What kind of assistance does the Department of Children and Family

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Louisiana Department of Children and Family Services

Information about the Application for Assistance

What kind of assistance does the Department of Children and Family Services

Economic Stability offer?

● Family Independence Temporary Assistance Program (FITAP) – Provides temporary cash

assistance to eligible low-income families who need assistance for children. FITAP recipients

also receive Medicaid benefits through the Louisiana Department of Health.

● Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program) –

Provides monthly benefits that help low-income households buy the food they need for good

health.

● Kinship Care Subsidy Program (KCSP) – Provides cash assistance for eligible children who

reside with qualified relatives other than parents. KCSP recipients also receive Medicaid benefits

through the Louisiana Department of Health.

● For more information about programs and services or for specific information about your case,

call 1-888-LAHELPU (1-888-524-3578).

How do you apply for assistance?

● Complete the Application for Assistance, form OFS 4APP.

● The Application for Assistance may be completed online and submitted electronically on the

DCFS website at www.dcfs.la.gov.

● You may also apply online or pick up a paper application at one of your local community partners.

● Return the completed form to any parish DCFS office, if a paper application is completed.

● One form may be used to apply for the FITAP, SNAP, and KCSP.

● You may file a separate application for SNAP. Whether you file a SNAP application (paper or

online) with another program or separately, your SNAP application will be processed according to

the same SNAP procedures, including timeliness, notice, and fair hearing requirements.

● If you file an application for SNAP jointly with another program and are denied benefits from the

other program, you do not have to turn in another application for SNAP. You may not be denied

SNAP benefits just because you may not be eligible for benefits from another program.

● We will determine your eligibility for all programs for which you apply.

● You need to be interviewed if you are applying for FITAP, SNAP, or KCSP.

● You need to provide verification to the parish DCFS office where you apply. Verification is

explained below.

If you are applying for:

Complete these pages

1-7

8-9

10-11

12-13

FITAP

√

SNAP

√

KCSP

√

Mail

Fax

Online

In Person

Department of Children and

Family Services ES

(225) 663-3164

CAFÉ’ Customer Portal

www.dcfs.la.gov/CAFE

Any DCFS Office

Document Processing Center

P. O. Box 260031

Baton Rouge, LA 70826-9918

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Do you need help completing the application form?

● You may ask someone to help you fill out the form, or

● You may ask the worker during your interview to help you fill out the form.

What happens after we receive your application form?

● You will be assigned a worker.

● You will be interviewed, if you are applying for FITAP, SNAP, or KCSP. You may receive an

appointment letter for a telephone interview. You may request to have a face-to-face interview

instead of a telephone interview.

● You will receive a list of verification that is required.

● Your worker will determine your eligibility within 30 days from the date of application.

● If you applied for FITAP, you may be required to participate in the Strategies to Empower People

(STEP) Program. The STEP Program provides opportunities for work-eligible FITAP families to

receive job training, employment, and supportive services to enable them to become self-

sufficient.

What will we do with the information that you provide?

● Information you give us on your application form will be verified by federal, state, and local offices

including computer cross-matching with other agencies. Someone from our agency may contact

other people in order to verify your eligibility for benefits.

● The alien status of household members is subject to verification through the United States

Citizenship and Immigration Service (USCIS) and may affect eligibility and benefit amount.

● You will not have to provide immigration status information or documents for any household

members who are not eligible because of immigration status and who are not asking for benefits.

If a member of your household does not wish to provide information about his/her citizenship or

immigration status, he or she will not be eligible for benefits. Other family or household members

may still receive benefits, if they are otherwise eligible. You can apply for and get benefits for

eligible household members even if your household includes other members who are not eligible

because of immigration status.

Why do we need your Social Security Number and are you required to provide it?

● The collection of information requested on the application form, including Social Security

Numbers (SSNs) of household members, is voluntary and authorized under the Food and

Nutrition Act of 2008, (7 U.S.C. 2011-2036), as amended. Failure to provide required information

including SSNs or proof you have applied for an SSN for household members may result in that

person’s ineligibility for SNAP and cash assistance. You will not have to provide Social Security

Numbers for any household members who are not eligible because of immigration status and who

are not asking for benefits.

● SSNs are used to:

o collect information from other sources,

o check identity of household members,

o determine whether your household is eligible, and

o prevent households from getting more benefits than they are entitled to receive.

● SSNs are used in state and federal program reviews, audits, and computer-matching with other

agencies such as Louisiana Workforce Commission, Social Security Administration, Internal

Revenue Service, etc., through the State Income and Eligibility Verification System.

● Under the Privacy Act of 1974(P.L. 93-579), SSNs may be released for various reasons including

those directly connected to the administration of the Child Support Enforcement Program.

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What type of verification do you need to provide?

Verification means proof of the information you report. The following table lists the information that

must be verified by each program and the examples of the proof that is required. Let your worker

know if you have any questions about what you must provide or if you need help in getting the proof.

It is our responsibility to help you get the proof that you need.

