FS-1 Instructions

APPLICATION FOR FOOD STAMP BENEFITS

PURPOSE: Food Stamp applications are entered in FAMIS without an FS-1when the applicant applies in person. Use the FS-1 as the Food Stamp application form in the following situations:

If an individual wishes to download the FS-1 from the Internet or wishes to complete a web application, instruct the individual to go to http://dss.mo.gov. Both the English and Spanish translations are on the website to download or complete online.

NUMBER OF COPIES AND DISPOSITION: The original is completed and filed in the case record.

NOTE: An FS-1 is not needed to add an individual to an active Food Stamp case. Enter the add-a-person in FAMIS. See the User Guide Adding A Member To The Supercase And/Or Eligibility Unit for complete instructions.

MANUAL REFERENCE: FS MANUAL 1100.000.00 - 1160.000.00

INSTRUCTIONS FOR COMPLETION: Complete this form in ink. All entries are made by the applicant or his/her authorized representative, except the section marked for Family Support Division (FSD) use. If an applicant has a physical or mental disability which prevents him/her from completing this form, the eligibility specialist may complete the eligibility statement based on information given by the applicant. If the eligibility specialist (ES) completes the application, explain on the FS-1 the reason the applicant was unable to make the necessary entries.

No changes or erasures are made after the form is signed by the applicant. If a change is made, the applicant must sign his/her name and the date by any correction(s).

If the applicant signs the FS-1 in the office because s/he cannot stay for the interview, the date filed is the date the applicant signs the form. If the FS-1 is mailed or faxed, the date the application is filed is the date the form containing name, address, and signature is received in the FSD office. If the FS-1 is faxed when the office is closed, the date of application is the next business day.

If the applicant cannot stay to meet with the ES or to complete the FS-1, the applicant must at least write his/her name, address, and sign the form. Make a copy of the form and send the original form home with the applicant to complete. Schedule an interview with the applicant following current procedures. Enter the request in FAMIS if enough information is available. If there is not enough information, register the application when the completed form is received or when the interview is conducted. The date of application is the date the applicant signed the FS-1 at the FSD office.

FOR FSD USE ONLY

DATE OF LAST FACE-TO-FACE (F-T-F) INTERVIEW: This area is used to assist staff in tracking recertifications since the last face-to-face interview was completed. List the date the last face-to-face interview was completed.

NOTE: An interview is required for ALL Food Stamp applications. The face-to-face interview is required only once per twelve months and may be waive.  See Food Stamp Manual section 1120.045.15 Waiver of the Office Interview.

DATE RECEIVED/APPLICATION DATE: Enter the date the FS-1 is received in the office either in the mail, by fax, by web, or through an in-person contact.

MAIL-IN/WALK-IN: Check (√) to indicate if the application was received in the mail or when the applicant came into the office.

SCN: Enter the Supercase Number assigned to this EU.

DCN: Enter applicant's Departmental Client Number. Use the Social Services Clearing Menu (SCLR) screen to determine the individual's DCN or to assign a new DCN if one has not been previously assigned.

NAME: Enter the full legal last, first and middle names of the applicant. This is written as the name will appear on the EBT card for the head of the EU if the application is approved. Avoid the use of nicknames, aliases, diminutives, or initials for first name, unless said initials are the applicant's actual legal name.

TELEPHONE: Space is provided for both a home/cell telephone number and a message telephone number. Complete both blanks, if applicable.

HOME ADDRESS: Enter the house number, street or rural route number, city, state and zip code where the applicant resides. If the EU does not have a residential address, the applicant must enter directions to the home or a description of where the EU lives.

MAILING ADDRESS: Enter the mailing address if it is different from resident address (the mailing address can be: the FSD office, in care of another residence, a post office box, or general delivery).

If the individual has a legal guardian, enter the address of the guardian as the applicant's mailing address. The complete address of the authorized representative is then entered.

SIGNATURE OF APPLICANT: The applicant signs the application. If the signature is made by mark, the mark is identified as such and enclosed in parentheses with the applicant's name typed or handwritten as shown.

The correct procedure for making the mark is illustrated below:

Signature of applicant: Robert T. (X) (his mark) Cummins.

