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Your Information Last Name First Name Middle Name Date of Birth Telephone Current Address Apt. Mailing Address (if different) City, State ZIP Are you Homeless? �� Yes �� No Do you plan to stay in DC? �� Yes �� No I am applying for: �� Medical Assistance/QMB �� Food Stamps �� IDA (Interim Disability Assistance) �� TANF/GC (Temporary Assistance for Needy Families/General Assistance for Children) Note: Your Food Stamp benefits start on the day that you apply. You can apply right away. Make sure to write down your name and address above and then sign at the bottom of this page. Expedited Food Stamps You might be able to get Food Stamps in less than a week! To see if you qualify, please tell us: 1. Will your household income be more than $150 this month? �� Yes �� No 2. Do you have more than $100 in cash or in the bank? �� Yes �� No 3. Is your income & ready cash this month more than your rent and utilities? �� Yes �� No If you answered NO to the questions above, then you may be eligible. Please tell us: (a) What will be your total income this month? $__________; (b) How much do you have in cash or the bank? $__________; and (c) What did you pay for housing (rent/ utilities) this month? $____________ 4. Are you or anyone in your household a migrant or seasonal farm worker? �� Yes �� No Authorized Representative Do you want someone else to act for or represent you? �� Yes �� No If YES, please tell us: Name of Your Authorized Representative: Address of Rep.: Telephone of Rep.: ___________________________ _________________________________ __________________ What do you want them to do? �� Do interviews �� Make Inquiries �� Report changes �� Use EBT card Signature By signing below, I give my permission to DHS to get information about me. DHS can get this from my employer, landlord, bank, and utility company. I give all of these people my permission to give information about me to DHS. I have reviewed the information in my application and I believe that all of my information on this entire eight-page form is true and correct. I know that if I give any false information, I may be breaking the law and I could be at risk of criminal prosecution and penalties. I know that state and federal officials will check this information. I agree to help with their investigations. I agree to follow the rules for DHS benefits. I have received a copy of these rules. I know that I will have to recertify for my benefits. I also understand that my child may get free health care through "HealthCheck." Authorized Representatives: If the applicant cannot sign this form, you may sign it for them. By signing, you certify that this person wants to apply for benefits and agrees to the conditions above. SIGNATURE: X ___________________________________ DATE: _________________ December 2015 1 of 8


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