What Must be Verified and Examples of Proof

SNAP

FITAP

(Cash)

KCSP

(Cash)

Identity – driver’s license, work or school ID, ID for health benefits or

another social services program, voter’s registration card, check stub, or

birth certificate

√

Age/Relationship - birth certificate, baptismal certificate, or hospital

birth records of the person to be included. If not your own child, birth

records to prove how the child is related to you

√

Social Security Number - copy of the social security card or papers you

received at the hospital for a newborn. A Social Security number is not

required for any household member who is not eligible due to

immigration status.

√

Alien status - if not a U.S. citizen, forms or cards from USCIS that prove

the person is a legal alien (unless you choose not to apply for this

person)

√

Wages - last 4 pay check stubs or employer’s statement for each person

who works

√

Self-employment - income tax returns, sales records, quarterly tax

records, personal wage record

√

Other income such as contributions, child support, alimony, Social

Security, SSI, VA, retirement checks, Unemployment Compensation

(UCB) - award letters, court orders, statements from contributors

√

Income that stopped within the last 2 months – pink slip, termination

notice, or statement from former employer, termination notice or

statement from source of any income that ended

√

Medical expenses - receipts, pharmacy printouts for last 3 months,

doctor bills or other papers that show medical expenses for household

members who are disabled or over age 59

√

Child support payments made to someone outside your home -

court order or other legal papers and proof that you are making

payments such as cancelled checks or wage withholding statements

√

Immunization - shot, school, or doctor’s records

√

Custody - court order, other legal papers, or provisional custody by

mandate

√

Home - proof of who lives in the home; such as current school records,

landlord’s written statement or the name and phone number of two

people (not related to you) who know your situation

√

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Rights and Responsibilities

When you receive benefits from the Louisiana Department of Children and Family Services, you have

certain rights and responsibilities that are explained below. Keep this important information for future

reference.

What are your rights?

This institution is prohibited from discriminating on the basis of race, color, national origin, disability,

age, sex and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin,

sex, religious creed, disability, age, political beliefs or reprisal or retaliation for prior civil rights activity

in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information

(e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State

or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech

disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally,

program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint

Form, (AD 3027), found online at: https://www.ascr.usda.gov/complaint_filing_cust.html and at any

USDA office, or write a letter addressed to USDA and provide in the letter all of the information

requested in the form. To request a copy of the complaint form, call (866) 632-9992.

Submit your completed form or letter to USDA by:

(1)

mail:

U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights

1400 Independence Avenue, SW

Washington, D.C.20250.9410

(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: https://www.fns.usda.gov/snap/contact_info/hotlines.htm.

To file a complaint of discrimination regarding a program receiving Federal financial assistance

through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office 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.

You may file a civil rights complaint with the Department of Children and Family Services (DCFS) by

completing the Civil Rights Complaint Form. Turn the form in to a local office; mail it to DCFS Civil

Rights Section, P O Box 1887, Baton Rouge, LA 70821;email DCFS.BureauofCivilR[email protected],

or; call (225) 342-0309. You may file a civil rights complaint with DCFS and USDA or only DCFS.

A program complaint may be filed with the Department of Children and Family Services (DCFS) by

emailing LaHelpU.DC[email protected] or by calling 225-342-2342.

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● Fair Hearing - If you do not agree with any decision made on your case, you have the right to

ask that your case be reviewed. You can tell us that you want a fair hearing in writing, in

person, or by calling the office. You have the right to look at your case record before the

hearing.

● Confidentiality – All the information you give us is confidential. This means that we cannot

give information about your case to other people except under special conditions. Examples

of those conditions include official review by other State and Federal agencies or Federal,

State and private collection agencies for the collection of claims against SNAP benefits.

Information from your case may also be given to law enforcement officials for the purpose of

catching persons fleeing to avoid the law and for investigation of a felony or probation/parole

violation.

● Voter Registration - If you are not registered to vote where you live now, you may indicate that

you would like to apply to register to vote on the Application for Assistance. Please note that

the information you give to the agency will remain confidential and will be used only for voter

registration purposes. Applying to register or refusing to register to vote will not affect the

amount of assistance or services that you may receive from the Department of Children and

Family Services. DCFS will assist you with completing a Louisiana Voter Registration

Application unless assistance is refused. You may fill out the application form in private.

What are your responsibilities?

● Cooperation - You have to cooperate by providing the information we need to determine your

eligibility for benefits for you and others for whom you are applying. You also have to provide

proof of the information you report. You will be expected to cooperate if a home visit is

necessary to determine your eligibility. If your case is selected for a quality control review by

state or federal reviewers, you have to cooperate with them.

● Report changes –

If you receive SNAP benefits, you must report if:

o Your household’s monthly income increases to more than the gross income limit for your

household size. This includes reporting the income of a person who moves into your home

if that person’s income combined with your SNAP household’s income is more than the

gross income limit for your household.

o Your household includes an Able-Bodied Adult Without Dependent (ABAWD), you must

report changes in work hours of the ABAWD who is subject to the SNAP time limit if the

change results in the ABAWD working an average of less than 20 hours per week or less

than 80 hours per month.

o Your household receives lottery or gambling winnings of $3500 or more, won in a single

game before taxes or other withholdings.

