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DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY ASSISTANCE – Certification Unit ________________________________________________________ INFORMATION SHEET CASE NAME: ______________________________________________________________________________ CASE NUMBER: ___________________________________________________________________________ CONTACT NUMBERS: Home: ____________________________ Cell: _______________________________ E-MAIL ADDRESS: _________________________________________________________________________ PLEASE SIGN & DATE WHERE APPLICABLE AND RETURN THE ATTACHED FORMS OF THIS PACKET TO THE CERTIFICATION OFFICE!! 1. QUESTIONNAIRE 2. CERTIFICATION TELEPHONIC INTERVIEW FORM 3. COMBINED APPLICATION FORM – PART I (CAF1) DO NOT submit any ORIGINAL DOCUMENTS!! DHS/DFA will NOT be responsible for any original documents!! Please check off below the copy of the document(s) that you have included. Rev. 12/2024 ____ Birth Certificate _____ Immigration/Naturalization Papers _____ Identification Cards _____ Utility Bills _____ Rental Lease, Mortgage Statement _____ Medical Bills, Receipts, and Statements _____ Pay Stubs, Income Statement from Employer, Self-employment Income, Job Separation Letter _____ Financial Contributions Statement _____ Social Security Award Letter, Veterans Benefit Award Letter, Child Support, Alimony, Unemployment, and Retirement Statement _____ Authorized Representative Form _____ Child Care Expenses Receipt or Statement _____ Medical Disability Certificate _____ Other (Please list below) ____________________________ ____________________________ ____________________________ ____________________________ ____________________________ DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY ASSISTANCE – Certification Unit _________________________________________________________ QUESTIONNAIRE Please answer the following questions. Your answers will help the Eligibility Worker understand your household circumstances. Household Composition Did any member of your SNAP/CASH household leave, is temporarily away, or has died? ( ) YES NO ( ) Did any member of your SNAP/CASH household have a newborn baby, or any person(s) moved in? ( ) YES NO ( ) Employment Income Did you or any member of your SNAP/CASH household become employed, quit working, got laid off, started working less or more hours, changed jobs, had a change in wages, started a business or is now self-employed? ( ) YES NO ( ) Benefits or other Income Did you or any member of your SNAP/CASH household received or started receiving any benefits or other income such as, child support, alimony, rental income, odd jobs, or monies from anyone to help meet your household’s personal needs or to pay any of the household bills? ( ) YES NO ( ) Lottery and Gambling Winnings Did you or any member of your SNAP/CASH household had winnings from lottery or gambling of $4,500.00 or more in a single game before taxes or other withholding? ( ) YES NO ( ) Resources Do you or any member of your SNAP household, who has been disqualified, because of an intentional program violation or noncompliance with the SNAP work requirement, own or jointly own any resources such as, but not limited to a savings or checking account, Christmas Club, vehicle(s), property or land or other assets in the Virgin Islands or elsewhere? ( ) YES NO ( ) CASH Households Do you or any member of your CASH household own or jointly own any resources such as, but not limited to, a savings or checking account, Christmas Club, vehicle(s), property, or land or other assets in the Virgin Islands or elsewhere? ( ) YES NO ( ) Rev. 12/2024 DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY ASSISTANCE – Certification Unit _________________________________________________________ CERTIFICATION TELEPHONIC INTERVIEW Case Number: _______________________ Case Name: ______________________________________ LAST FIRST Worker’s Name: _____________________ I CERTIFY UNDER PENALTY OF PERJURY THAT ALL ANSWERS I WILL PROVIDE DURING THE TELEPHONIC INTERVIEW WILL BE CORRECT AND ACCURATE TO THE BEST OF MY KNOWLEDGE, INCLUDING INFORMATION ABOUT THE CITIZENSHIP OR ALIEN STATUS OF EACH HOUSEHOLD MEMBER. I UNDERSTAND AND AGREE TO PROVIDE DOCUMENTS TO VERIFY WHAT I HAVE SAID. I UNDERSTAND AND AGREE THAT THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP/CASH) MAY CONTACT OTHER PERSONS OR ORGANIZATIONS TO OBTAIN