DHS RIGHTS AND RESPONSIBILITIES
You have a RIGHT to request, and if found eligible, to receive Financial or Medicaid or Supplemental Nutrition Assistance Program
benefits based on policies and standards established under State laws.
You have a RIGHT to appeal and to receive a Hearing before a Hearing Officer of the Department if you are dissatisfied with any Department decision, or if the Department delays in making a decision. If you request a Hearing, your appeal will be heard promptly. You may be represented by a lawyer or any other person you select to appear on your behalf. If you are not satisfied with any Department decision regarding your application, you have a right to request a hearing. You must request a hearing within ninety (90) days from the date you receive a written notice for Supplemental Nutrition Assistance Program benefits, thirty (30) days from the date you receive a written notice for RIW, Child Care, and Medicaid, and (10) days from the date you receive a written notice for GPA.
Non-discrimination Statement: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: ASCR USDA Complaint Filing , and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: firstname.lastname@example.org. This institution is an equal opportunity provider.
In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794), Americans with Disabilities Act of 1990 (42 U.S.C. 12101 et seq.), and Title IX of the Education Amendments of 1972 (20 U.S.C. 1681 et seq.), the Food and Nutrition Act of 2008, the Age Discrimination Act of 1975, the U.S. Department of Health and Human Services implementing regulations (45 C.F.R. Parts 80 and 84) and the U.S. Department of Education implementing regulations (34 C.F.R. Parts 104 and 106), and the U.S. Department of Agriculture, Food and Nutrition Services (7 C.F.R. 272.6); the Department of Human Services (DHS), does not discriminate on the basis of race, color, national origin, disability, religion, political beliefs, age, religion or gender> in acceptance for or provision of services, employment or treatment, in its education and other program activities. Under other provisions of applicable law, DHS does not discriminate on the basis of sexual orientation, gender identity or expression. For further information about these non-discrimination laws, regulations and complaint procedures for resolution of complaints of discrimination, contact DHS at 57 Howard Avenue, Cranston, Rhode Island 02920, telephone number 462-2130 (for deaf/hearing impaired 462-6239 or 711). The Community Relations Liaison Officer is the coordinator for implementation of Title VI, the Office of Rehabilitation Services (ORS) Administrator or his/ her designee is the coordinator for implementation of the Title IX, Section 504, and ADA. The Director of DHS or his/her designee has the overall responsibility for civil rights compliance for all agency programs.
You have a RIGHT to confidentiality. The Department uses information about you and other members of your household only for purposes directly related to the administration of the programs and in compliance of the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information.
DHS has my consent to use or disclose protected health information for the purposes of treatment, payment and health care operations in accordance with DHS notice of privacy practices.
The Department does not release information about you or other members of your household without your consent except as provided in Rhode Island General Laws 40-6-12 and 40-6-12.1, and regulations set forth in the DHS and SNAP Policy Manuals. Any person found guilty of violating the provisions of Rhode Island General Laws 40-6-12 shall be deemed guilty of a misdemeanor. Violators are subject to a maximum fine of two hundred dollars ($200), or imprisonment of up to six (6) months, or both.
You have a RIGHT to file a joint application for more than one program or file a separate application for SNAP benefits without applying for other program benefits. All SNAP applications, regardless of whether they are joint applications or separate applications, must be processed for SNAP purposes in accordance with SNAP procedural, timeliness, notice, and fair hearing requirements. No household shall have its SNAP denied solely on the basis that its application to participate in another program has been denied or its benefits under another program have been terminated without a separate determination by the Department that the household failed to satisfy a SNAP eligibility requirement. Households that file a joint application for SNAP and another program and are denied benefits for the other program shall not be required to resubmit the joint application or to file another application for SNAP, but shall have its SNAP eligibility dtermined based on the joint application in accordance with the SNAP processing time frames from the date the joint application was accepted by the Department.
You have a RESPONSIBILITY to supply the Department with accurate information about your income, resources and living arrangements.
You have a RESPONSIBILITY to tell us immediately (within ten (10) days) of any changes in your income, resources, family
composition, or any other changes that affect your household. For RIW Cash and CCAP, you must tell us immediately (within five (5) days) when a child leaves your household for any reason. For SNAP, if you are a simplified reporter, you must report changes in income which bring the household's gross income in excess of the applicable SNAP Gross Income Eligibility Standard for your household size. If you are unsure about your reporting requirements, contact you DHS worker.
You have a RESPONSIBILITY if you are applying for CCAP, to find a suitable child care provider for your child(ren) and to make appropriate arrangements to have your child(ren) attend that provider. The Department of Human Services will pay only for those hours when you are either at work or involved in a DHS approved education/training activity, and the cost of any child care in excess of those hours is your sole responsibility. If found eligible, you may be responsible for a share of the child care cost (co-payment) and you are responsible to make such payment directly to your child care provider. If you are not found eligible, you have 30 days from the written notice to request a hearing in writing to appeal your ineligibility. If the decision of the hearing is not in your favor, DHS is not responsible for any of the child care costs that you may have incurred with your child care provider. By signing this form, you are authorizing the Department of Human Services to inform the child care provider(s) after you have been notified if your child care assistance has been approved, discontinued or denied.
You have a RESPONSIBILITY to provide Social Security numbers (or proof that you have applied for one) for yourself and your household, or to apply, if you are required to, for them as a condition of eligibility. The collection of information on the application, as well as the Social Security numbers of all members of your household for whom you receive assistance, is authorized under the Food and Nutrition Act of 2008 (formerly the Food Stamp Act), as amended, 7 U.S.C. 2011-2036. This information will be used to determine whether your household is eligible or continues to be eligible to participate in SNAP, MA, RIW, GPA and/or CCAP. The Department will verify this information through computer matching with the Department of Labor and Training, the Social Security Administration, the Internal Revenue Service, the Food and Nutrition Service, and other governmental and non-governmental entities authorized by law, regulation or contract, and they will be subject to verification by Federal, State, and local officials. The income and eligibility information obtained from these agencies will be used to make sure your household is eligible for and receiving the correct amount of SNAP benefits, GPA, Child Care, RIW, and/or Medicaid. This information will also be used to monitor compliance with program regulations and for program management. This information 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. If a 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. Providing the requested information is voluntary. However, failure to provide a SSN will result in the denial of benefits to each individual failing to provide a SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members.
You have a RESPONSIBILITY to report and provide proof of your expenses shown in questions 29 through 38 in order to get the maximum amount of SNAP benefits allowed. Failure to report or provide proof of your expenses will be regarded as your statement that you do not want to receive a deduction for the unreported or unproven expense.
You have a RESPONSIBILITY to cooperate fully with State and Federal personnel conducting quality control reviews.
Only U.S. citizens and certain legal immigrants may be eligible for SNAP benefits. If there are non-citizens living with you who are not eligible, you may still apply for and receive benefits for other eligible household members. You are not required to provide immigration information for people not applying for benefits, but you may need to provide other information for those people, such as, income and resources.
RIW Restrictions on Use of EBT Cash Benefits and Penalties: Pursuant to Section 4004 of Public Law 112-96, it is prohibited for a TANF recipient to use their TANF cash assistance benefits received under RI Works, Rhode Island General Laws 40-5.2 et seq., in any electronic benefit transfer transaction (EBT) in:
Any person receiving cash assistance through the RI Works Program who uses an EBT card in violation of the above standards shall be subject to the following penalties:
RIW/SNAP EBT Card Replacement Provisions: Cardholders who request four (4) or more replacement EBT cards within a twelve (12) month period may be referred to the Fraud Unit for investigation of misuse or abuse of the EBT card. Documented violations may result in one or more of the following actions:
In all cases, the agency shall act to protect households containing homeless persons, elderly or disabled members, victims of crimes, and other vulnerable persons who may lose electronic benefits transfer cards but are not committing fraud.
I. RI WORKS PROGRAM, MEDICAID, CHILD CARE ASSISTANCE AND GENERAL PUBLIC ASSISTANCE - LIENS AND ASSIGNMENTS
I understand that pursuant to Rhode Island General Law, Sections 40-6-9, 40-6-10, or 40-8-15, without the necessity of signing any
a.) Regarding Child Support and Establishment of Paternity I have assigned any and all rights that I may have for and on behalf of myself, and for and on behalf of my child or children, to the Department of Human Services (DHS), against any person failing to provide for support, maintenance, and medical care for myself and my minor child or children for whom assistance is paid by the DHS. The DHS is authorized to perform the act of instituting suit to establish paternity and/or to collect support for myself or my child or children who receive or received assistance from the DHS.
b.) Regarding Amounts Recoverable from a Third Party
I have assigned any and all rights to the DHS, for and on behalf of myself and any person for whom I may legally act, for amounts recoverable from a third party equal to the amount of financial assistance and Medicaid provided as a result of accident, injury, or illness.
c.) Regarding Amounts Recoverable from Workers’ Compensation
The Department of Human Services may place a lien upon any pending award, order, or settlement, which I may be entitled to under the provisions of the Rhode Island Workers Compensation Act, Chapters 28-29 through 28-38 of the Rhode Island General Laws. The purpose of the lien is to secure reimbursement to the Department for financial and Medicaid payments made to me or on my behalf for the period of time for which my workers’ compensation award, order, or settlement is made.
d.) Regarding Lien on Deceased Recipient’s Estate for Medicaid Reimbursement
The DHS may place a lien upon the estate of a Medicaid recipient who was fifty-five (55) years of age or older at the time of death. R.I.G.L. 40-8-15 provides that the total sum of Medicaid paid on behalf of a Medicaid recipient who was fifty-five (55) years of age or older at the time of receipt of such assistance shall be a debt to the state and shall constitute a lien upon the estate of the recipient in favor of the DHS. However, the lien shall not be effective and shall not apply to the estate of a recipient who is survived by a spouse, or a child who is under the age of twenty-one (21) or a child who is blind or permanently and totally disabled as defined in Title XVI (SSI) of the Social Security Act.
I understand that as a condition of receiving RIW benefits, all persons from whom I am requesting RIW, unless exempt by law, are required to comply with the RIW Program requirements.
I understand that this application will serve as authorization to the Department of Human Services to obtain from Medical providers information that is pertinent to me or any person included in this application for as long as the case remains open.
I understand and agree that the DHS office may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits.
II. AUTHORIZED REPRESENTATIVE
You have a RIGHT to name an authorized representative. An authorized representative is a person designated by the head of the household or the spouse, or any other responsible member of the household, to act on behalf of the household in applying for program benefits, or using the benefits. The authorized representative for benefits may or may not be the same individual designated as an authorized representative for the application process or for meeting reporting requirements. The authorized representative designation must be made in writing.
You can authorize someone outside your home 1) to get your SNAP benefits for you and/or 2) to use them to buy food for you.
III. SNAP PENALTY WARNINGSI understand that:
Any member of my household who intentionally breaks a SNAP rule will be barred from the SNAP from one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. S/he may also be subject to prosecution under other applicable Federal and State laws. S/he may also be barred from the SNAP for an additional 18 months if court ordered. Any member of my household who intentionally breaks a SNAP rule can be barred from the Supplemental Nutrition Assistance Program:
1. Individuals found by a Federal, State, or local court to have used or received SNAP benefits in a transaction involving the sale of firearms, ammunitions or explosives shall be permanently ineligible for the Supplemental Nutrition Assistance Program upon the first occasion of such violation.
2. Individuals found to have made a fraudulent statement or representation with respect to the identity or place of residence of the individual in order to receive multiple SNAP benefits simultaneously shall be ineligible to participate in the Supplemental Nutrition Assistance Program for a period of ten (10) years.
3. Individuals found guilty by a Federal, State or local court of law for using or receiving benefits in a transaction involving the sale of a controlled substance (as defined in section 102 of the Controlled Substances Act (21 U.S.C. 802)) will not be eligible for benefits for two years for the first offense, and permanently for the second offense.
4. Individuals found guilty by a court of law for buying or selling illegal drugs or certain prescription drugs in exchange for SNAP benefits will be prohibited from participating in the SNAP for 24 months for the first offense and permanently for the second offense.
5. An individual convicted by a Federal, State, or local court of having trafficked benefits for an aggregate amount of $500 or more shall be permanently ineligible to receive SNAP benefits upon the first occasion of such violation.
Trafficking as defined in 7 CFR 271.2 means:
1) The buying, selling, stealing, or otherwise effecting an exchange of SNAP benefits issued and accessed via Electronic Benefit Transfer (EBT) cards, card numbers and personl identification numbers (PINs), or by manual voucher and signature, for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone;
2) The exchange of firearms, ammunition, explosives, or contgrolled substances for SNAP benefits;
3) Purchasing a product with SNAP benefits that has a container requiring a return depsit with the intent of obtaining cash by discarding the product and returning the container for the deposit amount, intentionally discarding the product, and intentionally returning the container for the deposit amount;
4) Purchasing a product with SNAP benefits with the intent of obtaining cash or consideration other than eligibile food by reselling the product, and subsequently intentionally reselling the product purchased with SNAP benefits in exchange for cash or consideration other than eligible food; or
5) Intentionally purchasing products originally pruchased with SNAP beenfits in exchange for cash or consideration other than eligible food.
6) Attempting to buy, sell, steal, or otherwise affect an exchange of SNAP benefits issued and accessed via Electronic Benefit Transfer (EBT) cards, card numbers and personal identification numbers (PINs), or by manual voucher and signatures, for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone.
DO NOT lie or hide information to get or continue to get SNAP benefits that your household should not get.
DO NOT trade or sell (or attempt to trade or sell) EBT cards or use someone else’s EBT card for your household.
DO NOT use SNAP benefits to buy non-food items, such as alcoholic drinks and cigarettes or to pay on credit accounts.
DHS can use or share information on this application for the administration of DHS programs, as well as the administration of other federally funded assistance programs in accordance with state and federal law, contract and regulation. DHS can release non-identifying information for research purposes. Any release of identifying information shall be done in accordance with state and federal law.
I understand the questions on this application and the penalty for hiding or giving false information or breaking any of the rules listed in this
I certify under penalty of perjury that my answers are correct, including information about citizenship and alien status, and complete to the best of my knowledge and belief. I know that under the state of Rhode Island General Laws, Section 40-6-15, a maximum fine of $1,000, or imprisonment of up to five (5) years, or both, may be imposed for a person who obtains or attempts to obtain, or aids or abets any person to obtain, public assistance to which s/he is not entitled, or who willfully fails to report income, resources or personal circumstances or increases therein which exceed the amount previously reported. I attest to the identity of the minor children identified herein and that all of the information contained in this application is true. I understand that I am breaking the law if I give wrong information and can be punished under federal law, state law or both.