These changes must be reported by the 10

of the month following the month in which the

change occurs.

In addition, if you are receiving:

o FITAP - You have to:

 Follow the reporting requirements explained in your Family Success Agreement and

report these changes within 10 days of your knowledge of the change.

 Report within 10 days if the only eligible child receiving FITAP benefits moves out of

your home.

o KCSP - You have to report within 10 days if the only eligible child receiving KCSP benefits

moves out of your home.

If you are not receiving SNAP benefits, and are receiving:

o FITAP or KCSP - You have to report within 10 days if:

 There is a change in the source of any income received in your household. This

includes changes in employers and new sources of income such as child support,

Social Security, SSI, etc.

 The amount of your household’s unearned income changes by more than $50 per

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month.

 The amount of your household’s earned income changes by more than $100 per

month.

 Someone moves into or out of your household.

 You move.

o FITAP or KCSP - In addition to the changes listed above, you have to report within 10

days any changes in:

 School attendance of any 18 year old in your household.

 Marital status of anyone in your household.

Information on Non-Cash Services

Your household may be authorized to receive the following non-cash TANF/MOE funded services.

For additional information, please visit our website at www.dcfs.louisiana.gov or contact your local

DCFS Office.

 Family Violence Prevention and Intervention Program - Provides services for victims of

domestic violence and their children. Services are limited to children and/or

parents/caretaker relatives who are victims of domestic violence. Call 1-888-411-1333.

 Jobs for America’s Graduates LA (JAGS-LA) Program - Helps keep in school students

(age 12 through 21) at risk of failing who face at least two barriers to success which may

include economic, academic, personal, environmental, or work related barriers; assists out-

of-school youth in need of a high school education; provides an avenue for achieving

academically; and assists students in ultimately earning recognized credentials that will

make it possible for them to exit school and enter post-secondary education and/or the

workforce. Call 225-219-0368.

 Nurse Family Partnership Program - Serves low-income, first-time mothers who are no

more than 28 weeks pregnant by providing nurse home visitation services beginning early

in pregnancy and continuing through the first two years of the child’s life. Call 504-219-

9520 or 337-898-6097.

 Court Appointed Special Advocates (CASA) - Enhances family stability by facilitating

links between the particular child/family and community resources/systems through trained,

qualified, and supervised advocates who provide skilled communication, necessary

transportation, efficient and thorough information gathering, and other services identified in

an individual case. Call 225-930-0305 and 1-888-567-2272.

 Drug Court Programs - Combines both treatment and educational components with the

ability of a supervising judge to award incentives and sanctions based upon the

performance of the clients while in treatment. Treatment is community-based and drug court

participants are required to meet with the judge on a regular basis to review progress. Call

504-568-2020.

 Alternatives to Abortion - Provides intervention services including crisis intervention,

counseling, mentoring, support services, and pre-natal care information, in addition to

information and referrals regarding healthy childbirth, adoption, and parenting to help

ensure healthy and full-term pregnancies as an alternative to abortion.

 LA 4 Public Pre-Kindergarten Program - Provides high quality early childhood education

for low income 4-year-olds in participating public school districts and Charter schools.

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Penalties

If you knowingly report incorrect information, your SNAP benefits or cash assistance may be denied,

reduced, or ended and you may be subject to criminal prosecution.

What penalties apply in SNAP?

If you do the following:

You will:

● Hide information or give false information

● Trade or sell SNAP benefits or EBT cards

● Use SNAP benefits to buy ineligible items, which

includes alcohol, tobacco, hot food, and any food sold

for on-premises consumption. Nonfood items are also

not allowed.

● Use someone else’s SNAP benefits

● Pay for food purchased on credit with SNAP benefits

Lose your SNAP benefits for:

● 1 year for the first violation

● 2 years for the second violation

● Permanently for the third violation

You may also be fined up to $250,000 or

imprisoned for up to 20 years or both.

● Trade SNAP benefits for illegal drugs

Lose your SNAP benefits for:

● 2 years for the first violation

● Permanently for the second violation

● Trade SNAP benefits for firearms, ammunition, or

explosives

● Trade, buy, or sell SNAP benefits of $500 or more

● Lose your SNAP benefits

permanently

● Give false information about who you are or where you

live in order to receive benefits in more than one case

at the same time

● Lose your SNAP benefits for 10 years

What penalties apply in FITAP and KCSP?

If you do the following:

You will:

● Hide information or give false information

Lose your benefits for:

● 1 year for the first violation

● 2 years for the second violation

● Permanently for the third violation

You may also be fined up to $50,000 or

imprisoned for up to 20 years or both.

● Use your EBT card:

 in a liquor store,

 in a gambling casino or gaming establishment,

 in a retail establishment that provides adult

entertainment in which performers disrobe or

perform in an unclothed state for entertainment

purposes,

 at any adult bookstore, any adult paraphernalia

store, or any sexually oriented business,

 at any tattoo, piercing, or commercial body art

facility,

 at any nail salon,

 at any jewelry store,

 at any amusement or video arcade,

 at any bail bonds company,

 at any night club, bar, tavern, or saloon,

 on any cruise ship,

 at any psychic business; or

 at any establishment where persons under age 18

are not permitted, or

 at an ATM in any of these establishments.

Lose your benefits for:

● 1 year for the first violation

● 2 years for the second violation

● Permanently for the third violation

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● Use your EBT card:

 at any retailer for the purchase of an alcoholic

beverage,

 at any retailer for the purchase of tobacco products,

 at any retailer for the purchase of lottery tickets,

 at any retailer for the purchase of jewelry.

● Give false information about where you live in order to

receive benefits in two or more states at the same time

● Lose your benefits for 10 years

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Louisiana Department of Children and

Family Services

OFFICE USE ONLY

Date Received

Application for Assistance

Assigned to

Is an EBT card needed? Yes No

Check only those programs for which you are applying:

Family Independence Temporary Assistance Program (FITAP)

Kinship Care Subsidy Program (KCSP)

Supplemental Nutrition Assistance Program (SNAP) (formerly the Food Stamp Program)

You can begin to apply and establish your application date by filling in your name, address and signature below

and give this form to us today. It will help us to process your application faster if you also give us a telephone

number where you can be reached during the day and provide a copy of a photo ID or other proof of identity.

Can you read and understand English? (¿Puede leer usted y poder comprender ingles?) Yes (Sí ) No

If No, what language can you read and understand? (¿Si no, qué idioma le puede lee y comprende?)

(Last Name)

(First Name)

(Middle Name)

Social Security Number

Street or Rural Route

Apt. or Lot#

City and State

Zip Code

Phone#

Mailing Address if different from above:

I certify under penalty of perjury, the truth of the information contained in this application, including the information concerning

citizenship and alien status of the members applying for benefits.

Your Signature

What if you need SNAP benefits right away?

We may be able to get SNAP benefits to you within 7 days of the date you apply if you qualify. You may qualify if:



The total amount of money you have received or expect to receive this month is less than $150 and you

have $100 or less in liquid resources such as cash, savings or checking accounts; or



Your household’s rent/mortgage and utilities are more than your total income and resources; or



Your household includes migrant or seasonal farm workers.

If any of the above describes your household, answer the following questions:

What is the total amount of money that your household will receive this month?

Include money from all sources such as earned income, contributions, Social

Security, SSI, VA, etc.

How much money does your household have in liquid resources? Include cash on

hand, checking accounts, savings accounts, etc.

How much is your household’s monthly rent or mortgage?

Do you pay for utilities, such as electricity, gas, water, etc.?

Yes No

Do you pay utility costs for heating or air conditioning?

Yes No

Do you pay telephone expenses?

Yes No

Is anyone in your household a migrant or seasonal farm worker?

Yes No

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Office Use Only

Income

Is #1 less than $150?  Yes  No

AND

Resources

Is #2 less than $101?  Yes  No

Total

(A)

If yes to both, Expedite. If no, consider shelter costs.

Rent/Mortgage

Is B greater than A?  Yes  No

If yes, Expedite. If no, consider migrant or seasonal farm worker status.

Utility Standard*

Is anyone in the household a migrant or seasonal farm worker?

 Yes  No

AND

Total

(B)

Is #2 less than $101?  Yes  No

If yes to both, Expedite. If no, the case is not expedited.

*If, on the reverse side, the answer to:

#4 is Yes and #5 is No, use BUA.

#5 is Yes, use SUA

#6 is Yes and #4 and #5 are No, use

TEL.

Expedited: Yes No If yes, enter “Expedited Date” on CP CA screen of LAMI.

Due Date*:

*The case must be certified and the client must have their EBT card in sufficient time to be able to use their

SNAP benefits by the 6th calendar day after the date of application. If the 6th calendar day falls on a weekend or

holiday, the due date becomes the previous workday.

Expedited status determined by:

Signature of Agency Representative

Date

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A. Tell Us About You

This information is requested solely for the purpose of determining DCFS compliance with

Federal civil rights laws. Your response will not affect consideration of your application and may

be protected by the Privacy Act. The information is being collected to assure that program

benefits are distributed without regard to race, color, or national origin.

Do you need a new Louisiana Purchase Card? Yes No

First Name

Middle Initial

Last Name

Maiden or Other Name

Mailing Address

Apt/Lot No.

City

State Zip Code

Home Address (If different from mailing)

Apt/Lot No.

City

State Zip Code

( )

Home Telephone Number

Cell Telephone Number

Work or Other Telephone Number

Social Security Number

Parish of Residence

Date of Birth

E-mail Address

Sex: Male Female

Ethnicity: Hispanic/Latino? Yes No

Highest grade level

completed in school?

Marital Status:

Racial Heritage (check all that apply):

Student?

Yes No

Married

Asian

Native Hawaiian/

U.S. Citizen?

Yes No

Separated

White

Pacific Islander

If no, do you have

Divorced

American Indian/

immigration papers?

Yes No

Never Married

Alaskan Native

Date of entry in U.S.:

Widowed

Black or African American

Would you like a copy of your application?

Yes No

If yes, what format would you like the copy of your application?

Paper

Electronic

B. Tell Us If You Have An Authorized Representative

An Authorized Representative is someone you allow us to talk with about your SNAP Program benefits. You can

name someone, but it is not required.

Would you like to have an Authorized Representative? Yes No

If yes, tell us about your Authorized Representative.

( )

Name of Authorized Representative Relationship to Applicant

Telephone Number

Address

City

State

Zip Code

For Office Use Only

Rights and Responsibilities discussed with applicant? Yes No

Reporting requirements explained to applicant? Yes No

Is an EBT card needed? Yes No

Is there an authorized representative? Yes No

Identity verified by: Driver’s License Identification card Other

Residency verified by:

Marital status verified by:

Reason for application:

FITAP/KCSP explained? Yes No Client selected: FITAP KCSP

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C. Tell Us About The Other People In Your Household – Do Not Include Yourself

List everyone else who lives in your household, even if you are not applying for them. This information is

requested solely for the purpose of determining DCFS compliance with Federal civil rights laws. Your response will

not affect consideration of your application and may be protected by the Privacy Act. The information is being

collected to assure that program benefits are distributed without regard to race, color, or national origin.

Don't miss out on No Cost Health Insurance. If you answer the question below, we will share what you entered

on this application with the Louisiana Department of Health (LDH). LDH will sign up anyone who qualifies and send

you a letter with more information about the Medicaid program. Children and adults (under age 65 without

Medicare) may qualify.

PLEASE ANSWER THE QUESTION BELOW.

Yes, please share my information with LDH so I do not need to complete another application.

No, please do not share my information. Do not help me get Medicaid.

Household Members (Enter Name)

Relation

to you

(NR=Not

Related)

Birth

Date

Social

Security

Number

Sex

(M/F)

Citizen?

(Yes/No)

Level *

Marital

Status

Race/

Ethnic

Code **

Last First MI

Complete these sections only for those who need benefits

**Race: (You may select more than one race)

**Ethnicity:

AN = Alaskan Native WH = White BL = Black or African American

Y = Hispanic or Latino

AI = American Indian AS = Asian PI = Native Hawaiian or other Pacific Islander

N = Not Hispanic or Latino

*ED Level: List highest grade completed or GED/college

If you need more space for additional household members, you can write the information on plain paper or ask for

an “Additional Household Members Form.”

If anyone for whom you are applying is not a U. S. citizen, your worker will complete an Alien Addendum and

Checklist with you during your interview for those for whom you are applying.

For Office Use Only

Household composition: person household

Are all members linked on LAMI? Yes No

Enumeration verified by:

Age and relationship verified by:

Document CR 5

Citizenship: Are all household members U.S. citizens? Yes No

If no, complete Alien Addendum and Alien Checklist for all aliens who the household is applying for benefits.

Names of aliens who have opted out of applying for benefits due to immigration status.

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D. Tell Us About Your Household

For Office Use Only

Please answer the following questions for yourself and everyone else in your

home.

Are you or anyone in your household a fleeing felon?

Yes No

Are you or anyone in your household in violation of

their probation or parole?

Yes No

Have you or anyone in your household been

convicted as an adult for a felony that occurred after

February 7, 2014, for one of the following crimes?

Yes No

Aggravated sexual abuse under section 2241 of title 18, U.S.C.; Murder

under section 1111 of title 18, U.S.C.; Sexual exploitation and other

abuse of children under chapter 110 of title 18, U.S.C.; A Federal or

State offense involving sexual assault, as defined in section 40002(a) of

the Violence Against Women Act of 1994 (42 U.S.C. 13925(a)); An

offense under State law determined by the Attorney General to be

substantially similar to an offense listed above.

If yes, who?

Is this person in compliance with terms of their

sentence?

Yes No

Have you or anyone in your household been

disqualified or had their benefits reduced or stopped

for breaking the rules of SNAP, FITAP, KCSP, or

SSI?

Yes No

4. If yes, complete supplement.

Do you or anyone in your household have a

disability?

Yes No

5. If yes, complete supplement.

Does anyone in your household attend high school,

college, vocational or technical school?

Yes No

6. If yes, is anyone attending an

institution of higher education?

Yes No

If yes, complete the following for each student:

If yes, complete supplement.

Eligible student

Ineligible student

Name of Student

Name of School and Program of study

How many hours does the student attend school each week?

Is this considered full or part-time? Full-time Part-time

Eligible student

Ineligible student

Name of Student

Name of School and Program of study

How many hours does the student attend school each week?

Is this considered full or part-time? Full-time Part-time

Do you usually buy food and prepare your meals with

Yes No

everyone who lives with you?

If no, who buys and prepares their food

separately?

Have you or anyone in your household received cash

Yes No

assistance or SNAP benefits in Louisiana or from

another state?

a. If yes, who?

b. When?

c. What state(s)?

Do you or anyone in your household have an

9. If yes, what type?

application pending for any benefits that you are not

receiving yet?