INFORMATION NEEDED TO DETERMINE ELIGIBILITY. I CERTIFY THAT I HAVE RECEIVED A COPY OF MY RIGHTS AND RESPONSIBILITIES, THE USDA NON- DISCRIMINATION STATEMENT, PENALTY WARNING, PRIVACY ACT STATEMENT, AND APPEAL RIGHTS FORMS. _______________________________ _________________________ SIGNATURE OF APPLICANT OR DATE HOUSEHOLD REPRESENTATIVE Rev. 12/2024 DEPARTMENT OF HUMAN SERVICES DIVISION OF FAMILY ASSISTANCE – Certification Unit ________________________________________________________ CERTIFICATION TELEPHONIC INTERVIEW (For DFA Office Use Only) DO NOT COMPLETE THIS PAGE Case Number: ______________________ Case Name: __________________________________ LAST FIRST Interview Date: _____________________ I CERTIFY UNDER PENALTY OF PERJURY THAT A TELEPHONIC INTERVIEW WAS CONDUCTED. I FURTHER CERTIFY THAT THE CONSEQUENCES AND PENALTIES, SHOULD THE ANSWERS/RESPONSES TO THE QUESTIONS PROVE TO BE INACCURATE, WERE FULLY EXPLAINED TO THE APPLICANT AND/OR HOUSEHOLD REPRESENTATIVE. Worker’s Name: ____________________________________ Worker’s Signature: ____________________________________ Rev. 12/2024 Virgin Islands of the United States Rev. 12/2024 Case Number: Supplemental Nutrition Assistance Program (SNAP) and CASH Assistance COMBINED APPLICATION – PART I Program(s) Applying For Check which applies SNAP CASH We consider all applications without regard to race, color, national origin, sex, age, or disability. Please read entire application, complete, and sign on page 4. Check which one applies NEW APPLICATION RECERTIFICATION You can begin to apply for SNAP/CASH benefits and establish your application date by filling in your name, address and signing this application and give it to us today. We are required to verify the information you provide and to act on your application within 30 days unless you qualified for SNAP right away. If you qualify to get SNAP benefits right away, we are required to act on your application within 7 days. So, the sooner you give us this application and any required verification, the quicker you will know whether you are eligible to receive SNAP/CASH benefits. If you are eligible, benefits will be provided back to the date you filed your application. You can apply for and get SNAP/CASH benefits for eligible household member(s) even if you are not eligible for benefits because of immigration status. For example, ineligible alien parent can apply for SNAP/CASH benefits for her/his children and receive benefits for the eligible children. The eligibility worker will tell you what information needs to be verified and the items to bring for your interview. YOU MAY GET SNAP BENEFITS RIGHT AWAY IF YOUR HOUSEHOLD: • Gross monthly income is less than $150 and your household’s resources, such as cash or checking/savings accounts, is $100 or less; or • Monthly rent/mortgage and utilities are more than your household’s gross monthly income, & liquid resources; or • You or a household member is a migrant or seasonal farmworker. ➢ The Certification Office will schedule an interview at which time the Eligibility Worker will assist you in completing Part II of the application. ➢ You may request a face-to-face interview or a telephone interview. DFA Stamp Date Received PRINT NAME LEGIBLY BELOW: Last First Middle________ ______ Answering the questions below will help us determine if your application must be processed within 7 days for SNAP. DO YOU LIVE IN AN APARTMENT? CHECK ONE Yes No DO YOU LIVE IN A HOUSE? CHECK ONE Yes No ARE YOU A BOARDER? CHECK ONE Yes No 1. How many people live in your home and eat with you? (Include yourself) _________________. 2. How much is your monthly rent or mortgage? $___________ 3. How much are your monthly utilities? $__________________ 4. Did all your household income recently stop? CHECK ONE Yes No If yes, when? ______________ 5. What is the total income you expect your household to receive this month? $____________________ 6. How much does your household (Including children) have in cash, checking or savings? (Give best total estimate) $___________________ 7. Is anyone in your household a migrant or seasonal farmworker? CHECK ONE Yes No 8. If anyone in your household was a migrant or seasonal farmworker at any time during the current migration season, was your household approved for a postponement of verification requirements? If yes, when, and where? CHECK ONE Yes No __________________________ STOP! DO NOT SIGN! BELOW FOR DFA