FOR OFFICE USE ONLY:
DATE
CASE NUMBER: _________________________________RECEIVED:________________
MISSISSIPPI
MDHS-EA-900
Revised 08-01-2020
Page 4
As part of the eligibility process for SNAP, I understand that certain household members including myself will be eligible to receive SNAP
benefits only by following requirements to register for work, seek employment, and/or accept suitable employment, unless a work exemption
is met by that household member. I understand that job seeking services are available through the MS Department of Employment Security,
and that I may be required to complete job seeking requirements at a later date. I will accept an offer of suitable employment whether it was
received through my own effort or through an employment and training referral. I understand that failure to comply with work registration
requirements may result in disqualification of a household member or the entire household from SNAP, and that I will explain these work
requirements to my household.
I understand that the information included on this application may be disclosed to other Federal and State agencies for official examination,
and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. I understand that if a SNAP/TANF claim
arises against my household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as
private claims collections agencies, for claims collection.
Information available through the Income and Eligibility Verification System (IEVS) will be used to verify statements you provide on this
application regarding household income. Information available through IEVS will be requested, used and may be verified through collateral
contacts when discrepancies are found by MDHS. Additionally, information you provide regarding household income, expenses, or
financial resources are subject to verification through third party electronic databases. Such information may affect your household’s
eligibility and level of benefits.
Information you provide on this application regarding the alien status of household members may be subject to verification by the United States
Citizenship and Immigration Services (USCIS) through use of the Systematic Alien Verification and Entitlements (SAVE) System. Submitted
information from USCIS may affect your household’s eligibility and level of benefits.
I understand that I can receive a copy of this completed SNAP application. I choose _____ paper _____ electronic or I _____ decline a copy.
*PENALTY WARNING*
PENALTY WARNING: *A Social Security Number (SSN) must be provided or applied for each person for whom assistance is
requested per the Food and Nutrition Act of 2008. SSNs will be verified and used for Federal and State data matches, including but
not limited to, Social Security, Internal Revenue Service, VA, MS Department of Employment Security, resource/income verifications,
program disqualifications, and for collection of fraud debts. State and federal laws provide for fines, imprisonment or both for any
person guilty of obtaining assistance to which he/she is not entitled by willfully withholding or giving false information. Information
may be verified through collateral contacts when discrepancies are found. Alien status of persons requesting benefits is subject to
verification with United States Citizenship and Immigration Services (USCIS) and will require submission of certain information from
this application to USCIS.
SNAP PENALTY WARNING: If your household receives SNAP, it must follow the rules listed below. Any member of your household
who breaks any of these rules on purpose can be barred from SNAP for 1 year for first offense, 2 years for second offense, and
permanently for third offense; fined up to $250,000, and imprisoned up to 20 years or both; and subject to prosecution under other
federal laws.
DO NOT give false information, or hide information to get or continue to get SNAP benefits. DO NOT trade or sell EBT cards. DO
NOT alter EBT cards to get SNAP benefits you are not entitled to receive. DO NOT use SNAP benefits to buy ineligible items such as
alcohol and tobacco or to pay food credit accounts. DO NOT use someone else’s SNAP benefits or EBT card for your household.
Individuals determined by a court to have committed the following program violations will be subject to the following penalties:
If you are found to have used or received benefits in a transaction involving the sale of a controlled substance, you will be ineligible
to receive SNAP benefits for a period of two years for the first offense and permanently upon the second such offense.
If you are found to have used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you will
be permanently ineligible to receive SNAP benefits upon the first occasion of such violation.
If you have been found guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently
ineligible to receive SNAP benefits upon the first occasion of such violation.
If you have been found to have made a fraudulent statement or representation with respect to your identity or place of residence in
order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the Program for a period of 10 years.
I certify under penalty of perjury that my answers to all questions about each household member, including those about
citizenship or alien status, are correct and complete.
Household member signature or mark (X): _________________________________________ Date: __________________
Witness if signed by mark: _______________________________________________________ Date: __________________