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Page 9 ENGLISH Rights & Responsibilities Health Coverage 55367 revised 07/14
Page 22 SPANISH Rights & Responsibilities Health Coverage 55367 revised 07/14
NOTE:
Callers should indicate which of the three scripts they will be utilizing. When in doubt, ask the caller.
Callers are to read statements contained in these documents prior to interpreting services being
rendered. If the caller refuses to read the statements, politely indicate this is a combined policy of
Propio and Indiana FSSA Division of Family Resources. The caller should be referred to their internal
management if they continue to refuse to read the statements.
The following information is being provided as a summary of your rights and responsibilities.
You received a copy of the complete rights and responsibilities at the time you applied for benefits.
Please be sure to read your copy of the rights and responsibilities over carefully and ask a worker if you
have any questions.
You have a right to equal treatment without regard to race, color, age, sex, disability, national
origin, religious or political beliefs.
You have a right to receive information about any Division of Family Resources (DFR) programs,
to have your application processed promptly, and information kept confidential unless directly
related to the administration of programs.
You also have a right to obtain help from DFR with your application, to reapply if your benefits
stop and to have a fair hearing if you disagree with action DFR takes on your case.
Getting benefits from the DFR means you have responsibilities too.
Remember to be truthful on your application and during your interview.
At any time, government officials, investigators and/or Quality Control will be checking your
information. Your cooperation is requested if they review your case.
If we find that you knowingly provided false information, your benefits may be denied or
cancelled. You can be fined or criminally prosecuted under Federal or State laws.
If you received benefits to which you are not entitled, you will have to pay DFR back. DFR can
intercept your tax refunds, Social Security or turn the claim over to a collection agency.
To avoid all of this, you must be truthful to the best of your knowledge.
By signing the application you have given permission for DFR to share your information with other
federal, state and local officials. We will use your information, including your Social Security Number to
match information and benefits from other service agencies, such as:
Social Security Administration
Internal Revenue Service
Indiana Department of Revenue
Indiana Department of Workforce Development
You need to know that what we learn about you may affect your eligibility and benefits.
SNAP households are subject to simplified reporting requirements. This means you are required to
report when your gross monthly income exceeds the gross monthly income guideline for your
household size. The monthly income limit is included in the notice of eligibility. To be considered timely,
the change must be reported by the 10th day of the next month. You can report changes by calling 1-
800-403-0864, going into the local office, by mail, fax or online.
Anyone convicted of a drug felony after August 22, 1996 or fleeing to avoid prosecution of a felony
conviction is not eligible to receive SNAP benefits. Also know that we will provide your information to
law enforcement if necessary to apprehend someone fleeing the law or in violation of probation or
parole.
If an individual voluntarily quits a job without good cause or is terminated from a job for disciplinary
reasons, it may affect your eligibility or the amount of benefits you receive.
If you are not part of an assistance group with a child under age 18, are able-bodied, and between the
ages of eighteen (18) and forty-nine (49), you may receive SNAP benefits no longer than three (3)
months unless you:
Work at least twenty (20) hours per week on average each month; or
Participate in a Job Program approved by the Family and Social Services Administration at least
twenty (20) hours per week; or
Meet one of the exemptions; or
Participate in a Community Work Experience Program (CWEP) activity.
If you have lost eligibility after receiving SNAP benefits for three (3) months, you may regain eligibility
by:
Working at least eighty (80) hours in a thirty (30) day period; or
Participating at least eighty (80) hours in a thirty (30) day period in an approved Job Program; or
Meeting one of the exemptions
If you are determined to be exempt from work registration, you may always volunteer to receive
employment and training services through IMPACT.
If you are eligible for SNAP benefits, you will use a Hoosier Works EBT Card to buy groceries. Here are
some rules that must be followed:
Do not sell or trade your SNAP benefits or Hoosier Works card.
Do not use someone else’s SNAP e efits for your ow perso al gai .
Do not use your card to buy alcohol, tobacco, drugs, firearms, ammunition, explosives, or non
food items.
If you break these rules, you can lose your benefits, be fined, or be prosecuted for trafficking.
Our rules are important to make sure benefits go only to the people who are truly eligible for them. We
appreciate your patience and cooperation. We want to help you and be fair. If you choose not to
provide information, we understand, but benefits may be denied.
The following information is being provided as a summary of your rights and responsibilities.
You did receive a copy of the complete rights and responsibilities at the time you applied for benefits.
Please be sure to read your copy of the rights and responsibilities over carefully and ask a worker if you
have any questions.
You have a right to equal treatment without regard to race, color, age, sex, disability, national
origin, religious or political beliefs.
You have a right to receive information about any Division of Family Resources (DFR) programs,
to have your application processed promptly, and information kept confidential unless directly
related to the administration of programs.
You also have a right to obtain help from DFR with your application, to reapply if your benefits
stop and to have a fair hearing if you disagree with action DFR takes on your case.
Getting benefits from the DFR means you have responsibilities too.
Remember to be truthful on your application and during your interview.
At any time, government officials, investigators and/or Quality Control will be checking your
information. Your cooperation is requested if they review your case.
If we find that you knowingly provided false information, your benefits may be denied or
cancelled. You can be fined or criminally prosecuted under Federal or State laws.
If you received benefits to which you were not entitled, you will have to pay DFR back. If you do
not repay, DFR can intercept your tax refunds, Social Security or turn the claim over to a
collection agency.
To avoid all of this, you must be truthful to the best of your knowledge.
By signing the application you have given permission for DFR to share your information with other
federal, state and local officials. We will use your information, including your Social Security Number to
match information and benefits from other service agencies, such as:
Social Security Administration
Internal Revenue Service
Indiana Department of Revenue
Indiana Department of Workforce Development
You need to know that what we learn about you may affect your eligibility and benefits.
SNAP households are subject to simplified reporting requirements. This means you are required to
report when your gross monthly income exceeds the gross monthly income guideline for your
household size. The monthly income limit is included in the notice of eligibility. To be considered timely,
the change must be reported by the 10th day of the next month. You can report changes by calling 1-
800-403-0864, going into the local office, by mail, fax or online.
Anyone convicted of a drug felony after August 22, 1996 or fleeing to avoid prosecution of a felony
conviction is not eligible to receive SNAP benefits. Also know that we will provide your information to
law enforcement if necessary to apprehend someone fleeing the law or in violation of probation or
parole.
If an individual voluntarily quits a job without good cause or is terminated from a job for disciplinary
reasons, it may affect your eligibility or the amount of benefits you receive.
If you are not part of an assistance group with a child under age 18, are able-bodied, and between the
ages of eighteen (18) and forty-nine (49), you may receive SNAP benefits no longer than three (3)
months unless you:
Work at least twenty (20) hours per week on average each month; or
Participate in a Job Program approved by the Family and Social Services Administration at least
twenty (20) hours per week; or
Meet one of the exemptions; or
Participate in a Community Work Experience Program (CWEP) activity.
If you have lost eligibility after receiving SNAP benefits for three (3) months, you may regain eligibility
by:
Working at least eighty (80) hours in a thirty (30) day period; or
Participating at least eighty (80) hours in a thirty (30) day period in an approved Job Program; or
Meeting one of the exemptions
If you are determined to be exempt from work registration, you may always volunteer to receive
employment and training services through IMPACT.
If you are eligible for SNAP benefits, you will use a Hoosier Works EBT Card to buy groceries. Here are
some rules that must be followed:
Do not sell or trade your SNAP benefits or Hoosier Works card.
Do not use someone else’s SNAP e efits for your ow perso al gai .
Do not use your card to buy alcohol, tobacco, drugs, firearms, ammunition, explosives, or non
food items.
If you break these rules, you can lose your benefits, be fined, or be prosecuted for trafficking.
In order to be eligible for TANF cash assistance, you must do the following:
Cooperate in creating a plan to help get you back to work.
Participate in work-related activities, designed to assist you with employment and training.
Provide proof of current immunizations for children. There are few exceptions.
Ensure all school-aged children maintain regular school attendance.
Cooperate in assigning child support rights to the Indiana Child Support Bureau
Cooperate in identifying any absent parents
Cooperate in establishing paternity and court ordered child support. There can be exceptions.
Also to receive TANF you must turn over to the Indiana Child Support Bureau payments for child
support, spousal support and cooperate with Child Support Enforcement staff.
Anyone convicted of a drug felony after August 22, 1996 is not eligible to receive TANF for ten (10) years
from the date of conviction. Anyone found to be fleeing to avoid prosecution of a felony conviction is
ineligible. Also know that we will provide your information to law enforcement if necessary to
apprehend someone fleeing the law or in violation of probation or parole.
While receiving TANF benefits, you must report all changes in your household circumstances to DFR
within 10 days. You can report changes by calling 1-800-403-0864, going into the local office, by mail, fax
or online.
Once you are determined eligible for TANF benefits, you will use a Hoosier Works EBT card to make cash
withdrawals and purchases. You must follow these rules in the use of your card:
Do ot sell or trade your ard or use so eo e else’s ard
Do not use your card at liquor stores, gambling establishments, horse racing facilities, gun stores
or adult entertainment establishments.
If you choose not to cooperate, or follow any guidelines, the TANF benefits for your entire household
may be denied, reduced, or discontinued.
And a final, very important, point: TANF is temporary. The receipt of TANF cash benefits is limited to a
total of 24 months for adults who are a datory for I dia a’s e ploy e t a d jo trai i g progra
and 60 months for their families. The 60 months includes TANF benefits received in Indiana as well as
other states. In that time, DFR will work with you to help you and your family. We can do it, but we
need your help.
The following information is being provided as a summary of your rights and responsibilities.
You did receive a copy of the complete rights and responsibilities at the time you applied for benefits.
Please be sure to read your copy of the rights and responsibilities over carefully and ask a worker if you
have any questions.
You have a right to equal treatment without regard to race, color, age, sex, disability, national
origin, religious or political beliefs.
You have a right to receive information about any Division of Family Resources (DFR) programs,
to have your application processed promptly, and information kept confidential unless directly
related to the administration of programs.
You also have a right to obtain help from DFR with your application, to reapply if your benefits
stop and to have a fair hearing if you disagree with action DFR takes on your case.
Getting benefits from the DFR means you have responsibilities too.
Remember to be truthful on your application and during your interview.
At any time, government officials, investigators and/or Quality Control will be checking your
information. Your cooperation is requested if they review your case.
If we find that you knowingly provided false information, your benefits may be denied or
cancelled. You can be fined or criminally prosecuted under Federal or State laws.
If you received benefits to which you are not entitled, you will have to pay DFR back. DFR can
intercept your tax refunds, Social Security or turn the claim over to a collection agency.
To avoid all of this, you must be truthful to the best of your knowledge.
By signing the application you have given permission for DFR to share your information with other
federal, state and local officials. We will use your information, including your Social Security Number to
match information and benefits from other service agencies, such as:
Social Security Administration
Internal Revenue Service
Indiana Department of Revenue
Indiana Department of Workforce Development
You need to know that what we learn about you may affect your eligibility and benefits.
In order to be eligible for TANF cash assistance, you must do the following:
Cooperate in creating a plan to help get you back to work.
Participate in work-related activities, designed to assist you with employment and training.
Provide proof of current immunizations for children. There are few exceptions.
Also to receive TANF you must turn over to the Indiana Child Support Bureau payments for child
support, spousal support and cooperate with Child Support Enforcement staff.
Anyone convicted of a drug felony after August 22, 1996 is not eligible to receive TANF for ten (10) years
from the date of conviction. Anyone found to be fleeing to avoid prosecution of a felony conviction is
ineligible. Also know that we will provide your information to law enforcement if necessary to
apprehend someone fleeing the law or in violation of probation or parole.
While receiving TANF benefits, you must report all changes in your household circumstances to DFR
within 10 days. You can report changes by calling 1-800-403-0864, going into the local office, by mail, fax
or online.
Once you are determined eligible for TANF benefits, you will use a Hoosier Works EBT card to make cash
withdrawals and purchases. You must follow these rules in the use of your card:
Do ot sell or trade your ard or use so eo e else’s ard
Do not use your card at liquor stores, gambling establishments, horse racing facilities, gun stores
or adult entertainment establishments.
If you choose not to cooperate, or follow any guidelines, the TANF benefits for your entire household
may be denied, reduced, or discontinued.
And a final, very important, point: TANF is temporary. The receipt of TANF cash benefits is limited to a
total of 24 months for adults who are a datory for I dia a’s e ploy e t a d jo trai i g progra
and 60 months for their families. The 60 months includes TANF benefits received in Indiana as well as
other states. In that time, DFR will work with you to help you and your family. We can do it, but we
need your help.
Please read this form about the rights and responsibilities for Health Coverage (Medicaid, Hoosier Healthwise, and the Healthy Indiana Plan) for
which you have applied for or are being redetermined. When we refer to “you”, we mean all persons applying for and receiving benefits in your
household. Ask a worker or call toll free at 1-800-403-0864 if you have any questions.
1. You have the right to apply for benefits at any time during normal office hours. The date you submit your application determines the date
your benefits begin if you are eligible. You have the opportunity to submit the application online, by mail, fax, over the telephone, or in-
person. You can also apply for health coverage through the Federally Facilitated Marketplace. Don’t delay in filing your application.
2. You may appoint someone to apply for benefits on your behalf.
3. A decision must be made on your application within the following time frames: forty-five (45) days for all categories of Health Coverage,
except Medicaid under the Disability category which is ninety (90) days.
4. You have the right to review information you provide that is entered into the on-line eligibility system.
5. You will need to answer all questions that are required to determine eligibility. All personal information you give is confidential and will
only be used to determine your eligibility for benefits.
6. Eligibility for benefits is determined without any regard to race, color, creed, sex, age, disability, national origin, or political belief.
Information is requested about your racial-ethnic heritage to comply with the Federal Civil Rights Law. However, you do not have to
provide this information. If you choose not to give us this information, we will indicate a race/ethnicity classification for you for data
collection purposes.
7. A Social Security number (SSN) must be given for each applicant who can legally have a number. If you don’t have an SSN you must
apply for one. This requirement does not apply to certain immigrants who cannot legally have a number and therefore can be eligible for
emergency services only under Medicaid/Hoosier Healthwise. Your SSN will be used to check the records of other State and Federal
agencies such as the Social Security Administration, Bureau of Motor Vehicles, Internal Revenue Service, Department of Homeland
Security, Department of Workforce Development, and other states’ public assistance records. Any information we receive about you from
these sources is kept strictly confidential, and used only to determine your eligibility for benefits. We may ask for the Social Security
numbers of family members who are not applying; however, you do not have to provide these numbers as a condition of eligibility.
Determination of eligibility will not be delayed, denied, or discontinued due to waiting on a Social Security number to be issued.
8. If you are an immigrant, you must provide the document showing your immigration status if we are unable to verify the information
electronically. A person who does not provide immigration documents or has no documentation can only be eligible for health coverage
for medical emergencies. The immigration status of lawful immigrants who are applying for or receiving benefits is subject to verification
by the U.S. Citizenship and Immigration Services (USCIS).
9. You will need to verify certain information you provide, if not able to be done so electronically, based on the requirements of the programs
you have chosen or may be eligible for. If you have tried to get the documentation, but are unable to do so, you can sign a release of
information and the worker will assist in obtaining the information. Any release of information form that you sign must have the name of
the person, agency, or organization that the worker will be contacting.
10. Certain persons must be included in the application and/or have their income, resources, needs and/or expenses counted in determining
eligibility for benefits. For this reason you must report everyone who lives with you.
11. You are required to report changes in your circumstances to the Division of Family Resources. The changes that you must report include
your new address if you move, increases or decreases in your household’s income, resources, or any change in your family
circumstances that may affect your eligibility for benefits. You must report changes within ten (10) days of the date on which you are
aware of the change. Also, there are certain circumstances in which resources are not counted and income of parents is exempt and
therefore changes do not have to be reported. You will be given a form describing your reporting requirements.
12. If you move, please tell us your new address so that important mail about your application and health plan membership will reach you
without delay. Also, you must tell us if you or your child(ren) becomes covered under other health insurance such as Medicare or
employer-sponsored health insurance.
13. You are required to provide complete and correct information to the best of your knowledge. A person who receives benefits by
intentionally giving false information or by failing to report information may be criminally prosecuted under State and Federal law.
14. You have the right to receive a written notice about any action taken on your application or on the benefits you receive.
15. You may request a fair hearing in writing if you disagree with any action taken on your case, including the late processing of your
application. Your case may be presented at the hearing by any person you choose.
16. In accordance with Federal Law and United States Department of Health and Human Services (HHS) policy, this institution is prohibited
from discriminating on the basis of race, color, national origin, sex, age, or disability. If you believe that you have been discriminated
against and wish to file a complaint, you may do so by contacting the Department of Health and Human Services, Regional Manager,
Region V, Office for Civil Rights, 233 N. Michigan Ave,, Suite 240, Chicago, Illinois 60601. You may call them at (800) 368-1019 or for
DFRNHAE01
Page 10
DFRNHAE02
Page 11
32. The goal of the Healthy Indiana Plan is to assist you in maintaining health care coverage until you can obtain employment that will
allow you to obtain health insurance on your own. To assist you in getting better employment, we have developed a partnership with
the Indiana Department of Workforce Development called the Gateway to Work program. By signing the application, you
acknowledge that your application will be screened for eligibility to the HIP Gateway to Work program, and if found eligible, your
contact and employment information will be shared with the Indiana Department of Workforce Development, so that you may
receive information about the State’s job search and training programs.
33. We will use electronic sources to verify income, citizenship, alien status, and other eligibility factors whenever possible; if certain eligibility
factors cannot be verified electronically, you may be asked to provide paper documentation.
34. If you are not eligible for Medicaid/Hoosier Healthwise/Healthy Indiana Plan, you may be eligible for other health insurance coverage
through the health insurance marketplace. If your application is denied or discontinued (for non-procedural reasons), your application will
be submitted to the health insurance marketplace for a determination of other insurance affordability programs. If your family income is
under 400% of the federal poverty level, you may be eligible for Advance Premium Tax Credits (APTC) or Cost Sharing Reduction (CSR)
through the marketplace.
35. Beginning in 2014, most individuals will be required to have health insurance coverage. Such coverage may be obtained through
employer-sponsored health insurance, qualified health plans through the marketplace, or through Medicaid/Hoosier Healthwise/Healthy
Indiana Plan.
36. The Affordable Care Act (ACA) mandates the use of the Modified Adjusted Gross Income (MAGI) financial methodology when
determining Medicaid income eligibility for most parents and other caretakers, children, pregnant women, and adults aged 19-64 who are
not blind, disabled, or in need of long term care services.
37. The Indiana Application for Health Coverage meets the requirements of an alternative single, streamlined application for all insurance
affordability programs.
38. Redeterminations will be completed every 12 months to determine if you still meet the eligibility requirements. We will first attempt to
complete your annual redetermination using available electronic data sources and will automatically continue your enrollment for another
12 months if found eligible. If we are unable to do this, you will receive a pre-populated reenrollment form in the mail that must be
completed and returned.
DFRNHAE03
Page 12
INDIANA APPLICATION FOR SNAP
AND CASH ASSISTANCE *DFRAAHE01*
State Form 53263 (R9 / 3-15) / DFR 2512
Part of State Publication 355
INSTRUCTIONS: Please fill out your application as completely as you can. It will help if you can answer all of the questions.
However, the application will be valid if you provide name(s), address, and signature. To be considered for expedited SNAP
(Food Assistance) service you must complete all of Section 8. Please do not forget to sign your application on Page 1 Section 3.
1. If you are completing this application on behalf of someone else and you do not live in their household, please provide
your name below and your contact information in Section 7. If you are completing this application on behalf of
someone else and you do live in their household, please provide your information in Section 9:
First Name MI Last Name Suffix
2. Information for person needing assistance: (additional individuals may be added in Section 9)
Check the Help This Person Needs: SNAP (Food Assistance) Cash Assistance (TANF or Refugee) Not Applying
If Not Applying is checked, completion of the Social Security Number and US Citizen information is optional.
First Name MI Last Name Suffix
Race: (select all that apply) White Black or African American Asian
3. Signature and Date Required: Read carefully, then sign & date below.
I understand the following:
• INFORMATION THAT I GIVE IS SUBJECT TO VERIFICATION BY FEDERAL, STATE, OR LOCAL OFFICIALS TO DETERMINE IF THE INFORMATION IS FACTUAL. IF
ANY INFORMATION IS INCORRECT, SNAP OR OTHER BENEFITS MAY BE REDUCED OR DENIED AND THE APPLICANT MAY BE SUBJECT TO CRIMINAL
PROSECUTION OR DISQUALIFIED FROM ANY PROGRAM FOR KNOWINGLY PROVIDING INCORRECT INFORMATION (7 CFR 273.2(b)(1)(i)).
• A person fleeing to avoid felony prosecution or jail after a felony conviction or is in violation of probation/parole resulting from a felony conviction is not eligible to receive SNAP and / or
Temporary Assistance for Needy Families (TANF).
• A person convicted under federal or state law of a felony which occurred after August 22, 1996, that includes possession, use, or distribution of a controlled substance is not eligible to receive SNAP
and / or TANF.
• If applying for Temporary Assistance for Needy Families (TANF), my signature assigns and transfers to the Division of Family Resources all child support rights (accrued, pending, and continuing)
which I have against absent parent(s). This assignment is subject to 42 USC SECTION 602(a)(26) as amended.
• If applying for SNAP, I am registering all persons required to register for work and perform specific work including cooperation with employment and training activities.
• I have received a copy of the "Notice Regarding Rights and Responsibilities" and I understand all information included on this form.
• To be considered for Expedited SNAP service, your household must have less than $150 in monthly gross income and have $100 or less in cash; or be a seasonal/migrant farm worker with $100 or
less in available cash; or have a combined cash and monthly gross income amount less than the household monthly rent/mortgage and utility expenses.
I certify under penalty of perjury, all information I have given on this application, any attachments and information provided during the eligibility determination process is complete and correct to the
best of my knowledge and belief, including the citizenship or immigration status of each applicant.
Signature Date (mm-dd-yyyy)
6. E-mail address:
7. If you are completing this application on behalf of someone else, please provide your contact information below:
Street Address
Telephone number:
NOTE: If you are a representative for the person(s) needing assistance, the applicant must complete and sign the
enclosed Authorized Representative form.
If yes, will you receive income from your former employer after today? Yes No
Will you receive more than $25 income from your new employer within 10 days? Yes No
Has everyone in your household (including you) been approved to receive SNAP benefits this month? Yes No
9. Provide the following information for all other persons who live at the home address in Section 2:
• Person listed in Section 2 does not need to be listed again.
• If Not Applying is checked, completion of the Social Security Number and US Citizen information is optional.
Check the Help This Person Needs: SNAP (Food Assistance) Cash Assistance (TANF or Refugee) Not Applying
M F Yes No
Race: (select all that apply) White Black or African American Asian
Check the Help This Person Needs: SNAP (Food Assistance) Cash Assistance (TANF or Refugee) Not Applying
M F Yes No
Race: (select all that apply) White Black or African American Asian
Check the Help This Person Needs: SNAP (Food Assistance) Cash Assistance (TANF or Refugee) Not Applying
M F Yes No
Race: (select all that apply) White Black or African American Asian
Check the Help This Person Needs: SNAP (Food Assistance) Cash Assistance (TANF or Refugee) Not Applying
M F Yes No
Race: (select all that apply) White Black or African American Asian
Check the Help This Person Needs: SNAP (Food Assistance) Cash Assistance (TANF or Refugee) Not Applying
M F Yes No
Race: (select all that apply) White Black or African American Asian
If more than six (6) people live at your address, please provide the information starting on page 6.
10. What is your preference for your application interview appointment? By telephone At an office
Please indicate if you need the following interpreter services for your application interview appointment:
Language interpreter
Language
11. Do you want to receive automated calls from our agency? Yes No
(Examples of calls you may receive are appointment reminders or due dates for requested documents.)
12. Do you want to register to vote? Yes No Your answer will not affect your eligibility for benefits.
Page 5 of 5
Page 17
Additional requirements for the specific programs are in the following sections.
1. You have the right to apply for benefits at any time during normal office hours. The date you turn in your application determines the date
your benefits begin if you are eligible. Don’t delay in filing your application.
2. You may appoint someone to apply for benefits on your behalf.
3. A decision must be made on your application within the following time frames: thirty (30) days for SNAP if you are not entitled to expedited
service; and sixty (60) days for Cash Assistance.
4. You have the right to review information you provide that is entered into the ICES computer system.
5. You will need to answer all questions that are required to determine eligibility for the programs you have chosen. All personal information
you give is confidential and will be used to determine your eligibility for benefits.
6. Eligibility for benefits is determined without any regard to race, color, creed, sex, age, handicap, national origin, or political belief.
Information is requested about your racial-ethnic heritage to comply with the Federal Civil Rights Law and the Food and Nutrition Act.
However, you do not have to provide this information as it is strictly voluntary. If you choose not to give us this information, we will indicate
a race/ethnicity classification for you for data collection purposes. This will not affect your eligibility or level of benefits. The reason for
collecting this information is to assure that program benefits are distributed without regard to race, color or national origin.
7. A Social Security number (SSN) must be given for each applicant who can legally have a number. If you don’t have an SSN you must apply
for one. Your SSN will be used to check the records of other State and Federal agencies such as the Social Security Administration, Bureau
of Motor Vehicles, Internal Revenue Service, Department of Workforce Development, and other states’ public assistance records. Any
information we receive about you from these sources is kept strictly confidential, and used only to determine your eligibility for benefits. We
may ask for the Social Security numbers of family members who are not applying; however, you do not have to provide these numbers as a
condition of eligibility. Determination of eligibility will not be delayed, denied, or discontinued due to waiting on a Social Security number to
be issued. If discrepancies are found, this may affect the household's eligibility and level of benefits.
8. If you are an immigrant, you must provide the document showing your immigration status. A person who does not provide immigration
documents or has no documentation cannot receive SNAP or Cash Assistance. The immigration status of lawful immigrants who are
applying for or receiving benefits is subject to verification through the Systematic Alien Verification System (SAVE) administered by the U.S.
Citizenship and Immigration Services (USCIS). Information received from USCIS may affect the household's eligibility and level of benefits.
9. Undocumented immigrants who are not applying for assistance will not be reported to the United States Citizenship and Immigration
Service.
10. In order to remain eligible for SNAP and Cash Assistance, you may be referred to the employment and training program. You will be
required to participate in the employment and training program and do specific activities, unless you meet certain exemption criteria. TANF
work ready applicants are required to complete Applicant Job Search (AJS) as a condition of the eligibility process. Failure to complete AJS
without good cause may be grounds for denying the TANF application.
11. If you voluntarily quit a job without good reason or if you are terminated from a job for disciplinary reasons, it may affect your eligibility and
the amount of benefits you receive.
12. You will need to verify certain information you provide, based on the requirements of the programs you have chosen. If you have tried to
get the papers, but are unable to do so, you can sign a release of information and the caseworker will get the information. Any release of
information form that you sign must have the name of the person, agency, or organization that the caseworker will be contacting. This
release is to be signed only if confidential information needs to be shared in order to obtain the verification, such as from a medical facility or
financial institution.
13. Certain persons must be included in the application and/or have their income, resources, needs and/or expenses counted in determining
eligibility for benefits. For this reason you must report everyone who lives with you. In certain instances, a limited amount of your personal
information may be disclosed to another household member or their authorized representative in order to complete the required eligibility
processes.
14. You are required to report changes in your circumstances to the Division of Family Resources. The changes that you must report include
your new address if you move, increases or decreases in your household’s income, resources, or any change in your family circumstances
that may affect your eligibility for benefits. You must report changes within ten (10) days of the date on which you are aware of the change.
SNAP assistance groups must only report when their gross monthly income exceeds the gross monthly income limit for their assistance
group size. The monthly income limit is included in the notice of eligibility. This change must be reported by the tenth (10th) day of the next
month following the change to be considered timely. You will be given a form describing your reporting requirements.
15. You are required to provide complete and correct information to the best of your knowledge. A person who receives benefits by intentionally
giving false information or by failing to report information may be criminally prosecuted under State and Federal law.
16. You have the right to receive a written notice about any action taken on your application or on the benefits you receive.
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17. You may request a fair hearing in writing if you disagree with any action taken on your case, including the late processing of your
application. Your case may be presented at the hearing by any person you choose. (Note: SNAP recipients may make their request for a
SNAP hearing verbally.)
18. Any individual who is fleeing to avoid prosecution or confinement after felony conviction, or is in violation of probation or parole
resulting from a felony conviction will be ineligible to receive SNAP and TANF benefits. Information in your case file may be
released to law enforcement officials to allow them to arrest persons fleeing to avoid the law.
19. Any individual who has been convicted under federal or state law of a felony, and this felony includes the possession, use, or
distribution of a controlled substance will be ineligible to receive benefits. Ineligibility under this provision is limited to
convictions based on behavior which occurred after August 22, 1996.
20. This institution is prohibited from discriminating on the basis of 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
3. email: program.intake@usda.gov
For any other information dealing with the 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 of 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.
SECTION 2 THIS SECTION APPLIES ONLY TO SNAP.
If you are not applying for SNAP benefits go on to Section 3.
1. If your household has little or no income, or includes a migrant or seasonal farm worker, your application for SNAP benefits may receive
special expedited processing. This means that you may receive SNAP benefits within seven (7) days from the date the application is filed.
To qualify for expedited processing, you must complete all the expedited service questions on the Application for Assistance. If you do not
qualify for expedited processing, you may request a conference. The conference will be scheduled within two (2) days and will not replace
or delay the request for a fair hearing.
2. To be eligible for SNAP benefits, persons age sixteen (16) through fifty-nine (59) must register for work and do specific activities. These
activities include work registration, accepting and keeping suitable employment, and cooperating with IMPACT. Individuals who fail to
cooperate with these rules without a good reason can be disqualified from receiving SNAP benefits until they cooperate or for at least two
(2) months for the first violation, six (6) months for the second violation, and thirty-six (36) months for the third violation. Some persons can
be exempt from these requirements. Ask a caseworker about exemptions.
3. If you are overpaid SNAP benefits and an overpayment claim is done against your household, the information on your application and all
Social Security Numbers (SSNs) may be referred to federal and state agencies and private collection agencies for collection purposes.
4. Every person who receives SNAP benefits must follow these rules:
DO NOT give false information to get or continue to get SNAP benefits.
DO NOT trade or sell SNAP benefits or Hoosier Works cards.
DO NOT alter documents to get more SNAP benefits than you are entitled to receive.
DO NOT use SNAP benefits to buy ineligible items, such as alcoholic drinks and tobacco.
DO NOT use someone else’s SNAP benefits or Hoosier Works card for your personal gain.
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NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE *DFRNRAE03*
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
State Form 54105 (R11 / 2-16) / DFR 0009C
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NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE *DFRNRAE04*
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
State Form 54105 (R11 / 2-16) / DFR 0009C
The following are examples of acceptable kinds of evidence that can be used in determining if good cause exists. If you need help in getting a
copy of any of the documents, reasonable assistance will be provided to help you obtain the necessary documents to support your claim.
Birth certificates, or medical or law enforcement records which indicate that the child was conceived as a result of incest or forcible rape;
court documents or other records which indicate that legal proceedings for adoption are pending in court;
court, medical, criminal, child protective services, social services, psychological or law enforcement records which indicate that the absent
parent might inflict physical or emotional harm on you or the child;
medical records which indicate emotional health history and present health status of you or the child for whom support would be sought or
written statements from a mental health professional indicating a diagnosis concerning the emotional health of you or the child;
a written statement from a public or private agency confirming that you are being assisted in resolving the issue of whether to keep or give up
the child for adoption; and
signed statements from individuals, including friends, neighbors, clergymen, social workers, and medical professionals who
might have knowledge of the circumstances providing the basis of your good cause claim.
Upon termination of TANF eligibility, the assignment ends with respect to current support. Assignment will not terminate with respect to monies
owed to the state and federal governments due to the provision of public assistance. After termination of assistance, in accordance with state
and federal laws, if the obligor owes current support and/or arrearages to both the former TANF recipient/payee and to the State, current
support and arrearage will be paid first to the former recipient/payee then to the State, with the exception of federal tax offsets which will be
applied first to amounts which the state and federal government are entitled. Support enforcement activities will continue for you although your
TANF has ended unless you notify the Child Support Bureau in writing that these services should be discontinued. If you close your Child
Support enforcement case, you are no longer entitled to services until you apply and pay the required application fee.
2. When you apply for TANF, you must follow these rules:
DO NOT make false or misleading statements.
DO NOT take any action to conceal or withhold facts, misrepresent your situation, or submit false documents.
If you break the above rules, you can be disqualified from the TANF Program six (6) months for the first violation, twelve (12) months for the
second violation and permanently for the third violation.
3. Any individual convicted in a court of a misdemeanor for breaking the rules below can be disqualified from the TANF program for a period of
twelve (12) months for the first and second violations and permanently for the third violation. Those convicted of committing a felony for
breaking the rules can be disqualified for ten (10) years for the first and second violations and permanently for the third violation.
DO NOT make false or misleading statements.
DO NOT take any action to conceal or withhold facts, misrepresent your situation, or submit false documents.
4. While you are on the TANF program, assistance with childcare may be available to you. Childcare assistance may also be available if you
lose TANF eligibility because of earnings.
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NOTICE REGARDING RIGHTS & RESPONSIBILITIES
FOR SUPPLEMENTAL NUTRITION ASSISTANCE *DFRNRAE05*
PROGRAM (SNAP) AND CASH ASSISTANCE
DIVISION OF FAMILY RESOURCES
State Form 54105 (R11 / 2-16) / DFR 0009C
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1. Usted tiene derecho a solicitar los beneficios en cualquier momento durante las horas normales de oficina. La fecha en que usted presenta su
solicitud determina la fecha del comienzo de sus beneficios si es elegible. Usted tiene la oportunidad de presentar la solicitud en línea, por
correo, fax, telefónicamente o en persona. También puede solicitar la cobertura de salud mediante Federally Facilitated Marketplace. No se
retrase en completar su solicitud.
2. Usted puede designar a una persona para que solicite los beneficios en su nombre.
3. Se tomará una decisión con relación a su solicitud dentro de los siguientes períodos de tiempo: cuarenta y cinco (45) días para todas las
coberturas del seguro de salud, excepto Medicaid de acuerdo con la categoría de Discapacidad que es de noventa (90) días.
4. Usted tiene derecho a rever la información que suministra y fue ingresada en el sistema de elegibilidad en línea.
5. Usted deberá responder a todas las preguntas que son requeridas para la determinación de la elegibilidad. Toda la información personal que
proporcione es confidencial y se usará para la determinación de su elegibilidad para los beneficios.
6. La elegibilidad para los beneficios se determina sin consideración de raza, color, credo, sexo, edad, discapacidad, origen nacional o creencia
política. La información solicitada sobre su descendencia racial y étnica es para cumplir con la Ley Federal de Derechos Civiles. Sin embargo,
usted no tiene que suministrar dicha información. Si usted decide no ofrecernos esta información, indicaremos una raza/clasificación étnica
para usted con el propósito de la recolección de datos.
7. Se deberá otorgar un número de Seguro Social (Social Security number (SSN), en inglés) por cada uno de los solicitantes que pueda tener,
legalmente, un número. Si usted no tiene un SSN deberá solicitar uno. Este requisito no corresponde a algunos inmigrantes que legalmente
no pueden tener un número y por lo tanto pueden ser elegibles para servicios de emergencia únicamente de acuerdo con Medicaid/Hoosier
Healthwise. Su SSN será usado para la revisación de los registros de otras agencias estatales y federales, como Social Security
Administration, Bureau of Motor Vehicles, Internal Revenue Service, Department of Homeland Security, Department of Workforce Development
y otros registros de asistencia pública de otros Estados. Cualquier información que recibamos sobre usted de parte de estas fuentes se
mantiene en forma estrictamente confidencial y se usa únicamente para determinar su elegibilidad para los beneficios. Puede ser que
solicitemos los números de Seguro social de los miembros de la familia que no están presentando la solicitud, sin embargo, usted no tiene
que suministrarlos como una condición de elegibilidad. La determinación de la elegibilidad no se retrasará, rechazará o descontinuará debido
a la espera de la emisión de un número de Seguro social.
8. Si usted es un inmigrante deberá suministrar el documento que muestra su estatus inmigratorio si no podemos verificar la información
electrónicamente. La persona que no suministre los documentos inmigratorios o no tenga documentación puede ser elegible únicamente para
cobertura de salud para casos de emergencia. El estatus inmigratorio de los inmigrantes legales que solicitan o reciben beneficios está sujeto
a verificación de parte del U.S. Citizenship and Immigration Services (USCIS).
9. Usted tendrá que verificar determinada información que suministre, si no lo puede hacer electrónicamente, en base a los requisitos de los
programas que ha elegido o para los que puede ser elegible. Si ha tratado de obtener los documentos necesarios pero no lo puede hacer,
podrá firmar una descarga de información y el trabajador del caso le asistirá para obtener la información. Cualquier formulario de descarga de
información que usted firme deberá tener el nombre de la persona, la agencia u organización con la que se comunicará el trabajador.
10. Determinadas personas deberán estar incluidas en la solicitud y/o tener sus ingresos, recursos, necesidades y/o gastos en consideración para
la determinación de la elegibilidad de los beneficios. Por esta razón, usted deberá reportar a cada persona que vive con usted.
11. Se requiere que usted reporte los cambios de sus circunstancias a Division of Family Resources (División de Recursos para la Familia). Los
cambios que deberá reportar incluyen su nueva dirección, si se muda, aumentos o disminución del ingreso de su grupo familiar, los recursos o
cualquier cambio en las circunstancias familiares que podría afectar su elegibilidad para los beneficios. Usted debe reportar los cambios
dentro de los diez (10) días de la fecha en la que tiene conocimiento del cambio. Además, hay determinadas circunstancias en las que no se
consideran los recursos y el ingreso de los padres está exento y, por lo tanto, los cambios no tienen que ser reportados. Se le entregará un
formulario describiendo sus requisitos para reportar.
12. Si se muda por favor díganos cuál es su nueva dirección de modo que la correspondencia importante sobre su solicitud y membresía del plan
de salud le lleguen sin retraso. Además, deberá decirnos si usted o su(s) hijo(s) inician una cobertura de acuerdo con otro programa de salud
como Medicare o una cobertura de salud patrocinada por el empleador.
13. Se requiere que usted suministre la información completa y correcta a su mejor saber y entender. La persona que reciba los beneficios
mediante el suministro intencional de información falsa o sin haber reportado información puede ser procesada criminalmente de acuerdo con
la ley estatal o federal.
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AVISO RELACIONADO CON LOS DERECHOS Y LAS
RESPONSABILIDADES PARA LA COBERTURA DE SALUD *DFRNHAS02*
14. Usted tiene derecho a recibir un aviso escrito sobre cualquier acción tomada con relación a su solicitud o los beneficios que recibe.
15. Usted puede solicitar una audiencia imparcial por escrito si está en desacuerdo con cualquier acción tomada con respecto a su caso,
incluyendo el procesamiento tardío de su solicitud. Su caso puede ser presentado en la audiencia por cualquier persona de su elección.
16. De acuerdo con la Ley Federal y la política del United States Department of Health and Human Services (HHS) esta institución tiene prohibido
discriminar en base a la raza, el color, origen nacional, el sexo, la edad y la discapacidad. Si usted considera que se ha discriminado en su
contra y desea presentar una queja de discriminación puede hacerlo comunicándose con el Department of Health and Human Services,
Regional Manager, Region V, Office for Civil Rights, 233 N. Michigan Ave., Suite 240, Chicago, Illinois 60601. Usted puede llamarles al (800)
368-1019 o para las llamadas TDD, (800) 537-7697.
17. La categoría para la que usted reúne los requisitos será elegida para usted. Algunas categorías ofrecen cobertura limitada. Usted será
aprobado para la mayoría de los beneficios para los que es elegible recibir en base a la información que suministró. Sin embargo, si desea
que su elegibilidad sea determinada de acuerdo con una categoría distinta tiene derecho a elegir su categoría.
18. Usted debe presentar documentos para cualquier beneficio para el que puede ser elegible, como Social Security o pensiones o beneficios por
discapacidad.
19. Los beneficios pagados en su nombre después que cumpla cincuenta y cinco (55) años de edad se convierten en un reclamo preferido contra
su patrimonio. Este reclamo es prioritario con respecto a todos los otros reclamos excepto los reclamos anteriormente registrados y los
impuestos.
20. Se le podría requerir que pague el reembolso de los beneficios de cobertura de salud que fueron pagados en su nombre, incluyendo los
honorarios de capitación pagados para un plan de salud o suministrador si usted ha sido determinado como elegible incorrectamente por una
agencia o error del cliente o mediante el suministro de información fraudulenta.
21. Nosotros no reportaremos a los inmigrantes indocumentados al United States Citizenship and Immigration Service. La solicitud de beneficios
de cobertura de salud no afectará su estatus inmigratorio o las posibilidades de convertirse en un residente permanente o ciudadano de los
Estados Unidos de América.
22. Sus derechos a los pagos para el cuidado médico están asignados al Estado de Indiana si usted es encontrado elegible para los beneficios.
Esto incluye los derechos al sustento médico y pagos por el cuidado médico que usted tiene en su nombre y el de sus dependientes que están
aprobados para los beneficios de acuerdo con esta solicitud. Sin embargo, la asignación no incluye los pagos de Medicare.
Debe decirnos qué seguro de salud tiene. Debe decirnos sobre cualquier acción legal o administrativa que tome para obtener pago para el
cuidado médico, como un arreglo por lesiones personales.
El establecimiento de la paternidad es un servicio importante para los miembros de Medicaid /Hoosier Healthwise en beneficio de los niños
que no tienen padres legales. Le aconsejamos comunicarse con la oficina local del procurador de su condado cuando sus hijos están
registrados en Medicaid/Hoosier Healthwise. Con excepción de los niños registrados en el Paquete C este es un servicio gratuito al igual que
otros servicios para el sustento de los niños.
23. Para los niños registrados en el Paquete C de Hoosier Healthwise hay un máximo de la cantidad de costo-participación que usted tendrá que
pagar. Esta cantidad es el 5% de su ingreso anual antes de los impuestos. Es responsabilidad suya llevar un registro de la cantidad de
primas y copagos que usted paga. Si usted llega al máximo deberá comunicarse con la Oficina de Recursos para la familia y suministrar sus
recibos para no tener que efectuar más pagos. Si sus hijos están aprobados para el Paquete C, el aviso de aprobación que usted reciba le
informará cuál es el máximo del costo-participación.
24. Los indios americanos y nativos de Alaska miembros de una tribu reconocida federalmente están exentos de algunas primas y los copagos y
otros requisitos de co-participación. Usted deberá suministrar una identificación tribal para poder recibir esta exención.
25. Determinados ingresos recibidos por los indios americanos y los nativos de Alaska miembros de una tribu reconocida federalmente están
exentos. El ingreso exento incluye: las distribuciones de Alaska Native Corporations and Settlement Trusts, las distribuciones de cualquier
propiedad administrada ubicada dentro de una ex reserva federal o bajo la supervisión del Secretario del Interior, las distribuciones o pagos
de renta, arrendamientos, regalías, derechos de paso, o recursos naturales de extracción y cosecha, las distribuciones de los intereses de
propiedad de bienes inmuebles o el uso de los derechos a los ítems que tienen un significado particular y son religiosos, espirituales o de
significado cultural y la asistencia financiera al estudiante suministrada de acuerdo con los programas educativos del Bureau of Indiana
Affairs.
26. Los servicios preventivos de salud están disponibles para los niños menores de veintiún años (21). Usted puede solicitar asistencia con la
programación de citas y efectuar los arreglos del transporte para los servicios de Health Watch comunicándose con un trabajador.
27. Si usted está solicitando Medicaid para servicios de cuidado a largo plazo (servicios en una institución de Medicaid o servicios de exención) se
le requiere específicamente por ley federal que suministre toda la información sobre las anualidades que posean usted o su cónyuge. Para las
anualidades compradas el o después del 1 de noviembre de 2009 el Estado de Indiana se convertirá en el beneficiario restante de preferencia
de acuerdo con la anualidad por la cantidad total de la asistencia médica pagada en su nombre.
28. Si usted es elegible para el Programa de Medicare Savings Program tomará, como mínimo, entre 3 y 4 meses para que Social Security
Administration deje de retener la prima Parte B de su cheque. Sin embargo, usted recibirá un reembolso de la cantidad total de primas que le
debemos.
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29. Los servicios de Planificación familiar (Family Planning Services, en inglés) están disponibles de acuerdo con el programa de Medicaid de
Indiana. Los hombres y mujeres que no reúnan los requisitos para la cobertura total de Medicaid pueden calificar para estos servicios si
reúnen los requisitos de ingresos. Si usted está registrado en Hoosier Healthwise para el embarazo determinaremos su elegibilidad para
Family Planning Services cuando termine su embarazo.
30. Si se determina que usted es elegible para el Children’s Health Insurance Plan (CHIP)-Seguro de Salud para niños- o el Healthy Indiana Plan
(HIP)- Plan Healthy Indiana- y se requiere que haga las primas o contribuciones a una cuenta POWER , usted debe efectuar dichos pagos
para ser y permanecer elegible.
31. Si usted tiene una apelación CHIP o HIP que permite que los beneficios se mantengan durante el proceso administrativo de apelación, deberá
continuar pagando su prima o contribución a la cuenta POWER para mantener la cobertura. Si el juez en derecho administrativo
(Administrative Law Judge (ALJ), en inglés) emite un fallo a su favor decidiendo que sus beneficios de CHIP o HIP no sean descontinuados o
rechazados, su cobertura será restituida a la fecha en que fue descontinuada o rechazada. Usted será responsable de los pagos de la
cantidad de primas o contribuciones a la cuenta POWER retroactiva a la fecha de la discontinuidad o rechazo. Planifique ahorrar dinero para
reembolsar sus primas o contribuciones a su cuenta POWER retroactiva a la fecha de discontinuidad o rechazo.
32. La meta del Healthy Indiana Plan es asistirle con el mantenimiento de la cobertura de salud hasta que usted pueda obtener empleo que le
permitirá conseguir su propio seguro de salud. Para asistirle en obtener un mejor empleo hemos desarrollado una asociación con el Indiana
Department of Workforce Development llamado Programa Gateway to Work. Al firmar la solicitud usted reconoce que su solicitud será
examinada para la elegibilidad con el Programa HIP Gateway to Work y, si se le encuentra elegible, su contacto e información de empleo
serán compartidos con el Indiana Department of Workforce Development de manera que usted pueda recibir información sobre los programas
del Estado relacionados con la búsqueda de trabajo y capacitación.
33. Usaremos medios electrónicos para la verificación del ingreso, la ciudadanía, el estado como extranjero y otros factores de elegibilidad cuando
sea posible; si determinados factores de elegibilidad no pueden verificarse electrónicamente se podría solicitarle suministrar documentación
impresa.
34. Si usted no es elegible para Medicaid/Hoosier Healthwise/Healthy Indiana Plan, podría ser elegible para otra cobertura del seguro de salud
mediante el health insurance marketplace (seguro de salud en el mercado). Si su solicitud es rechazada o descontinuada (por razones no
relacionadas con el procedimiento) la misma será presentada en el health insurance marketplace para una determinación de otros programas
de seguro económico. Si el ingreso de su familia se encuentra por debajo del 400% del nivel de pobreza federal, usted podría ser elegible para
el Advance Premium Tax Credits (APTC) o Cost Sharing Reduction (CSR) mediante el mercado.
35. A partir del 2014, la mayoría de las personas tendrán el requerimiento de contar con una cobertura de seguro de salud. Dicha cobertura puede
obtenerse mediante el seguro de salud patrocinado por el empleador, planes de salud calificados mediante el mercado o a través de
Medicaid/Hoosier Healthwise/Healthy Indiana Plan.
36. The Affordable Care Act (ACA) exige el uso de la metodología financiera Modified Adjusted Gross Income (MAGI) al determinar la elegibilidad
de ingreso para Medicaid para la mayoría de los padres y otros cuidadores, niños, mujeres embarazadas y adultos entre 19 y 64 años de
edad que no sean ciegos, se encuentren discapacitados o necesiten servicios para el cuidado a largo plazo.
37. The Indiana Application for Health Coverage reúne los requisitos de una solicitud alternativa única, reestructurada para todos los programas
económicos de seguro.
38. Las redeterminaciones se completarán cada 12 meses para determinar si usted reúne los requisitos de elegibilidad. Primero haremos el
intento de completar su redeterminación anual usando los medios de datos electrónicos disponibles y continuaremos automáticamente su
registro durante otros 12 meses si se le encuentra elegible. Si no podemos hacer esto, usted recibirá un formulario para volver a registrarse
con un ingreso previo de datos por correo que deberá ser completado y devuelto.
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SOLICITUD PARA SNAP Y
ASISTENCIA CASH DE INDIANA *DFRAAJS01*
Formulario del Estado 53622 (R9 / 6-15) / DFR 2512S
INSTRUCCIONES: Por favor complete su solicitud de la manera más detallada posible. Es importante que usted responda todas las preguntas.
Sin embargo, la solicitud será válida si usted proporciona el(los) nombre (s), la dirección y la firma. Para ser considerado para el servicio
acelerado de SNAP (Asistencia alimentaria) usted debe completar toda la Sección 8-Por favor no olvide firmar su solicitud en la página 1,
Sección 3.
1. Si está completando esta solicitud en nombre de otra persona y usted no vive en su grupo familiar, por favor suministre
su nombre abajo y su información de contacto en la Sección 7. Si usted está completando esta solicitud en nombre de
otra persona y vive en su grupo familiar, por favor suministre su información en la Sección 9:
Primer nombre Inicial segundo nombre Apellido Sufijo
2. Información para la persona que necesita asistencia: (las personas adicionales pueden agregarse en la Sección 9)
Marcar qué ayuda necesita esta persona: SNAP (Asistencia alimentaria) Asistencia cash (TANF o Refugiado) No solicita
Si marca No solicita es optativo completar el número de Seguro Social y la información sobre ciudadanía de Estados Unidos de América.
Primer nombre Inicial segundo nombre Apellido Sufijo
Condado: Teléfono:
6. Correo electrónico:
7. Si está completando esta solicitud en nombre de otra persona por favor suministre su información de contacto abajo:
Dirección de la calle
Teléfono:
NOTA: Si usted es un representante de la(s) persona(s) que necesita(n) asistencia el solicitante deberá completar y
firmar el formulario anexo de Representante autorizado.
¿Alguien de su grupo familiar es trabajador migratorio o trabajador del campo por temporada? Sí No
¿Usted recibirá más de $25 de ingresos de su nuevo empleador dentro de los 10 días? Sí No
¿Todos en su grupo familiar (incluyéndose usted mismo) han sido aprobados para recibir los
Sí No
beneficios de SNAP este mes?
9. Suministre la siguiente información para todas las personas que viven en la dirección familiar de la Sección 2:
• La persona listada en la Sección 2 no necesita ser listada nuevamente.
• Si se marca No solicita, es optativo completar el número de Seguro Social y la información sobre ciudadanía de EUA.
Marque la ayuda que necesita esta persona: SNAP (Asistencia alimentaria) Asistencia cash (TANF o Refugiado) No solicita
Nombre Inicial segundo nombre Apellido Sufijo
M F Sí No
Marque la ayuda que necesita esta persona: SNAP (Asistencia alimentaria) Asistencia cash (TANF o Refugiado) No solicita
M F Sí No
Marque la ayuda que necesita esta persona: SNAP (Asistencia alimentaria) Asistencia cash (TANF o Refugiado) No solicita
M F Sí No
Marque la ayuda que necesita esta persona: SNAP (Asistencia alimentaria) Asistencia cash (TANF o Refugiado) No solicita
M F Sí No
Marque la ayuda que necesita esta persona: SNAP (Asistencia alimentaria) Asistencia cash (TANF o Refugiado) No solicita
Nombre Inicial segundo nombre Apellido Sufijo
M F Sí No
Si más de seis (6) personas viven en su dirección por favor suministre la información comenzando en la página 6.
10. ¿Cuál prefiere para su cita de entrevista para la solicitud? Por teléfono En una oficina
Por favor indique si necesita los siguientes servicios de interpretación para su cita de entrevista para la solicitud:
Intérprete de idiomas
Idioma:
12. ¿Desea registrarse para votar? Sí No Su respuesta no afectará su elegibilidad para recibir beneficios.
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AVISO RELACIONADO CON LOS DERECHOS Y
LAS RESPONSABILIDADES DEL PROGRAMA DE
*DFRNRAS01*
ASISTENCIA NUTRICIONAL SUPLEMENTARIA Y
ASISTENCIA CASH
DIVISION DE RECURSOS PARA LA FAMILIA
Formulario del Estado 54106 (R10 / 3-16) / DFR 0009CS
13. Determinadas personas deberán estar incluidas en la solicitud y/o tener sus ingresos, recursos, necesidades y/o gastos en consideración para la
determinación de la elegibilidad de los beneficios. Por esta razón, usted deberá reportar a cada persona que vive con usted. En determinados casos,
una cantidad limitada de su información personal puede ser dada a conocer a otro miembro del grupo familiar o sus representantes autorizados para
poder completar los procesos de elegibilidad requeridos.
14. Se requiere que usted reporte los cambios de sus circunstancias a Division of Family Resources (División de Recursos para la Familia). Los
cambios que deberá reportar incluyen su nueva dirección, si se muda, aumentos o disminución del ingreso de su grupo familiar, los
recursos o cualquier cambio en las circunstancias familiares que podría afectar su elegibilidad para los beneficios. Usted debe reportar los
cambios dentro de los diez (10) días de la fecha en la que tiene conocimiento del cambio. Los grupos de asistencia de SNAP deben
reportar únicamente cuando su ingreso bruto mensual sobrepasa el límite del ingreso bruto mensual para el tamaño de su grupo de
Página 1 de 5
DFRNRAS01
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AVISO RELACIONADO CON LOS DERECHOS Y
LAS RESPONSABILIDADES DEL PROGRAMA DE
*DFRNRAS02*
ASISTENCIA NUTRICIONAL SUPLEMENTARIA Y
ASISTENCIA CASH
DIVISION DE RECURSOS PARA LA FAMILIA
Formulario del Estado 54106 (R10 / 3-16) / DFR 0009CS
SECCIÓN 1 (continuo) ESTA SECCIÓN ES PARA SNAP Y ASISTENCIA CASH.
asistencia. El límite de los ingresos mensuales está incluido en el aviso de ilegibilidad. Este cambio deberá ser reportado antes del décimo
(10mo) día del mes siguiente al cambio para ser considerado dentro del límite de tiempo. Se le entregará un formulario describiendo sus
requisitos para reportar.
15. Se requiere que usted suministre la información completa y correcta a su mejor saber y entender. La persona que reciba los beneficios
mediante el suministro intencional de información falsa o sin haber reportado información puede ser procesada criminalmente de acuerdo con la
ley estatal y federal.
16. Usted tiene derecho a recibir un aviso escrito sobre cualquier acción tomada con relación a su solicitud o los beneficios que recibe.
17. Usted puede solicitar una audiencia imparcial por escrito si está en desacuerdo con cualquier acción tomada con respecto a su caso, incluyendo
el procesamiento tardío de su solicitud. Su caso puede ser presentado en la audiencia por cualquier persona de su elección. (Observación:
Los beneficiarios de SNAP pueden hacer su solicitud para una audiencia de SNAP de manera verbal).
18. Cualquier persona que huya para evitar ser procesada por un delito o prisión después de haber sido declarado culpable de un delito, o se
encuentre en violación de la libertad condicional o período de prueba por haber sido condenado por un delito será inelegible para recibir
los beneficios de SNAP y TANF. La información en el archivo de su caso podría hacerse pública y puesta a disposición de
las autoridades a cargo del cumplimiento de la ley para permitirles arrestar a las personas que huyan para evitarla.
19. Cualquier persona encontrada culpable de un delito grave de acuerdo con la ley federal o estatal y este delito incluye la posesión, el uso
o distribución de una sustancia controlada será inelegible para recibir beneficios. La inelegibilidad de acuerdo con esta disposición está
limitada a condenas basadas en el comportamiento que ocurrió después del 22 de agosto de 1996.
20. Se prohíbe a esta institución discriminar sobre la base de raza, color, nacionalidad, discapacidad, edad, sexo y, en algunos casos, creencias
religiosas o políticas.
El Departamento de Agricultura de los EE. UU. también prohíbe la discriminación por motivos de raza, color, nacionalidad, sexo, credo religioso,
discapacidad, edad, creencias políticas, o en represalia o venganza por actividades previas de derechos civiles en algún programa o actividad
realizados o financiados por el USDA.
Las personas con discapacidades que necesiten medios alternativos para la comunicación de la información del programa (por ejemplo, sistema
Braille, letras grandes, cintas de audio, lenguaje de señas americano, etc.), deben ponerse en contacto con la agencia (estatal o local) en la que
solicitaron los beneficios. Las personas sordas, con dificultades de audición o discapacidades del habla pueden comunicarse con el USDA por medio
del Federal Relay Service [Servicio Federal de Retransmisión] al (800) 877-8339. Además, la información del programa se puede proporcionar en
otros idiomas.
Para presentar una denuncia de discriminación, complete el Formulario de Denuncia de Discriminación del Programa del USDA, (AD-3027) que está
disponible en línea en: http://www.ascr.usda.gov/complaint_filing_cust.html y en cualquier oficina del USDA, o bien escriba una carta dirigida al
USDA e incluya en la carta toda la información solicitada en el formulario. Para solicitar una copia del formulario de denuncia, llame al (866) 632-
9992. Haga llegar su formulario lleno o carta al USDA por:
Para obtener información adicional relacionada con problemas con el Programa de Asistencia Nutricional Suplementaria (SNAP, por sus siglas en
inglés), las personas deben comunicarse con el número de línea directa USDA SNAP Hotline al (800) 221-5689, que también está disponible en
español, o llame a los números de información/líneas directas de los estados (haga clic en el vínculo para ver una lista de los números de las líneas
directas de cada estado) que se encuentran en línea en: http://www.fns.usda.gov/snap/contact_info/hotlines.htm
Para presentar una denuncia de discriminación relacionada con un programa que recibe asistencia financiera federal a través del Departamento de
Salud y Servicios Humanos de los EE. UU. (HHS, por sus siglas en inglés), escriba a: HHS Director, Office for Civil Rights, Room 515-F, 200
Independence Avenue, S.W., Washington, D.C. 20201, o llame al (202) 619-0403 (voz) o al (800) 537-7697 (sistema TTY).
Página 2 de 5
DFRNRAS02
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AVISO RELACIONADO CON LOS DERECHOS Y
LAS RESPONSABILIDADES DEL PROGRAMA DE
*DFRNRAS03*
ASISTENCIA NUTRICIONAL SUPLEMENTARIA Y
ASISTENCIA CASH
DIVISION DE RECURSOS PARA LA FAMILIA
Formulario del Estado 54106 (R10 / 3-16) / DFR 0009CS
Página 3 de 5
DFRNRAS03
Page 33
AVISO RELACIONADO CON LOS DERECHOS Y
LAS RESPONSABILIDADES DEL PROGRAMA DE
*DFRNRAS04*
ASISTENCIA NUTRICIONAL SUPLEMENTARIA Y
ASISTENCIA CASH
DIVISION DE RECURSOS PARA LA FAMILIA
Formulario del Estado 54106 (R10 / 3-16) / DFR 0009CS
Excepción: Usted puede reclamar una causa justificada por negarse a cooperar en el intento del Estado para cobrar el Sustento
familiar si considera que la cooperación no sería en beneficio del niño. Las siguientes son circunstancias en las cuales podría determinarse
que usted tiene una causa justificada:
La cooperación es anticipada en que puede resultar en serios daños físicos o emocionales al niño;
La cooperación es anticipada en que puede resultar en serios daños físicos o emocionales a usted que son tan serios que reducen su
capacidad para cuidar al niño adecuadamente;
El niño nació como consecuencia de una violación o incesto;
Los procesos judiciales están en marcha para la adopción del niño; o
Usted está trabajando con una agencia que le ayuda a decidir si debe o no entregar al niño en adopción.
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AVISO RELACIONADO CON LOS DERECHOS Y
LAS RESPONSABILIDADES DEL PROGRAMA DE
*DFRNRAS05*
ASISTENCIA NUTRICIONAL SUPLEMENTARIA Y
ASISTENCIA CASH
DIVISION DE RECURSOS PARA LA FAMILIA
Formulario del Estado 54106 (R10 / 3-16) / DFR 0009CS
Los siguientes son ejemplos de clase de evidencia que pueden ser usadas para la determinación de una existencia de causa justificada.
Si usted necesita ayuda para obtener una copia de cualquiera de los documentos se le ofrecerá asistencia razonable para ayudarle a obtener los
documentos necesarios para respaldar su reclamo.
Partidas de nacimiento o registros médicos o de las autoridades de orden público que indiquen que el niño fue concebido como resultado del
incesto o violación forzada;
Documentos de la corte u otros registros que indiquen que los procesos legales para la adopción se encuentran pendientes en la corte;
Registros de la corte, médicos, criminales, de servicios para la protección del niño, servicios sociales, psicológicos o de las autoridades de orden
público que indiquen que el padre ausente podría causarle daño físico o emocional a usted o al niño;
Registros médicos que indiquen una historia de salud emocional y el estatus actual de su salud o del niño para el que se desea el sustento o
declaraciones escritas de un profesional para la salud mental indicando un diagnóstico relacionado con su salud emocional o la de su niño;
Una declaración escrita de una agencia pública o privada confirmando que usted está siendo asistida para resolver el tema de entregar o no al
niño en adopción; y
Declaraciones escritas de personas, incluyendo amigos, vecinos, miembros del clero, asistentes sociales y profesionales médicos que
podrían tener conocimiento de las circunstancias suministrando las bases de su reclamo de una causa justificada.
En el momento de la terminación de la elegibilidad de TANF, la asignación cesa con respecto al sustento actual. La asignación no terminará con
respecto al dinero debido al estado y los gobiernos federales debido a la prestación de asistencia pública. Después de la terminación de la asistencia,
de acuerdo con las leyes estatales y federales, si la persona legalmente obligada debe sustento actual y/ o obligaciones pendientes al
beneficiario previo de TANF/receptor y al estado, el sustento actual y las obligaciones serán pagadas primero al beneficiario/ receptor previo y
luego al estado, con la excepción de las compensaciones federales impositivas que se aplicarán, en primer lugar, a las cantidades a las que
tenga derecho el gobierno estatal y federal. Las actividades de aplicación del sustento continuarán para usted si bien su TANF ha terminado
excepto si usted le comunica, por escrito, al Child Support Bureau que estos servicios deberían ser descontinuados. Si usted cierra su caso de
aplicación del Sustento para el niño ya no tendrá derecho a recibir los servicios hasta que efectúe la solicitud y pague la tarifa para la solicitud
requerida.
2. Cuando usted solicite TANF deberá seguir las siguientes reglas:
NO hacer declaraciones falsas o engañosas.
NO tomar ninguna acción para esconder o retener los hechos, distorsionar su situación o suministrar documentos falsos.
Si usted viola las reglas arriba descritas se le podría excluir del Programa TANF durante seis (6) meses si es su primera violación, doce
(12) meses por la segunda violación y permanentemente por la tercera violación.
3. Cualquier persona encontrada culpable en una corte por el delito menor de violación de las reglas abajo indicadas puede ser
descalificada del programa TANF durante doce (12) meses por la primera y segunda violación y permanentemente por la tercera
violación. Las personas encontradas culpables por haber cometido un delito de violación de las reglas pueden ser descalificadas
durante diez (10) años por la primera y segunda violación y permanentemente por la tercera.
NO haga declaraciones falsas o engañosas.
NO tome ninguna acción para esconder o retener los hechos, distorsionar su situación o suministrar documentos falsos.
4. Mientras forme parte del programa TANF podría estar disponible para usted un servicio de asistencia para el cuidado de los niños.
La asistencia para el cuidado de los niños también podría estar disponible si pierde su elegibilidad TANF debido a las ganancias.
5. Mientras usted forme parte del programa TANF deberá seguir las siguientes reglas:
Garantizar que sus hijos reciban sus vacunas de acuerdo con su edad.
Garantizar que sus hijos en edad escolar asistan a la escuela regularmente.
Garantizar que sus hijos sean criados en un hogar seguro.
Usted no usará drogas ilegales ni otras sustancias que podrían interferir con su capacidad para ser autosuficiente.
Usted cooperará con el programa IMPACT para desarrollar un plan de autosuficiencia y cumplirá con los requisitos especificados en el plan.
Si no cumple o se niega a cooperar con el programa IMPACT podrían imponerse sanciones que incluyen la pérdida de los beneficios
cash.
Usted no recibirá beneficios cash adicionales para los niños nacidos después de los diez (10) meses que siguen a la fecha en que se le
autorizó a recibir los beneficios TANF.
Si usted es un padre menor de edad, residirá con un adulto que sea pariente suyo, como un padre, padrastro o abuelo o un adulto que sea
su guardián legal.
6. El recibo de los beneficios cash TANF estará limitado a un total de veinticuatro (24) meses para los adultos y sesenta (60) meses para
sus familias.
7. Como una condición de elegibilidad los solicitantes adultos considerados de acuerdo con el mandato del programa de IMPACT serán
referidos a IMPACT para completar un programa de búsqueda de trabajo. El incumplimiento para completar el programa de búsqueda de
trabajo sin una causa justificada es un factor para rechazar la solicitud de TANF.
8. De acuerdo con la ley de Indiana (IC12-13-14-4.5) es un delito menor de Clase C para los beneficiarios de TANF que usen sus beneficios
de la tarjeta electrónica HoosierWorks Card (EBT) para acceder a los beneficios TANF en las tiendas de bebidas alcohólicas o
licorerías, establecimientos de juego, establecimientos de apuestas en carreras de caballos, tiendas de venta de armas y
establecimientos para el entretenimiento de adultos. Una persona condenada por un delito menor de Clase C puede ser encarcelada hasta
sesenta (60) días y multada hasta quinientos ($500) dólares.
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DFRNRAS05