OFFICE USE ONLY! _______________________________________ ______________ SIGNATURE (Certification Unit only!! DATE of person screening for Expedited Service Physical Address where you live: Address line 1: ______________________________________________________________________________ City State Zip Mailing Address where you receive mail: Address line 1: _____________________________________________________________________________ City State Zip Phone number and e-mail address where you can be reached Home: ______________________________________ Cell: ________________________________________ Email: ____________________________________________________________________________________ Do you wish to receive Program text messages to your cell phone? CHECK ONE Yes No [Cell phone data charges apply] Application and information can be submitted in person (drop box), by mail, email, or fax to the SNAP office in your District shown below. ST. CROIX, VI Department of Human Services Certification Office 4102 Mars Hill Frederiksted, VI 00840-3376 Ph. (340) 772-7100, Ext. 7159, 7072 Fax. (340) 772-9591 E-Mail: certoffice.stx@dhs.vi.gov ST. THOMAS/WATER ISLAND, VI Department of Human Services Certification Office 1303 Hospital Ground, Ste. 1 St. Thomas, VI 00802-6722 Ph.(340) 774-0930 or (340) 774-2399 Fax. (340) 777-5449 E-Mail: certoffice.stt@dhs.vi.gov ST. JOHN, VI Department of Human Services Certification Office Multi-Purpose Building 307 Enighed Contant Cruz Bay, St. John, VI 00830 Ph. (340) 776-6334 Fax. (340) 777-5449 E-Mail: certoffice.stt@dhs.vi.gov MEMBER INFORMATION COMBINED APPLICATION – PART I THE FOLLOWING PERSONS ARE MANDATORY HOUSEHOLD MEMBERS, IF LIVING WITH YOU. 1. Spouse. 2. Natural, adopted, and stepchildren under the age of 22 years or other minor(s) who live with you and under the age of 18, and is under your parental control and is financially or otherwise dependent on a member of the household. 3. Household (HH) members who purchase and prepare meals together with your household. List yourself as person #1. List spouse as person #2 – if applicable. List all of the other persons in your home even if you are not applying for them. ETHNICITY: Please indicate your "Yes" or "No" response by marking the box beneath your choice Y (Yes) or N (No) RACE: Enter the letter(s) that corresponds to the HH member below. (I) Native American or Alaska Native; (A) Asian; (B) Black or African American; (P) Native Hawaiian or Pacific Islander; (W) White LANGUAGE: Enter the number that corresponds to the HH member below. (1) English; (2) Spanish; (3) French-Creole; (4) Arabic; (5) Chinese; or (6) Other The provision of this information is voluntary. It will not affect the eligibility of the person(s) applying or the level of benefits received. Full Legal Name (including initial). List yourself first. List everybody who lives with you even if they are not applying. L I N E LAST NAME FIRST NAME M I SOCIAL SECURITY NUMBER (SSN) SSN is not required for individuals not applying for benefits (but who are included as members of the HH) If none, state “None” DATE OF BIRTH MM/DD/YYYY MARITAL STATUS Married/ Single/ Divorced Choose One GENDER Male/ Female/ Other Choose One Relationship to you Do you buy/ or prepare food with this person? Select Y(Yes) or N(No) ETHNICITY Hispanic or Latino Select Y(Yes) or N(No) RACE Please select/indicate one or more from the following race categories by marking the associated box. Codes Defined Above** LANGUAGE - See Codes above YES NO YES NO I A B P W 1 Self 2 3 4 5 6 7 Criminal History Inquiry: Please answer the following questions for yourself and anyone else for whom you are applying. If you answer “Yes”, list the name of the person(s) to whom the “Yes” answer applies. 1. Are you or anyone in your household a fleeing felon or a parole or probation violator, or is not in compliance with the terms of your sentence? CHECK ONE Yes No If “Yes” list, the name(s). _________________________________ _________________________________________ ________________________________________ 2. Have you or any member in your household been convicted as an adult of aggravated sexual, abuse, murder, sexual exploitation, and other abuse of children, a Federal or State offence involving sexual assault or an offence under State law determined by the Attorney General to be substantially similar to such an offence after February 7, 2014? CHECK ONE Yes No If “Yes” list, the