified. Any person found guilty of violating these rules or committing fraud may be fined up to $250,000, jailed up to 20 years and/or required to repay SNAP benefits. You can also be barred from the TANF Program for the same period for fraud and the same maximum penalties apply (CLIENT’s COPY) Pp. 5-7 PRIVACY ACT STATEMENT Page 7 | Rev. 10/2022 “The collection of this information, including the Social Security Number (SSN) of each household member, is authorized under the Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036. The information will be used to determine whether your household is eligible or continues to be eligible to participate in SNAP. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. This information may be disclosed to other Federal and State agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. If a SNAP claim arises against your household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action. Providing the requested information, including the SSN of each household member, is voluntary. However, failure to provide SSN will result in the denial of SNAP benefits to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members. APPEAL RIGHTS You or your representative may request a fair hearing if you disagree with any action taken on your SNAP or Cash assistance case. You may choose anyone you like to present your case at the hearing. For SNAP, you can request a hearing on any action by us or a loss of benefits which occurred in the prior 90 days. In addition, after you are certified for benefits, you can request a fair hearing to dispute the current level of benefits at any time within your current certification period. All such appeals should be addressed to the Director of Operations. For CASH programs you must appeal within 30 days to the Director of Operations. If you wish your SNAP or CASH benefit to continue until the hearing you must appeal within 10 days from the date the notice was sent. To request a fair hearing write to: Department of Human Services, Office of Hearings and Appeals, 4102 Mars Hill, Frederiksted, VI 00840; or call: (340) 772-7100 Ext. 7187. COMPLETE ONLY IF REQUESTING A FAIR HEARING. You may fill out this form, tear it off, and mail to: Department of Human Services Office of Hearing and Appeals 4102 Mars Hill Frederiksted, VI 00840-3376 Name of person requesting hearing Date Address City State Zip Code Reason for Hearing: ______________________________________________ __________________ ___________________________________________________ Applicant’s Signature Today’s Date Telephone number (where you can be reached) *DO NOT COMPLETE – FOR DFA OFFICE USE ONLY* MM/DD/YYY DD/MM/YYY Case Number Case Worker Date Notice Sent Date Request Received (CLIENT’s COPY) Pp. 5-7