Yes No

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E. Tell Us About Your Household’s Work

For Office Use Only

Tell us about any money received by you or anyone in your household for work

including full-time, part-time, temporary, or seasonal jobs, self-employment,

training, military reserve pay, or work study. This includes money received

from wages, salaries, tips, or commissions.

Do you or anyone in your household work?

Yes No

Complete the following information for each person who works for an

employer. If anyone works for more than one employer, complete a separate

block for each employer. Use plain paper if you need more space.

Person Who Works For An Employer

Use OFS 3

Name

Start Date

Verified by:

Employer’s Name

Phone #

Address

How often paid?

Weekly

Every two weeks

Twice monthly

Monthly

Other

Are reimbursements received?

Yes No

# of hours worked per week

Hourly wage

# of days worked per week

Do you ever work overtime?

Yes No

Is commission earned?

Yes No

If yes, how much?

How often?

Is this piecework?

Yes No

Rate per piece?

If yes, how often?

How many hours?

Are tips earned?

Yes No

If yes, how much?

How often?

Is this Work Study?

Yes No

Person Who Works For An Employer

Name

Start Date

Use OFS 3

Employer’s Name

Phone #

Verified by:

Address

How often paid?

Weekly

Every two weeks

Twice monthly

Monthly

Other

Are reimbursements received?

Yes No

# of hours worked per week

Hourly wage

# of days worked per week

Do you ever work overtime?

Yes No

Is commission earned?

Yes No

If yes, how much?

How often?

Is this piecework?

Yes No

Rate per piece?

If yes, how often?

How many hours?

Are tips earned?

Yes No

If yes, how much?

How often?

Is this Work Study?

Yes No

Is anyone on strike?

Yes No

Has anyone in your household (including you)

stopped working in the last 60 days?

Yes No

5. If yes, complete supplement.

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Complete the following information for each person who is self-employed. This

includes fishermen, child care providers, hair dressers, and people who do odd

jobs such as cutting grass, picking up cans, etc. Use plain paper if you need

more space.

For Office Use Only

Persons Who Are Self-Employed

6. Verified by:

Prior year’s income tax

Name

return

Accountant or

Type of Business

bookkeeper records

Personal business

Monthly Business Income

records

Monthly Business Expenses

# Hours Worked Per Week

Is anyone in your household (including you) looking

for work?

Yes No

7. If yes, complete supplement.

Is anyone in your household a migrant or seasonal

farm worker?

Yes No

Do you or anyone in your household rent a room?

Yes No

10.

Do you or anyone in your household pay someone

else in your home for meals?

Yes No

F. Tell Us About Other Income

Do you or anyone in your household receive money from a source other

than work? Yes No If yes, check each type of income.

Annuity Income

Roomer/Boarder

Child Support Income

Social Security

Contributions From

Family/Friends

Scholarships/Grants/School

Loans

Disability Insurance Benefits

SSI

Energy Check

Spousal Support/Alimony

Interest Income

Tribal Money

Loans

Training Allowance (WIOA)

Military Allotment

Trust Income

Oil Lease/Royalties

Unemployment Benefits

Railroad Benefits

Veterans Benefits

Rental Income

Workers Compensation

Retirement Pension

Other

For Office Use Only

FITAP

SNAP

Name

Age

WR Code

Reason For Exemption

WR Code

Reason For Exemption

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For each box checked in #1 of this section on page 5, complete the

following information. Include any money you expect to receive in the

next 30 days.

For Office Use Only

Name

Type Of

Income

Amount

How Often

(Weekly,

Monthly, etc)

Do You Expect

This Income To

End

Yes No

Verified by:

If yes, when?

Yes No

If yes, when?

Yes No

If yes, when?

Yes No

If yes, when?

Is someone court-ordered to pay child support to you

or anyone in your household?

Yes No

3. If yes, complete supplement.

Do you or anyone in your household receive any

money from a child’s parent who is not court-ordered

to pay?

Yes No

4. If yes, complete supplement.

G. Tell Us About Your Expenses

Living Arrangement

In order to receive the most benefits possible, you need to tell us about your

household expenses. Failure to report any of the expenses listed below will be

seen as a statement by your household that you do not want to receive a

deduction for the unreported expense.

Public housing

HUD or Section 8 subsidy

Other subsidy

No rent subsidy

HOUSING EXPENSES

Check each type of housing expense that you or anyone in your

household has.

Rent

Electricity

Mortgage(s), (if buying)

Gas

Are insurance and property taxes

included in the mortgage

payment? Yes No

Are any of these bills past due?

Yes No

Lot Rent

Sewer

Homeowner’s Insurance

Water

Flood Insurance

Garbage

Property Tax

Telephone

Condominium Fees

Other

For each box checked in #1 of this section, complete the following

information.

Type Of Housing

Expense

Name and Phone Number of

Person or Company Paid

Amount

Paid

How Often Paid

(Weekly, Monthly,

Etc.)

Indicate how each expense was

verified.

Eligible for: SUA

BUA

TEL

None

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Do you pay housing expenses for a home you are no

longer living in but plan to return to?

Yes No

For Office Use Only

Is your household responsible for paying a utility bill

for using a heater or air conditioner?

Yes No

Does anyone help you pay your housing expenses?

Yes No

5. If yes, complete supplement.

Do you receive energy assistance?

Yes No

If yes, is the assistance through the Low-Income

Home Energy Assistance Program (LIHEAP)?

Yes No

Is any of the rent you pay used to pay utilities?

Yes No

DEPENDENT CARE EXPENSES

Do you or anyone in your household pay someone to

care for a child, or an adult who is elderly or disabled,

so that you or a household member can work, attend

training or school, or look for work?

Yes No

1. If yes, complete the OFS 4DC-

Dependent Care Expense

Worksheet

Certified for CCAP?

Yes No

If yes, complete the following information.

Paid For Whom

Name And Telephone

Number Of Person Paid

Amount

Paid

How Often Paid

(Weekly,

Monthly, Etc.)

What is co-payment amount?

CHILD SUPPORT EXPENSES

Does anyone in your household pay court-ordered child

support?

Yes No

Court-ordered child support

expenses:

If yes, complete the following information.

Who Pays

Paid to Whom

Amount

Paid

How Often Paid

(Weekly, Monthly,

Etc.)

MEDICAL EXPENSES

We can allow a medical deduction in your SNAP case for each household

member who has a disability or is over the age of 59. A deduction may be given

for medical expenses that are more than $35.00 per month.

Is there anyone in your household who has a disability

or is over the age of 59?

Yes No

If yes, answer the questions in this section.

If no, skip to the Household Resources section on the

next page.

Does this person have to pay medical expenses?

Yes No

If yes, do you want to verify these expenses so

that you can receive a medical deduction?

Yes No

Medical expenses:

Use form SNAP 1MW

Check each medical expense that this person has.

Dental Bills

Prescribed Medicine

Hospital Bills

Prescription Drug Plan

Health Insurance Or

Premium

Medicare Premiums

Nursing Home

Medical Appliances

Other

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For each box checked in # 2 on page 7, complete the following information.

For Office Use Only

Names

Type of Expense

Amount

Paid

How Often Paid

(Weekly, Monthly,

Etc.)

Medical Transportation Expense is money spent for trips to the doctor, hospital,

drug store, etc. This includes miles driven in your own vehicle.

Does any elderly or disabled person listed on previous

page have medical transportation costs?

Yes No

Does this person use their own vehicle or a

household member’s vehicle?

Yes No

If yes, complete the following information.

Name Of Person

List All Places Visited

For Medical Purposes

(Ex. Doctors, Drug

Store, Hospital, Etc.)

# Of Miles

Traveled

Round

Trip

Number Of

Visits Per Month

Does this person pay someone other than a

household member for medical transportation?

Yes No

If yes, complete the following information.

Name Of Person

Who Is Paid

Where Does

This Person

How

Much

Does This

Person

Pay Per

Trip

How Many Trips

Does This

Person Pay For

Each Month

If you need more space, you can write the information on plain paper.

Will you or anyone in your household be reimbursed for

any of the medical expenses listed above?

Yes No

5. If yes, complete supplement.

Does anyone help pay the medical expenses?

Yes No

6. If yes, complete supplement.

When management is

questionable, use form OFS

4MW.

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H. Tell Us About Your Household’s Resources

For Office Use Only

Resources include cash, money in the bank, Certificates of Deposit, stocks, and

bonds. Resources do not include personal property such as jewelry, furniture,

electrical equipment, or clothing.

Check each resource listed below that you or anyone in your household has.

Bank/Credit Union Account

Cash On Hand

(Checking)

Certificate Of Deposit (CD)

Bank/Credit Union Account

Money Market Account

(Saving)

Mutual Funds

Joint Account

Savings Bond

Bonds

Stocks

For each box checked above, complete the following information.

In Whose Name Is The

Resource Listed

Type Of

Resource

How

Much

Is It

Worth

Where Is The Resource (Include

Name Of Bank Or Company,

Where Money Is Held, Address

Of Property, Etc.)

Are liquid resources $1500 or

less? Yes No

Have you or anyone in your household received a

Federal tax refund in the last twelve months?

Yes No

3. If yes, complete supplement.

Have you or anyone in your household received or

do you or anyone in your household expect to receive

a lump sum of money?

Yes No

4. If yes, complete supplement.

Countable lump sum

Non-countable lump sum

Does your name or the name of anyone in your

household appear on a bank/credit union account with

someone else?

Yes No

How was this verified?

Client statement

Bank statement

Other

If yes, whose names are on the account?

Why is this name on the account?

Does someone else make deposits into this

account?

Yes No

If yes, who and how much per month?

Have you or anyone in your household sold, traded,

given away, or transferred a resource in the last three

months?

Yes No

6. If yes, complete supplement.

For Office Use Only

IF YOU ARE APPLYING FOR SNAP BENEFITS ONLY, SKIP TO PAGE 12.

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COMPLETE THIS PAGE ONLY IF YOU ARE APPLYING FOR FITAP OR KCSP

I. FITAP or KCSP

For Office Use Only

Are you applying for FITAP or KCSP?