name(s). _________________________________ _________________________________________ ______________________________________ Has anyone listed on this application received SNAP/CASH here in the U.S. Virgin Islands or elsewhere this month or anytime in the past? CHECK ONE Yes No If yes, When? ____________________ Where? ___________________________________________ Programs: ________________________________ Date City State SNAP/CASH Case Number: YOUR RESPONSIBILITIES NOTE: If you sign this application as an Authorized Representative of a person who is requesting or receiving assistance, you agree 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 $4,500 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. Case Number: DECLARATION 1. I understand the questions on this application form and the penalty for hiding or giving false information or breaking any of the rules listed in the penalty warning. 2. I understand and agree to provide documents to prove what I have said. 3. I understand and agree that the Certification Office may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits. 4. I understand that information through IEVS will be requested, and such information may affect my household’s eligibility and level of benefits. 5. I understand that if my household receives more SNAP/CASH Assistance than it is entitled to receive, all adult household members are jointly and individually liable for the repayment of the over-issued benefits. This is true whether or not the household was at fault. 6. I understand that the immigration status of any household member may be subject to verification by United State Citizenship and Immigration Services (USCIS), and that the submitted information received from USCIS may affect the household’s eligibility and level of benefits. SNAP WORK REQUIREMENTS SANCTIONS: 1. I understand that failure to comply with the SNAP work requirement will result in the disqualification of one (1) month for the first violation three (3) months for the second violation and six (6) months for the third or subsequent. 2. I understand that the entire household will be disqualified if the Head of the Household fails to comply with the work requirements. 3. I understand that I am prohibited from receiving an increase in SNAP benefits when my household’s income is reduced because of a penalty imposed under a Federal, State or Local mean-tested Public Assistance Program. 4. I understand that I or any household member will become ineligible if, without good cause, (i) refuse to provide sufficient information to allow a determination of employment status or job availability; (ii) reduce the numbers of hours you work if, after reduction, you are employed less than 30 hours per week; (iii) voluntarily and without good cause quit a job of 30 hours or more. 5. I attest that I received “The Smart Family Brochure”. 6. I understand that by signing this application, I consent to an investigation to verify or confirm the information I have provided. PENALTY OF PERJURY: I certify, under penalty of perjury, that the information given on this application is true, complete, are correct to the best of my knowledge, including information I have given regarding the felony conviction of certain crimes and the U.S. citizenship or immigration status of all household members. AUTHORIZATION FOR CONSENT: I hereby consent and give permission to the VI Department of Human Services (VIDHS) to obtain, disclose, and verify information concerning my household to and from other Federal and Local entities, which is necessary for the determination of eligibility to receive benefits or services from the VIDHS. This authorization includes but is not limited to, investigation and verification of banking information, housing, other sources of income, employment information and any other necessary information to be used for the determination of eligibility to receive benefits or services from the VIDHS. Applicant/Authorized Rep.: Please read Rights and Responsibilities attached to this application, BEFORE signing. Please sign application. Print Name: _____________________________________________________ Signature of Applicant or Authorized Representative: Date: _________________________________________ _____________________ Print Worker Name: _____________________________________________ Worker Signature: Date: _________________________________________ ______________________ Case Number: