PA Application for Benefits (SNAP, Cash & Medical Assistance) : simplebooklet.com

PA 600 3/23Pennsylvania Application for BenetsIf you have a disability and need this application in large print or another format, please call our helpline at 1-800-692-7462. Individuals who are deaf, hard of hearing, or have speech disabilities and wish to communicate with the helpline may call PA Relay Services by dialing 711. You can apply online at: www.compass.state.pa.us.This is an application for cash, health care and the Supplemental Nutrition Assistance Program (SNAP) benets. If you need this application in another language or someone to interpret, please contact your local county assistance ofce. Language assistance will be provided free of charge.Esta es una solicitud de benecios en efectivo, benecios de atención médica y del Programa de Asistencia Nutricional Suplementaria (SNAP). Si necesita esta solicitud en otro idioma o un intérprete, comuníquese con la ocina de asistencia de su condado. La asistencia lingüística se proporcionará de forma gratuita.此为现金、医疗和补充营养援助计划 (SNAP) 福利申请表。如需其他语言版本或口头翻译，请联系当地的县援助办公室。免费获取语言协助。RESET FIELDS

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PA 600 3/23Family Safety: Information About Your Benets and Domestic ViolenceDomestic violence happens when someone in your life harms you. Abuse can be physical, sexual or emotional. It includes:• Physically hurting you or your children• Threatening or trying to hurt you, your children or your property• Forcing you to have sex• Sexually abusing your children• Controlling where you go and who you see• Not allowing you or your children to have food, clothing or medical care• Keeping you from going to work or school• Following or stalking youIf you are or have been a victim of domestic violence or are at risk of further violence, your caseworker can excuse you from requirements for cash assistance if domestic violence prevents you from complying. Sometimes people cannot safely follow welfare requirements because they fear that they or their children will be abused if they do so. These include:• Support cooperation• Time limits• Work (RESET)• Requirements that teen parents live at home• Other requirements on a case-by-case basis• VericationIf you need to be excused from welfare requirements because of domestic violence, tell your caseworker.If you or your children are or have been victims of domestic violence, or are at risk of further violence, your caseworker can:• Talk to you if you want to talk. You can ask to talk in private. Your caseworker and the staff will keep your personal information condential. However, the law says that the Department of Human Services must report child abuse to the Children and Youth Agency.• Help you nd local programs where you can get counseling, safety planning, shelter, legal services and other help.• Help you understand the rules for applying for cash assistance, and how they affect you if you apply. Certain TANF requirements may be waived based upon domestic violence.For more information about crisis intervention, counseling, accompaniment to police, medical and court facilities, temporary emergency shelter, and prevention and education programs, call:The Pennsylvania Coalition Against Domestic Violence 1-800-932-4632 (in PA) 303-839-1852 (National)PA CareerLink® - Important InformationPA CareerLink® is a program of the Pennsylvania Department of Labor and Industry to help job seekers nd jobs. The Labor and Industry staff knows about current labor market conditions and can give you information and resources to help your job search. It is recommended that you register with PA CareerLink® to get started. You can register with PA CareerLink® at www.pacareerlink.pa.gov/.

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PA 600 3/23Page 1What language do you prefer? ¿Qué idioma preere usted? English/Inglés Spanish/Español Other/Otro (specify/especique) Do you need an interpreter? ¿Necesita un intérprete? Yes/Sí No If yes, what language? En caso armativo, ¿de qué idioma? Go paperless! Would you like to receive your notices online?Go to www.compass.state.pa.us and enroll on your MyCOMPASS Account.• We can start your application as soon as you write your name and address, and sign and return this application.• We encourage you to answer as many questions as you can unless the instructions tell you that you can choose not to answer. The more complete information we have, the faster we can process your application.• If you are eligible, SNAP benets start from the date we receive your application. We will tell you within 30 days if you are eligible or not. IMPORTANT: All persons applying must provide or apply for a Social Security number (SSN) and answer citizenship questions. Providing an SSN is optional for persons not applying for benets, but providing it can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health care coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit www.ssa.gov. TTY users should call 1-800-325-0778. Note: If you are a non-citizen applying for Emergency Medical Services only, you do not need to provide information about your immigration status or apply for or provide an SSN.Tell us about you, the applicant: We will need to contact an adult/parent/caretaker.Name (Include rst, middle initial, last, sufx - Jr./Sr./etc.):Home address (Include street, apt. number, city, state & ZIP code+4)School district: Township or municipality: How long have you lived at this address?Phone number:( )Phone type: Home Work CellSecond phone number:( )Phone type: Home Work CellCheck here if you do not have a home address. You still need to give a mailing address.Mailing address (if different from home address):Quick SNAP: You may be able to get SNAP within 5 days! Answer these questions, then sign this application and give it to your county assistance ofce by 5 p.m. today! Your county assistance ofce will set up an interview with you.Total monthly income, for you and anyone who is applying, before taxes are taken out: $Are you, or anyone you are applying for, getting SNAP now? Yes NoDo you pay for utilities other than telephone? Yes No If yes, which utilities?Total resources (resources are money in cash, checking and savings accounts): $Do you pay for telephone services? Yes NoAre you, or anyone you are applying for, a seasonal or migrant farm worker? Yes NoTotal monthly rent or mortgage for you and anyone who is applying: $Do you pay for heating or the cost to run air conditioning? Yes NoDo you, or anyone you are applying for, live in a shelter for abused or battered women and children? Yes NoSign here:XYour signature or your representative’s signature DateGetting StartedWhat do you want to apply for? Cash assistance Health Care Coverage SNAP (Supplemental Nutrition Assistance Program)

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PA 600 3/23Page 3Person 2CAO Use Only Line #:Name (Include rst, middle initial, last, sufx-Jr./Sr./etc.) Are you applying for this person? Yes NoSocial Security number:Birthdate (MM/DD/YYYY):Sex M FDriver’s license or state ID number if this person has one: MaritalStatus Single Separated Married Divorced WidowedHow is this person related to you? Spouse Child Stepchild Not Related Other _____________________________________________Does this person live with you? Yes NoIs this person in school? Yes NoIf yes, what grade? Name of school:Full-time student? Yes NoIs this person pregnant? Yes NoIf yes, due date? How many babies are expected?Answer the questions below if you are applying for this person.You do not need to answer these questions if you are applying only for SNAP. Yes No If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only? Yes No If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income. Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No Regardless of age, are they afraid that information they may receive where they live about family planning services could cause physical, emotional, or other harm from their spouse, parents, or other person?If yes, do they have another address (other than where they live) where they’d like to get information about family planning services?Is this person a U.S. citizen or national? Yes NoIf this person is not a U.S. citizen or national, answer the following questions:Does this person have eligible immigration status? Yes If yes, ll in the document type and ID number:Document type: Document ID number:Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes NoRACE (Optional)(Check all that apply) Black or African American Asian Native Hawaiian or Pacic Islander American Indian or Alaska Native (See Appendix A) White Other _______________________________ETHNICITY (Optional) Hispanic or Latino Non Hispanic or LatinoPerson 3CAO Use Only Line #:Name (Include rst, middle initial, last, sufx-Jr./Sr./etc.) Are you applying for this person? Yes NoSocial Security number:Birthdate (MM/DD/YYYY):Sex M FDriver’s license or state ID number if this person has one: MaritalStatus Single Separated Married Divorced WidowedHow is this person related to you? Spouse Child Stepchild Not Related Other _____________________________________________Does this person live with you? Yes NoIs this person in school? Yes NoIf yes, what grade? Name of school:Full-time student? Yes NoIs this person pregnant? Yes NoIf yes, due date? How many babies are expected?Answer the questions below if you are applying for this person.You do not need to answer these questions if you are applying only for SNAP. Yes No If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only? Yes No If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income. Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No Regardless of age, are they afraid that information they may receive where they live about family planning services could cause physical, emotional, or other harm from their spouse, parents, or other person?If yes, do they have another address (other than where they live) where they’d like to get information about family planning services?Is this person a U.S. citizen or national? Yes NoIf this person is not a U.S. citizen or national, answer the following questions:Does this person have eligible immigration status? Yes If yes, ll in the document type and ID number:Document type: Document ID number:Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes NoRACE (Optional)(Check all that apply) Black or African American Asian Native Hawaiian or Pacic Islander American Indian or Alaska Native (See Appendix A) White Other _______________________________ETHNICITY (Optional) Hispanic or Latino Non Hispanic or Latino

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PA 600 3/23Page 4Person 4CAO Use Only Line #:Name (Include rst, middle initial, last, sufx-Jr./Sr./etc.) Are you applying for this person? Yes NoSocial Security number:Birthdate (MM/DD/YYYY):Sex M FDriver’s license or state ID number if this person has one: MaritalStatus Single Separated Married Divorced WidowedHow is this person related to you? Spouse Child Stepchild Not Related Other _____________________________________________Does this person live with you? Yes NoIs this person in school? Yes NoIf yes, what grade? Name of school:Full-time student? Yes NoIs this person pregnant? Yes NoIf yes, due date? How many babies are expected?Answer the questions below if you are applying for this person.You do not need to answer these questions if you are applying only for SNAP. Yes No If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only? Yes No If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income. Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No Regardless of age, are they afraid that information they may receive where they live about family planning services could cause physical, emotional, or other harm from their spouse, parents, or other person?If yes, do they have another address (other than where they live) where they’d like to get information about family planning services?Is this person a U.S. citizen or national? Yes NoIf this person is not a U.S. citizen or national, answer the following questions:Does this person have eligible immigration status? Yes If yes, ll in the document type and ID number:Document type: Document ID number:Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes NoRACE (Optional)(Check all that apply) Black or African American Asian Native Hawaiian or Pacic Islander American Indian or Alaska Native (See Appendix A) White Other _______________________________ETHNICITY (Optional) Hispanic or Latino Non Hispanic or LatinoPerson 5CAO Use Only Line #:Name (Include rst, middle initial, last, sufx-Jr./Sr./etc.) Are you applying for this person? Yes NoSocial Security number:Birthdate (MM/DD/YYYY):Sex M FDriver’s license or state ID number if this person has one: MaritalStatus Single Separated Married Divorced WidowedHow is this person related to you? Spouse Child Stepchild Not Related Other _____________________________________________Does this person live with you? Yes NoIs this person in school? Yes NoIf yes, what grade? Name of school:Full-time student? Yes NoIs this person pregnant? Yes NoIf yes, due date? How many babies are expected?Answer the questions below if you are applying for this person.You do not need to answer these questions if you are applying only for SNAP. Yes No If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only? Yes No If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income. Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No Regardless of age, are they afraid that information they may receive where they live about family planning services could cause physical, emotional, or other harm from their spouse, parents, or other person?If yes, do they have another address (other than where they live) where they’d like to get information about family planning services?Is this person a U.S. citizen or national? Yes NoIf this person is not a U.S. citizen or national, answer the following questions:Does this person have eligible immigration status? Yes If yes, ll in the document type and ID number:Document type: Document ID number:Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes NoRACE (Optional)(Check all that apply) Black or African American Asian Native Hawaiian or Pacic Islander American Indian or Alaska Native (See Appendix A) White Other _______________________________ETHNICITY (Optional) Hispanic or Latino Non Hispanic or Latino

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PA 600 3/23Page 5Person 6CAO Use Only Line #:Name (Include rst, middle initial, last, sufx-Jr./Sr./etc.) Are you applying for this person? Yes NoSocial Security number:Birthdate (MM/DD/YYYY):Sex M FDriver’s license or state ID number if this person has one: MaritalStatus Single Separated Married Divorced WidowedHow is this person related to you? Spouse Child Stepchild Not Related Other _____________________________________________Does this person live with you? Yes NoIs this person in school? Yes NoIf yes, what grade? Name of school:Full-time student? Yes NoIs this person pregnant? Yes NoIf yes, due date? How many babies are expected?Answer the questions below if you are applying for this person.You do not need to answer these questions if you are applying only for SNAP. Yes No If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only? Yes No If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income. Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No Regardless of age, are they afraid that information they may receive where they live about family planning services could cause physical, emotional, or other harm from their spouse, parents, or other person?If yes, do they have another address (other than where they live) where they’d like to get information about family planning services?Is this person a U.S. citizen or national? Yes NoIf this person is not a U.S. citizen or national, answer the following questions:Does this person have eligible immigration status? Yes If yes, ll in the document type and ID number:Document type: Document ID number:Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes NoRACE (Optional)(Check all that apply) Black or African American Asian Native Hawaiian or Pacic Islander American Indian or Alaska Native (See Appendix A) White Other _______________________________ETHNICITY (Optional) Hispanic or Latino Non Hispanic or LatinoPerson 7CAO Use Only Line #:Name (Include rst, middle initial, last, sufx-Jr./Sr./etc.) Are you applying for this person? Yes NoSocial Security number:Birthdate (MM/DD/YYYY):Sex M FDriver’s license or state ID number if this person has one: MaritalStatus Single Separated Married Divorced WidowedHow is this person related to you? Spouse Child Stepchild Not Related Other _____________________________________________Does this person live with you? Yes NoIs this person in school? Yes NoIf yes, what grade? Name of school:Full-time student? Yes NoIs this person pregnant? Yes NoIf yes, due date? How many babies are expected?Answer the questions below if you are applying for this person.You do not need to answer these questions if you are applying only for SNAP. Yes No If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family Planning Services program only? Yes No If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income. Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage? Yes No Regardless of age, are they afraid that information they may receive where they live about family planning services could cause physical, emotional, or other harm from their spouse, parents, or other person?If yes, do they have another address (other than where they live) where they’d like to get information about family planning services?Is this person a U.S. citizen or national? Yes NoIf this person is not a U.S. citizen or national, answer the following questions:Does this person have eligible immigration status? Yes If yes, ll in the document type and ID number:Document type: Document ID number:Does this person have a sponsor? Yes No Has this person lived in the U.S. since 1996? Yes NoRACE (Optional)(Check all that apply) Black or African American Asian Native Hawaiian or Pacic Islander American Indian or Alaska Native (See Appendix A) White Other _______________________________ETHNICITY (Optional) Hispanic or Latino Non Hispanic or Latino

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PA 600 3/23Page 6Other questions about people in your home:Please answer these questions about you or anyone in your home who is applying for benets.Does anyone get cash assistance, Medical Assistance or SNAP in another state now? Yes NoIf yes, what state and county?Have you or anyone in your household been disqualied or agreed to be disqualied for food stamps or SNAP benets in another state? Yes NoIf yes, tell us who:Has anyone ever applied for any benets using a different name or Social Security number? Yes NoIf yes, please tell us the name and Social Security number:Is anyone in the U.S. military, or has anyone been in the U.S. military? Yes NoIs anyone a widow, spouse, or child (under age 18) of anyone in the U.S. military, or anyone who has been in the U.S. military? Yes NoWas anyone in foster care at age 18 or older? Yes NoIf yes, who? State:Is anyone disabled, seriously ill, or in need of medical attention? Yes NoIf yes, who? What is the disability?Does anyone have a medical condition that requires health sustaining medication? Yes NoIf yes, who?Does anyone live in a medical or long term care facility or have a physical, mental or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.)? Yes NoDoes anyone have paid or unpaid medical bills this month or the last three months? Yes NoHas anyone been a victim of domestic abuse? Yes NoIs anyone in treatment for drug or alcohol abuse? Yes NoIf yes, who?Absent relatives: This section is for cash applicants.If anyone is applying for a child who has parents not living in your home or if anyone applying has a spouse not living in your home, please answer these questions so that we can try to get support. You do not need to ll out this section if providing this information or seeking support would put you or family members at risk of domestic violence or make it more difcult to escape domestic violence, or if your child was born as a result of rape or incest, or if you are considering adoption.If it would be a problem for you to provide this information or seek support because of domestic violence, rape or incest or because you are considering putting a child up for adoption, check this box: Name of person with an absent relative: Name of absent relative: Absent relative is a: Parent SpouseName of person with an absent relative: Name of absent relative: Absent relative is a: Parent SpouseName of person with an absent relative: Name of absent relative: Absent relative is a: Parent SpouseName of person with an absent relative: Name of absent relative: Absent relative is a: Parent SpouseName of person with an absent relative: Name of absent relative: Absent relative is a: Parent SpouseName of person with an absent relative: Name of absent relative: Absent relative is a: Parent Spouse If you are applying for cash assistance, you must name the parents of any minor children and help the Domestic Relations Section (DRS) collect support by providing the information they need unless you have good cause. If you do not help the DRS by providing the information needed and do not have a good reason for not helping, any cash assistance amount for which you are approved will be lowered by at least 25 percent. If approved for cash assistance, you must give the Department and DRS the right to collect cash for you and others for whom you are applying. The law says that support rights will be assigned to the state if you accept cash assistance. If support is paid for a child who gets cash assistance, the family may get some of the support in addition to the cash assistance grant.

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PA 600 3/23Page 12COUNTY ASSISTANCE OFFICE STAFF WILL COMPLETE THIS BOX BASED UPON YOUR RESPONSE ABOVE__/__/__CAO USE ONLY1. Yes No Is anyone in the application group receiving SNAP and not living in a certied shelter for battered women and children?2. Yes No Is there any postponed verication from a previous expedited issuance that the household must provide?3. Yes No Are the household liquid resources equal to or less than $100?4. Yes No Is the countable monthly gross income less than $150?5. Yes No Is this a migrant or seasonal farm worker household?6. Yes No Is the household destitute?7. Yes No Are combined monthly gross income and liquid resources less than monthly shelter expenses?EXPEDITED REVIEWInitials: Date: Eligible Denied -CLIENTNOTIFIEDReason for denial:REGISTERED FOR CATEGORIESCriminal history inquiry: You do not need to answer these questions if you are applying only for health care.Please answer the following questions for yourself and anyone else for whom you are applying:Does anyone have a summons or warrant to appear as a defendant at a criminal court proceeding? Yes NoIf yes, who?Does anyone owe nes, costs or restitution for a felony or misdemeanor offense? Yes NoIf yes, who?Does anyone have a payment plan for nes and costs? Yes NoIf yes, who?Is anyone on probation or parole? Yes NoIf yes, who?Is anyone who is on probation or parole not complying? Yes NoIf yes, who?Has anyone been convicted of welfare fraud? Yes NoIf yes, who?Is anyone eeing from law enforcement? Yes NoIf yes, who?Is anyone required to register as a convicted sexual offender? Yes NoIf yes, who?Is anyone who is required to register as a convicted sexual offender not complying with their registration requirements? Yes NoIf yes, who?If you are not registered to vote where you live now, would you like to apply to register to vote here today?  Yes  NoIF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.To register, you must: 1) Be at least 18 on the day of the next election; 2) Be a citizen of the United States for at least one month PRIOR TO THE NEXT ELECTION; 3) Reside in Pennsylvania and the voting district at least 30 days prior to the next election.Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this agency.If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Please contact the county assistance office if you would like help.If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-free telephone number 1-877-VOTESPA.) Voter Registration (Optional): This section is for U.S. Citizens only

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PA 600 3/23Page 13Your Rights and Responsibilities Read about your rights and responsibilities:RIGHT TO NONDISCRIMINATIONThis 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 benets. 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 le a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_ling_cust.html, and at any USDA ofce, 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 Ofce of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410(2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.To le a complaint of discrimination regarding a program receiving Federal nancial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Ofce for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY). This institution is an equal opportunity provider.RIGHT TO CONFIDENTIALITYWe will keep your information private. It will only be used to decide which programs you may be eligible for. The county assistance ofce (CAO), when requested, must provide federal, state and local law enforcement ofcials with the address, Social Security number (SSN) and photograph (if available) of an individual who is eeing to avoid prosecution, custody or connement for a felony or violating probation or parole. Any person knowingly violating any of the rules and regulations of this department shall be guilty of a misdemeanor and, upon conviction shall be sentenced to pay a ne, not exceeding one hundred ($100) dollars, or to undergo imprisonment, not exceeding six months, or both (62 P.S. section 483).RIGHT TO A WRITTEN NOTICEWe will give you a written notice explaining your benets. If we deny, change, suspend or stop benets, we will give you a written explanation of why. You have 30 days (90 days for Supplemental Nutrition Assistance Program (SNAP) benets) from the mailing date of the notice to ask for a hearing.RIGHT TO APPEALYou have the right to ask for a Department of Human Services (DHS) hearing to appeal a decision if you believe it is unfair or incorrect, or if DHS fails to act on your application for benets. You may le the appeal at the CAO. If you appeal, you may also request an agency conference before the hearing. If your appeal involves expedited SNAP benets, you have the right to have this conference with a supervisor within two work days. At the hearing you may represent yourself, or someone else, such as a lawyer, friend or relative may represent you.RIGHT TO CLAIM GOOD CAUSEIf you apply for cash or Medical Assistance benets, the law requires you to cooperate with establishing paternity and seeking support. You may be excused from these requirements if you prove it may be dangerous for you and/or your children. This is known as good cause. Unless a good cause exemption is established, you will be required to meet employment and training requirements. You will also be required to meet semi-annual reporting requirements unless good cause is granted.RIGHT TO CERTIFICATE OF CREDITABLE COVERAGEFederal law limits when health coverage may be denied or limited for a pre-existing condition. If you enroll in a group health plan that excludes treatment for a condition you already had, you can be credited for the time you received Medical Assistance coverage. This may help you obtain coverage. Contact your caseworker to request this certicate.RESPONSIBILITY TO PROVIDE INFORMATIONYou must give true, correct and complete information. You must help in proving the information you give. Benets may be denied if you fail to provide certain proof. If you cannot provide proof, you should ask the CAO to help you obtain it. If you are contacted by DHS or the Ofce of State Inspector General, you must fully cooperate with those persons or investigators. If you are age 55 or older and receive Medical Assistance to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, you may be required to repay the cost of these services from your probate estate. If you are applying for cash assistance, we may require you to sign an agreement to repay benets that you, your spouse and your children have received.RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERSFor cash, Medical Assistance and/or SNAP benets, you must provide an SSN for each person for whom you are applying. If you do not have an SSN, you must apply for one. Not providing an SSN may result in not being able to receive benets. For cash benets, we may ask for an SSN for anyone whose income or resources may affect your eligibility or the amount of benets. Your SSN will be used for identity, for computer matches which verify income and resources, and to prevent duplication of state and federal benets. A non-citizen who is applying for emergency Medical Assistance only is not required to provide an SSN. (42 U.S. Code 1320b-7)RESPONSIBILITY TO USE THE PA ACCESS CARD LAWFULLYOnce you are eligible for benets, you will be issued a PA ACCESS card. This card may only be used for the person who is eligible and only during the eligibility period. You may only use the card for services that are needed and reasonable.RESPONSIBILITY TO REPORT CHANGESIf you qualify for benets, you will be required to report changes in your circumstances to your caseworker or to the Customer Service Center. Types of changes reported would include people leaving or moving into the house, a new address, a new job for someone, if someone loses a job, birth of a child, new sources of income or changes to income, and lottery and gambling winnings. Your caseworker and notices you receive will cover the specics in detail based on the programs and benets you are eligible for. Failure to report required changes within the program guidelines could result in a loss of benets, sanctions, or civil or criminal charges. You may report changes to the CAO in person, by phone, fax, mail or through a MyCOMPASS account. You may also report changes to the Customer Service Center at 1-877-395-8930, or for Philadelphia, 1-215-560-7226 any time.PRIVACY ACT STATEMENT(i) The collection of this information, including the Social Security number (SSN) of each household member, is authorized under the Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036d. The information will be used to determine whether your household is eligible or continues to be eligible to participate in the SNAP Program. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management.(ii) This information may be disclosed to other federal and state agencies for ofcial examination, and to law enforcement ofcials for the purpose of apprehending persons eeing to avoid the law.(iii) If a SNAP claim arises against your household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.(iv) Providing the requested information, including the SSN of each household member, is voluntary. However, failure to provide an SSN will result in the denial of SNAP benets to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members.

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PA 600 3/23Page 14Prohibitions and Penalties Read about your responsibilities:IF THIS HAPPENS WITHOUT GOOD CAUSE THIS MAY HAPPEN (PENALTY)ALL BENEFITSSNAPCASHMEDICAL ASSISTANCEMisuse Electronic Benets Transfer (EBT) Card or PA ACCESS Card. Fine, prison, or both.Do not report changes, as required. Benets cut or stopped.On purpose, give information that is false, incorrect or incomplete, or not report changes.Fine, disqualication and/or jail time for Welfare Fraud, disqualication for administrative hearing proceedings.Not eligible for cash:• First time - 6 months.• Second time - 12 months.• Third time - forever.Not eligible for SNAP:• First time - 12 months.• Second time - 24 months.• Third time - forever.Trade, sell or attempt to trade, sell, buy or use another person’s ACCESS Card.Not eligible:• All court convictions - 12 months.SNAPOn purpose, misuse SNAP benets, for example, trade, sell, or buy EBT Card or SNAP benets; convert benets; or dump containers purchased with SNAP benets to receive deposits – or buy things not covered by SNAP, such as alcohol or tobacco – or use SNAP benets to pay for food already received or food on credit.Not eligible:• First time - 12 months.• Second time - 24 months.• Third time - forever.• First time court conviction over $500 - forever.Purchase a product with SNAP benets with the intent of obtaining cash or consideration other than eligible food by reselling the product in exchange for cash or consideration other than eligible food.On purpose, purchase products originally purchased with SNAP benets in exchange for cash or consideration other than eligible food.Use/receive SNAP benets to buy drugs or controlled substances.Not eligible:• First time - 24 months.• Second time - forever.Use/receive SNAP benets in sale of rearms, ammunition, or explosives. First time - not eligible forever.Be convicted for buying, selling or trading SNAP benets for total of $500 or more. Not eligible forever.Lie about who you are or where you live to receive more than one SNAP benet. Not eligible for 10 years.Flee to avoid prosecution, custody, or connement because of a felony/attempted felony – or ee because of breaking probation or parole.Not eligible until you do what the law says.CASHDo not comply with your court penalty, including payment of nes, for a felony or misdemeanor. Not eligible until you comply with your penalty.Lie about where you live to receive cash in two or more states. Not eligible for 10 years.Flee to avoid prosecution, custody, or connement because of a felony conviction/attempted felony; fail to appear as a defendant at a criminal court proceeding when issued a summons or a bench warrant for a summary offense, felony or misdemeanor; ee because of breaking probation/parole; or have any active warrant against you.Not eligible until you do what the law says.If you are found guilty of fraud or breaking the above rules:• Fine up to $250,000 for SNAP and up to $15,000 for Cash;• Jail up to 20 years for SNAP and up to seven years for Cash; and/or• Paying back benets received.• Disqualication from benets for periods stated above by program.SNAP WORK RULESFor household members – physically and mentally t – over age 15 and under 60 – not otherwise exempt or with good cause.Not eligible:• First time - one month and until you do what is required.• Second time - three months and until you do what is required.• Three or more times - six months each time and until you do what is required.Refuse to:• Accept a job.• Tell CAO about work status and job availability.On purpose, take action to:• Quit a job.• Cut work hours to less than 30 per week (unless another job already meets work requirements). CASH WORK RULESDo not meet cash work requirements on purpose, as written on the Agreement of Mutual Responsibility (AMR). Not eligible:• First violation - You will be ineligible for a minimum of 30 days or until the failure to comply ceases, whichever is longer.• Second violation - You will be ineligible for a minimum of 60 days or until the failure to comply ceases, whichever is longer.• Third violation - You will be permanently disqualied.If the reason for sanction occurs within the rst 24 months of receipt of cash assistance, whether consecutive or interrupted, the sanction applies only to the individual.If the reason for sanction occurs after 24 months of receipt of cash assistance, whether consecutive or interrupted, the sanction applies to the entire family.

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PA 600 3/23Page 15Understanding Your Rights and ResponsibilitiesWhen I sign this form:• I understand that Pennsylvania receives information from the Income Eligibility Verication System (IEVS), nancial institutions, consumer reporting, and state and federal agencies to verify the information I give them. Information available through IEVS and other entities will be requested, used and may be veried through collateral contact when conicting details are found by the state agency, and such information may affect my household’s eligibility and level of benets.• I understand that by signing this application, I am authorizing any nancial institution to disclose, through electronic or any other means, any and all nancial information held by that institution, to the Department of Human Services or its designated agent or contractor for the purpose of identifying and verifying resources (also called “assets”) when needed to determine and redetermine eligibility for Medical Assistance. I understand that nancial information includes deposits, withdrawals, account closures and other relevant information requested or received from the nancial institution, including other transactions undertaken by the nancial institution with respect to the account or asset. I understand that this authorization is effective until Medical Assistance eligibility is denied or ends, or if I decide to revoke it by written notication to the department, whichever happens rst. I understand that if I revoke this authorization, that may make me or my household ineligible for Medical Assistance. • I understand that if I misrepresent, hide or withhold facts that may affect my eligibility for benets, I may be required to repay my benets and I may be prosecuted and disqualied from receiving certain future benets.• I understand that I can designate an authorized representative by completing the Authorized Representative section and submitting it with this application.• I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is being submitted by someone acting on my behalf.• I received a copy of my rights and responsibilities, have read them or someone has read them to me, and I understand them.• I understand that the information entered in this application will be kept condential and used only to administer benets. I authorize the release of personal, nancial and medical information for the purpose of determining eligibility.• I understand that the Department of Human Services or its designees may contact me via methods including email and text messaging to help process my application or request feedback on the application process. If I do not want email or text messages, I understand the Department of Human Services will still process my application.• I understand that any changes I am required to report must be reported within the rst 10 days of the month following the month of change. • I understand that my household may lose SNAP benets if a household member receives lottery or gambling winnings equal to or greater than the SNAP resource limit for elderly or disabled households.• I understand that I will receive a written notice explaining the benets. If benets are denied, changed, suspended or stopped, the written notice will explain why.• I understand that I will have 30 days (90 days for SNAP (food stamp) benets) from the date of the notice to request a hearing if I do not agree with the decision made on this application.• I understand that my situation is subject to verication from employers, nancial sources and other third parties.• I understand that applicants must provide their Social Security number or apply for one if they do not have one. This number may be used to check the information on this application.• I understand that I must use the Electronic Benet Transfer (EBT) or the PA ACCESS Card only during the period I am eligible. I must use the EBT or the PA ACCESS Card only for the person who is eligible and may get only the benets that are needed and reasonable.• I understand that I may not use Cash Assistance funds issued through my PA ACCESS card to make EBT transactions in liquor stores, casinos (gambling casinos, gaming establishments), or places for adult entertainment.• I understand that I do not have to provide a Social Security number for anyone who is not applying for assistance. If I do provide their Social Security number, it may be used to check the information on this application.• I certify that all information that has been entered is true under penalty of perjury.• I understand that I have the right to a certicate of creditable coverage to verify my medical coverage. Federal law limits when Medical Assistance coverage may be denied or limited for a pre-existing condition. If I enroll in a group health plan that has a pre-existing condition clause, I can get credit for the time I received Medical Assistance.• I understand that if I am determined eligible for Medical Assistance, I will be placed in the most comprehensive Medical Assistance benet package that is available to me. I understand that I may be required to enroll in a health plan. I understand that enrolling in a health plan may be free or low cost to me, because the Department pays a monthly fee to the health plan for me. I understand that the monthly fee is a capitation fee. I understand that if I receive Medical Assistance that I am not eligible for, due to error, fraud, or any other reason, then I may be required to repay the Department all monthly fees paid on my behalf.• If I receive cash benets, I will cooperate with the requirements of the child support enforcement program as directed by the department. I give the Department and the Domestic Relations Section the right to pursue and collect cash and/or medical support for me and others for whom I am applying.• I understand that if I report or provide proof of the household expenses, I will get the maximum amount of SNAP (food stamp) benets allowed. Failure to report or provide proof of the household expenses will be regarded as my statement that I do not want to receive a deduction for the unreported or unproved expense. (Authority: United States Department of Agriculture, Food and Nutrition Service, Mid-Atlantic Region, Administrative Notice 6-99, issued January 4, 1999).• I understand that I have the right to receive credit for the household expenses at the time I report and provide proof of them at any time during my SNAP (food stamps) certication period.• I understand that I have the right to ask the county assistance ofce (CAO) for assistance in getting proof of expenses and that the CAO can contact other people for conrmation if I am having trouble getting proof of anything.• I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for CHIP. • I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for federal benets and/or explore private health care options through Pennsylvania’s Health Insurance Marketplace (Pennie). If this is the case, I authorize the Department to give my name and information on this application to Pennie.• Renewal of coverage in future years: To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow Pennsylvania’s Health Insurance Marketplace (Pennie) to use my income data, including information from tax returns. Pennie will send me a notice, let me make any changes, and I can opt out at any time. Yes, renew my eligibility automatically for the next: (Check one): Five years (the maximum number of years allowed) Four years Three years Two years One year Do not use my information from tax returns to renew my coverage.IMPORTANT: If your household is eligible for SNAP/LIHEAP, you may receive a Fast Track consent form in the mail that could allow you and your household members to be automatically enrolled in Medical Assistance.Name of Authorized Representative Address of Authorized Representative Phone NumberCOUNTY ASSISTANCE OFFICE ONLYI have explained to the applicant her or his rights and responsibilities.CAO Signature DateSign here:XYour signature or your representative’s signature Date

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PA 600 3/23American Indian or Alaska Native Family Member (AI/AN)Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your Application for Health Care Coverage. You do not need to complete this appendix if you are applying only for SNAP.Tell us about your American Indian or Alaska Native family member(s).American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer the following questions to make sure your family gets the most help possible.NOTE: If you have more people to include, make a copy of this page and attach.AI/AN PERSON 1 Please Print All InformationName (rst name, middle name, last name):Member of a federally recognized tribe? Yes NoIf yes, tribe name: ________________________________ State: ____________Has this person ever gotten a service from the Indian Health Service, a tribal health program or urban Indian health program, or through a referral from one of these programs? Yes NoIf no, is this person eligible to get services from the Indian Health Service, tribal health programs or urban Indian health programs, or through a referral from one of these programs? Yes NoCertain money received may not be counted for health care. List any income (amount and how often) reported on your application that includes money from these sources:• Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties.• Payments from natural resources, farming, ranching, shing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations).• Money from selling things that have cultural signicance.$ _______________________________________How often? ______________________________AI/AN PERSON 2 Please Print All InformationName (rst name, middle name, last name):Member of a federally recognized tribe? Yes NoIf yes, tribe name: ________________________________ State: ____________Has this person ever gotten a service from the Indian Health Service, a tribal health program or urban Indian health program, or through a referral from one of these programs? Yes NoIf no, is this person eligible to get services from the Indian Health Service, tribal health pro-grams or urban Indian health programs, or through a referral from one of these programs? Yes NoCertain money received may not be counted for health care. List any income (amount and how often) reported on your application that includes money from these sources:• Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties.• Payments from natural resources, farming, ranching, shing, leases, or royalties from land designated as Indian trust land by the Department of Interior (including reservations and former reservations).• Money from selling things that have cultural signicance.$ _______________________________________How often? ______________________________Appendix A

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PA 600 3/23Health Coverage from Job(s)Tell us about the job that offers coverage. You DO NOT need to answer these questions unless someone in the household is eligible for health coverage from a job. You do not need to complete this appendix if you are applying only for SNAP.Write your name and Social Security number in the Employee Information section. You may need to ask your employer to help you complete the Employer Information section. If you are unable to get this information from your employer timely, or you feel like completing this would delay the start of your application, you may submit your application without Appendix B.Attach a copy of this page for each job that offers coverage.EMPLOYEE InformationEmployee name (rst, middle, last): Social Security number:EMPLOYER InformationEmployer name: Employer identication number (EIN)Employer address (include street, number, city, state & ZIP code +4): Employer phone number:( )Who can we contact about employee health coverage at this job?Phone number (if different from above):( )Email address:Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next three months? Yes (continue) If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? __________________ No (STOP and return this form to employee)Tell us about the health plan offered by this employer.Does the employer offer a health plan that covers an employee’s spouse or dependent(s)? Yes. Which people: Spouse Dependent(s) No (go to the next question)Does the employer offer a health plan that meets the minimum value standard?* Yes (go to the next question) No (STOP and return form to employee)For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.How much would the employee have to pay in premiums for this plan? $ _________________________How often? Weekly Every two weeks Twice a month Monthly Quarterly YearlyIf your plan will end soon and you know that the health plans offered will change, go to the next question. If you don’t know, STOP and return form to employee.What change will the employer make for the new plan year? Employer will not offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reect the discount for wellness programs. See question above.)How much would the employee have to pay in premiums for this plan? $ ________________________How often? Weekly Every two weeks Twice a month Monthly Quarterly YearlyDate of change: (mm/dd/yyyy) _____________________________*An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benet costs covered by the plan is no less than 60 percent of such costs (Section 36B(C)(2)(C)(ii) of the Internal Revenue Code of 1986).Appendix B

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PA 600 3/23CLIENTYour Rights and Responsibilities Read about your rights and responsibilities:RIGHT TO NONDISCRIMINATIONThis 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 benets. 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 le a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online at: http://www.ascr.usda.gov/complaint_ling_cust.html, and at any USDA ofce, 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 Ofce of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410(2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov.For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at: http://www.fns.usda.gov/snap/contact_info/hotlines.htm.To le a complaint of discrimination regarding a program receiving Federal nancial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Ofce for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY). This institution is an equal opportunity provider.RIGHT TO CONFIDENTIALITYWe will keep your information private. It will only be used to decide which programs you may be eligible for. The county assistance ofce (CAO), when requested, must provide federal, state and local law enforcement ofcials with the address, Social Security number (SSN) and photograph (if available) of an individual who is eeing to avoid prosecution, custody or connement for a felony or violating probation or parole. Any person knowingly violating any of the rules and regulations of this department shall be guilty of a misdemeanor and, upon conviction shall be sentenced to pay a ne, not exceeding one hundred ($100) dollars, or to undergo imprisonment, not exceeding six months, or both (62 P.S. section 483).RIGHT TO A WRITTEN NOTICEWe will give you a written notice explaining your benets. If we deny, change, suspend or stop benets, we will give you a written explanation of why. You have 30 days (90 days for Supplemental Nutrition Assistance Program (SNAP) benets) from the mailing date of the notice to ask for a hearing.RIGHT TO APPEALYou have the right to ask for a Department of Human Services (DHS) hearing to appeal a decision if you believe it is unfair or incorrect, or if DHS fails to act on your application for benets. You may le the appeal at the CAO. If you appeal, you may also request an agency conference before the hearing. If your appeal involves expedited SNAP benets, you have the right to have this conference with a supervisor within two work days. At the hearing you may represent yourself, or someone else, such as a lawyer, friend or relative may represent you.RIGHT TO CLAIM GOOD CAUSEIf you apply for cash or Medical Assistance benets, the law requires you to cooperate with establishing paternity and seeking support. You may be excused from these requirements if you prove it may be dangerous for you and/or your children. This is known as good cause. Unless a good cause exemption is established, you will be required to meet employment and training requirements. You will also be required to meet semi-annual reporting requirements unless good cause is granted.RIGHT TO CERTIFICATE OF CREDITABLE COVERAGEFederal law limits when health coverage may be denied or limited for a pre-existing condition. If you enroll in a group health plan that excludes treatment for a condition you already had, you can be credited for the time you received Medical Assistance coverage. This may help you obtain coverage. Contact your caseworker to request this certicate.RESPONSIBILITY TO PROVIDE INFORMATIONYou must give true, correct and complete information. You must help in proving the information you give. Benets may be denied if you fail to provide certain proof. If you cannot provide proof, you should ask the CAO to help you obtain it. If you are contacted by DHS or the Ofce of State Inspector General, you must fully cooperate with those persons or investigators. If you are age 55 or older and receive Medical Assistance to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, you may be required to repay the cost of these services from your probate estate. If you are applying for cash assistance, we may require you to sign an agreement to repay benets that you, your spouse and your children have received.RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERSFor cash, Medical Assistance and/or SNAP benets, you must provide an SSN for each person for whom you are applying. If you do not have an SSN, you must apply for one. Not providing an SSN may result in not being able to receive benets. For cash benets, we may ask for an SSN for anyone whose income or resources may affect your eligibility or the amount of benets. Your SSN will be used for identity, for computer matches which verify income and resources, and to prevent duplication of state and federal benets. A non-citizen who is applying for emergency Medical Assistance only is not required to provide an SSN. (42 U.S. Code 1320b-7)RESPONSIBILITY TO USE THE PA ACCESS CARD LAWFULLYOnce you are eligible for benets, you will be issued a PA ACCESS card. This card may only be used for the person who is eligible and only during the eligibility period. You may only use the card for services that are needed and reasonable.RESPONSIBILITY TO REPORT CHANGESIf you qualify for benets, you will be required to report changes in your circumstances to your caseworker or to the Customer Service Center. Types of changes reported would include people leaving or moving into the house, a new address, a new job for someone, if someone loses a job, birth of a child, new sources of income or changes to income, and lottery and gambling winnings. Your caseworker and notices you receive will cover the specics in detail based on the programs and benets you are eligible for. Failure to report required changes within the program guidelines could result in a loss of benets, sanctions, or civil or criminal charges. You may report changes to the CAO in person, by phone, fax, mail or through a MyCOMPASS account. You may also report changes to the Customer Service Center at 1-877-395-8930, or for Philadelphia, 1-215-560-7226 any time.PRIVACY ACT STATEMENT(i) The collection of this information, including the Social Security number (SSN) of each household member, is authorized under the Food and Nutrition Act of 2008, as amended, 7 U.S.C. 2011-2036d. The information will be used to determine whether your household is eligible or continues to be eligible to participate in the SNAP Program. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management.(ii) This information may be disclosed to other federal and state agencies for ofcial examination, and to law enforcement ofcials for the purpose of apprehending persons eeing to avoid the law.(iii) If a SNAP claim arises against your household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.(iv) Providing the requested information, including the SSN of each household member, is voluntary. However, failure to provide an SSN will result in the denial of SNAP benets to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members.

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PA 600 3/23CLIENTProhibitions and Penalties Read about your responsibilities:IF THIS HAPPENS WITHOUT GOOD CAUSE THIS MAY HAPPEN (PENALTY)ALL BENEFITSSNAPCASHMEDICAL ASSISTANCEMisuse Electronic Benets Transfer (EBT) Card or PA ACCESS Card. Fine, prison, or both.Do not report changes, as required. Benets cut or stopped.On purpose, give information that is false, incorrect or incomplete, or not report changes.Fine, disqualication and/or jail time for Welfare Fraud, disqualication for administrative hearing proceedings.Not eligible for cash:• First time - 6 months.• Second time - 12 months.• Third time - forever.Not eligible for SNAP:• First time - 12 months.• Second time - 24 months.• Third time - forever.Trade, sell or attempt to trade, sell, buy or use another person’s ACCESS Card.Not eligible:• All court convictions - 12 months.SNAPOn purpose, misuse SNAP benets, for example, trade, sell, or buy EBT Card or SNAP benets; convert benets; or dump containers purchased with SNAP benets to receive deposits – or buy things not covered by SNAP, such as alcohol or tobacco – or use SNAP benets to pay for food already received or food on credit.Not eligible:• First time - 12 months.• Second time - 24 months.• Third time - forever.• First time court conviction over $500 - forever.Purchase a product with SNAP benets with the intent of obtaining cash or consideration other than eligible food by reselling the product in exchange for cash or consideration other than eligible food.On purpose, purchase products originally purchased with SNAP benets in exchange for cash or consideration other than eligible food.Use/receive SNAP benets to buy drugs or controlled substances.Not eligible:• First time - 24 months.• Second time - forever.Use/receive SNAP benets in sale of rearms, ammunition, or explosives. First time - not eligible forever.Be convicted for buying, selling or trading SNAP benets for total of $500 or more. Not eligible forever.Lie about who you are or where you live to receive more than one SNAP benet. Not eligible for 10 years.Flee to avoid prosecution, custody, or connement because of a felony/attempted felony – or ee because of breaking probation or parole.Not eligible until you do what the law says.CASHDo not comply with your court penalty, including payment of nes, for a felony or misdemeanor. Not eligible until you comply with your penalty.Lie about where you live to receive cash in two or more states. Not eligible for 10 years.Flee to avoid prosecution, custody, or connement because of a felony conviction/attempted felony; fail to appear as a defendant at a criminal court proceeding when issued a summons or a bench warrant for a summary offense, felony or misdemeanor; ee because of breaking probation/parole; or have any active warrant against you.Not eligible until you do what the law says.If you are found guilty of fraud or breaking the above rules:• Fine up to $250,000 for SNAP and up to $15,000 for Cash;• Jail up to 20 years for SNAP and up to seven years for Cash; and/or• Paying back benets received.• Disqualication from benets for periods stated above by program.SNAP WORK RULESFor household members – physically and mentally t – over age 15 and under 60 – not otherwise exempt or with good cause.Not eligible:• First time - one month and until you do what is required.• Second time - three months and until you do what is re-quired.• Three or more times - six months each time and until you do what is required.Refuse to:• Accept a job.• Tell CAO about work status and job availability.On purpose, take action to:• Quit a job.• Cut work hours to less than 30 per week (unless another job already meets work requirements). CASH WORK RULESDo not meet cash work requirements on purpose, as written on the Agreement of Mutual Responsibility (AMR). Not eligible:• First violation - You will be ineligible for a minimum of 30 days or until the failure to comply ceases, whichever is longer.• Second violation - You will be ineligible for a minimum of 60 days or until the failure to comply ceases, whichever is longer.• Third violation - You will be permanently disqualied.If the reason for sanction occurs within the rst 24 months of receipt of cash assistance, whether consecutive or interrupted, the sanction applies only to the individual.If the reason for sanction occurs after 24 months of receipt of cash assistance, whether consecutive or interrupted, the sanction applies to the entire family.

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PA 600 3/23CLIENTUnderstanding Your Rights and ResponsibilitiesWhen I sign this form:• I understand that Pennsylvania receives information from the Income Eligibility Verication System (IEVS), nancial institutions, consumer reporting, and state and federal agencies to verify the information I give them. Information available through IEVS and other entities will be requested, used and may be veried through collateral contact when conicting details are found by the state agency, and such information may affect my household’s eligibility and level of benets.• I understand that by signing this application, I am authorizing any nancial institution to disclose, through electronic or any other means, any and all nancial information held by that institution, to the Department of Human Services or its designated agent or contractor for the purpose of identifying and verifying resources (also called “assets”) when needed to determine and redetermine eligibility for Medical Assistance. I understand that nancial information includes deposits, withdrawals, account closures and other relevant information requested or received from the nancial institution, including other transactions undertaken by the nancial institution with respect to the account or asset. I understand that this authorization is effective until Medical Assistance eligibility is denied or ends, or if I decide to revoke it by written notication to the department, whichever happens rst. I understand that if I revoke this authorization, that may make me or my household ineligible for Medical Assistance. • I understand that if I misrepresent, hide or withhold facts that may affect my eligibility for benets, I may be required to repay my benets and I may be prosecuted and disqualied from receiving certain future benets.• I understand that I can designate an authorized representative by completing the Authorized Representative section and submitting it with this application.• I understand and agree that I am responsible for any fraudulent statements made on this application, even if the application is being submitted by someone acting on my behalf.• I received a copy of my rights and responsibilities, have read them or someone has read them to me, and I understand them.• I understand that the information entered in this application will be kept condential and used only to administer benets. I authorize the release of personal, nancial and medical information for the purpose of determining eligibility.• I understand that the Department of Human Services or its designees may contact me via methods including email and text messaging to help process my application or request feedback on the application process. If I do not want email or text messages, I understand the Department of Human Services will still process my application.• I understand that any changes I am required to report must be reported within the rst 10 days of the month following the month of change. • I understand that my household may lose SNAP benets if a household member receives lottery or gambling winnings equal to or greater than the SNAP resource limit for elderly or disabled households.• I understand that I will receive a written notice explaining the benets. If benets are denied, changed, suspended or stopped, the written notice will explain why.• I understand that I will have 30 days (90 days for SNAP (food stamp) benets) from the date of the notice to request a hearing if I do not agree with the decision made on this application.• I understand that my situation is subject to verication from employers, nancial sources and other third parties.• I understand that applicants must provide their Social Security number or apply for one if they do not have one. This number may be used to check the information on this application.• I understand that I must use the Electronic Benet Transfer (EBT) or the PA ACCESS Card only during the period I am eligible. I must use the EBT or the PA ACCESS Card only for the person who is eligible and may get only the benets that are needed and reasonable.• I understand that I may not use Cash Assistance funds issued through my PA ACCESS card to make EBT transactions in liquor stores, casinos (gambling casinos, gaming establishments), or places for adult entertainment.• I understand that I do not have to provide a Social Security number for anyone who is not applying for assistance. If I do provide their Social Security number, it may be used to check the information on this application.• I certify that all information that has been entered is true under penalty of perjury.• I understand that I have the right to a certicate of creditable coverage to verify my medical coverage. Federal law limits when Medical Assistance coverage may be denied or limited for a pre-existing condition. If I enroll in a group health plan that has a pre-existing condition clause, I can get credit for the time I received Medical Assistance.• I understand that if I am determined eligible for Medical Assistance, I will be placed in the most comprehensive Medical Assistance benet package that is available to me. I understand that I may be required to enroll in a health plan. I understand that enrolling in a health plan may be free or low cost to me, because the Department pays a monthly fee to the health plan for me. I understand that the monthly fee is a capitation fee. I understand that if I receive Medical Assistance that I am not eligible for, due to error, fraud, or any other reason, then I may be required to repay the Department all monthly fees paid on my behalf.• If I receive cash benets, I will cooperate with the requirements of the child support enforcement program as directed by the department. I give the Department and the Domestic Relations Section the right to pursue and collect cash and/or medical support for me and others for whom I am applying.• I understand that if I report or provide proof of the household expenses, I will get the maximum amount of SNAP (food stamp) benets allowed. Failure to report or provide proof of the household expenses will be regarded as my statement that I do not want to receive a deduction for the unreported or unproved expense. (Authority: United States Department of Agriculture, Food and Nutrition Service, Mid-Atlantic Region, Administrative Notice 6-99, issued January 4, 1999).• I understand that I have the right to receive credit for the household expenses at the time I report and provide proof of them at any time during my SNAP (food stamps) certication period.• I understand that I have the right to ask the county assistance ofce (CAO) for assistance in getting proof of expenses and that the CAO can contact other people for conrmation if I am having trouble getting proof of anything.• I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for CHIP. • I understand that if some or all of the individuals applying do not qualify for Medical Assistance, that they may be eligible for federal benets and/or explore private health care options through Pennsylvania’s Health Insurance Marketplace (Pennie). If this is the case, I authorize the Department to give my name and information on this application to Pennie.• Renewal of coverage in future years: To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow Pennsylvania’s Health Insurance Marketplace (Pennie) to use my income data, including information from tax returns. Pennie will send me a notice, let me make any changes, and I can opt out at any time. Yes, renew my eligibility automatically for the next: (Check one): Five years (the maximum number of years allowed) Four years Three years Two years One year Do not use my information from tax returns to renew my coverage.

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PA 600 3/23Who sees and shares my health information?Why is my protected health information used and disclosed by DHS?For TreatmentFor PaymentFor Operating Our ProgramsFor Public Health ActivitiesFor Law Enforcement Purposes and As Required by Legal ProceedingsFor Government ProgramsFor National SecurityFor Public Health and SafetyFor ResearchFor Coroners, Funeral Directors and Organ DonationFor Reasons Otherwise Required By LawDo other laws also protect certain health information about me?

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PA 600 3/23Can I ask DHS to use or disclose my health information?                  What are my rights regarding my health information?Right to See and Copy Your Health InformationRight to Correct or Add InformationRight to Receive a List of DisclosuresRight to Request Restrictions on Use and DisclosureRight to Request Condential CommunicationRight to Receive Notication of a Breach

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PA 600 3/23Whom do I contact about my rights or to ask questions about this notice?www.dhs.pa.govHow do I le a complaint?Effective: April, 2003 – Revised July 28, 2015

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PA 600 3/23ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-800-692-7462 (TDD: 711).ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-692-7462 (TDD: 711).注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-800-692-7462 (TDD: 711)。ВНИМАНИЕ: Если вы говорите на русском языке, товы можете воспользоваться бесплатными услугами перевода. Звоните1-800-692-7462(телетайп:711).CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-800-692-7462 (TDD: 711).주: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-800-692-7462(TDD: 711)번으로 전화해 주십시오.သတိျပဳရန္ - အကယ္၍ သင္သည္ ျမန္မာစကား ကို ေျပာပါက၊ ဘာသာစကား အကူအညီ၊ အခမဲ့၊ သင့္အတြက္ စီစဥ္ေဆာင္ရြက္ေပးပါမည္။ ဖုန္းနံပါတ္ 1-800-692-7462 (TTY: 711) သုိ႔ ေခၚဆိုပါ။ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-800-692-7462 (TDD: 711).KUJDES: Nëse itni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-800-692-7462 (TDD: 711). 