Yes No

If yes, complete this page. If no, skip to page 12.

Do you or anyone in your household need to get away from an

2. If yes, issue Flyer DV

abusive situation?

Yes No

Are immunizations current on all children?

Yes No

3. Verification:

OFS IM

If no, who?

Why:

CR9

Are you or anyone in your household pregnant?

Yes No

LINKS

If yes, who?

Due date:

HEALTH INSURANCE

Can you or anyone in your household get health

5. If yes, provide BHSF Flyer

LaHIPP

insurance through an employer?

Yes No

COLLATERALS

Please complete the following information for two people who are not

*Note: If client checked “Yes” for

#5 on page 3, complete OFS 90

or OFS 90L.

related to you who can verify your household situation.

Name

Address

Daytime

Phone Number

CUSTODY

If you are not the parent of the child(ren) for whom

7. Custody verified by:

you are applying, do you have custody?

Yes No

If yes, complete the following information.

Children For Whom You Have

Custody

Type Of Custody

Effective Date Of

Custody

A non-custodial parent is a parent who does not live in the home with his/her child. Tell us about the non-

custodial parent(s) of each child living in your home. This includes both mother and father if you are not the

parent of the child(ren). If a child’s biological father and legal father are not the same person, give the requested

information for both fathers. Use plain paper if you need more space.

Non-Custodial Parent Information

Name

Social Security Number

Date of Birth

Street Address

City

State

Phone Number

Employer

Name(s) of Children

Parental Relationship (relationship of children’s parents):

Married

Widowed

Never Married

Divorced

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Non-Custodial Parent Information

Name

Social Security Number

Date of Birth

Street Address

City

State

Phone Number

Employer

Name(s) of Children

Parental Relationship (relationship of children’s parents):

Married

Widowed

Never Married

Divorced

10.

Non-Custodial Parent Information

Name

Social Security Number

Date of Birth

Street Address

City

State

Phone Number

Employer

Name(s) of Children

Parental Relationship (relationship of children’s parents):

Married

Widowed

Never Married

Divorced

For Office Use Only

Living in the home with qualified relative? Yes No

Verified by:

Landlord statement

School records

Collateral

Other

NCP: Complete form 4NCP and 4NCP Supplement, if applicable:

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Read Carefully And Sign Below

I certify under penalty of perjury that the information I have given on this application is true, complete, and

correct to the best of my knowledge, including the information I have given regarding the felony conviction of

certain crimes and the U.S. citizenship or immigration status of all household members. I understand that I and

any adult household member will be subject to disqualification and prosecution and will be required to repay

ineligible benefits if we knowingly give false, incorrect, or incomplete information in order to obtain or try to

obtain financial or food assistance. By signing this application, I give permission for the release of information

to the Department of Children and Family Services by any persons or agencies who have knowledge of my

circumstances.

Remember, you must turn in proof of the information you reported on this application form and

verification of your identity.

Your Signature (or mark)

Date Signed

Signature (or mark) of your wife or husband

Date Signed

Signature of Minor Unmarried Parent

Date Signed

If you, or your wife or husband, sign with an “X” mark, ask two people to witness the mark; if applicant

is blind, ask three people to witness.

Witness

Signature of Person Who Helped You Complete this Form and His or Her Relationship to You

Signature

Relationship

Signature of Agency Representative

Date

I want to withdraw my

application because

Signature of Applicant

Date

How to submit the Application for Assistance to the Department of Children and Family

Services (DCFS):

By Mail:

Department of Children and Family Services ES

Document Processing Center

P. O. Box 260031

Baton Rouge, LA 70826-9918

By Fax:

(225)663-3164

In Person:

Any DCFS Office

If you have any questions regarding the application process, please contact the Customer

Service Center at 1-888-LAHELPU (1-888-524-3578).

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Voter Registration

If you are not registered to vote where you live now, would you like to apply to register to

vote here today? (Check one)

I want to register to vote. I do not want to register to vote.

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED

NOT TO REGISTER TO VOTE AT THIS TIME.

Applying to register or declining to register to vote will not affect the amount of assistance that

you will be provided by this agency. Voter eligibility requirements are found on the voter

registration application form.

Note: If you do register to vote, the location where your application was submitted will remain

confidential. If you decline to register to vote, this fact will remain confidential. Applying to register

or declining to register to vote will be used only for voter registration purposes.

If you would like help in 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. (Check one)

Yes, I would like help. No, I do not want help.

For assistance in completing the voter registration application form outside our office, contact the

Department of Children and Family Services at 1-888-LAHELPU or 1-888-524-3578.

If completed outside our office, this declaration form and your completed voter registration

application form (if you filled one out) should be returned to the DCFS ES Document Processing

Center at P.O. Box 260031, Baton Rouge, LA 70826-9918.

Signature or Mark

Name Typed or Printed

Date

Signatures of Two Witnesses If Signed With Mark:

COMPLAINTS

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 Louisiana Secretary of State, Commissioner of Elections, P.O. Box 94125, Baton Rouge, LA

70804-9125 or by calling (225) 922-0900 or 1-800-883-2805.

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