DATE: Enter the date applicant signs the FS-1.

HOUSEHOLD MEMBERS:

  1. Enter the following information for each EU member.

    NAME: The applicant lists the full legal name of each person in the EU with the applicant's name entered on line one.

    SEX (M/F): The applicant enters his/her gender.

    RELATIONSHIP: The applicant enters the relationship of each EU member to herself/himself.

    DATE OF BIRTH: The applicant enters the birth date for each EU member.

    SOCIAL SECURITY NUMBER: The applicant enters the social security number for each EU member.

    HISPANIC OR LATINO Y/N: The applicant enters "yes" or "no" if any EU member is Hispanic.

    RACE: The applicant selects and enters the race code as shown at the bottom of the EU members section.

    CITIZEN (Y/N): The applicant enters "yes" or "no" to attest to his/her United States citizenship and the United States citizenship of all EU members.

    BUY & COOK TOGETHER: Place a check (√) mark if the EU member listed buys and cooks food together.

  2. LANGUAGE: The applicant enters "yes" or "no" if any member speaks English well. If no EU member speaks English well, the EU member enters what language is most often spoken.
  3. FOSTER CARE: Applicant checks (√) "yes" or "no" if any EU member(s) is in foster care. If "yes", applicant lists the name of the EU member(s).

HOUSEHOLD'S DECLARATION INQUIRY:

  1. Applicant checks (√) "yes" or "no" if any EU member has been convicted of trafficking Food Stamp benefits of $500 or more after 9-22-96. If "yes", applicant lists the name of the EU member(s) who has been convicted.
  2. Applicant checks (√) "yes" or "no" if any EU member is fleeing to avoid prosecution, custody, or jail for a crime that is a felony. If "yes", applicant lists the name of the EU member(s).
  3. Applicant checks (√) "yes" or "no" if any EU member is violating a condition of probation or parole. If "yes", applicant lists the name of the EU member(s).
  4. Applicant checks (√) "yes" or "no" if any EU member is receiving Food Stamp benefits under another identity or as a member of another EU or in another state. If "yes", applicant lists the name of the EU member(s).
  5. Applicant checks (√) "yes" or "no" if any EU member has been convicted of a felony committed after 8-22-96 relating to illegal possession, use, or distribution of a controlled substance. If "yes", applicant lists the name of the EU member(s).
  6. Applicant checks (√) "yes" or "no" if any EU member has ever been convicted of fraudulently receiving duplicate Food Stamp benefits in any State after 9-22-96. If "yes", applicant lists the name of the EU member(s).
  7. Applicant checks (√) "yes" or "no" if any EU member has been convicted of trading Food Stamp benefits for guns, ammunitions, or explosives after 9-22-96. If "yes", applicant lists the name of the EU member(s).
  8. Applicant check (√) "yes" or "no" if any EU member has been convicted of trading Food Stamp benefits for drugs after 9-22-96. If "yes", applicant lists the name of the EU member(s).

EXPEDITED SERVICE: This section notifies the EU of the expedited service qualifications.

OUT OF STATE: Applicant checks (√) "yes" or "no" if any EU member(s) received benefits out of state in the last 30 days. If "yes", applicant lists the name of any EU member(s), State where benefits were received, county where benefits were received, and last month benefits were received.

DISABILITY: Applicant checks (√) "yes" or "no" if any EU member(s) has a disability. If "yes", applicant lists the name of the EU member(s) and the disability.

HIGHER EDUCATION: Applicant checks (√) "yes" or "no" if any EU member(s) age 18-49 is attending school. If "yes", applicant lists the name of the EU member(s), and states if the EU member(s) is works 20 hrs weekly averaged, has a disability, has work study, participates in on-the-job training, cares for a child under 12, participates in WIA training program, or receives Temporary Assistance.

BANK ACCOUNTS, CASH, ETC.: Applicant checks (√) "yes" or "no" if any EU member(s) have liquid resources or jointly own resources with another EU member or jointly own with someone outside of the EU. If "yes", applicant lists the name of the EU member(s) who have resources, the type of resource, resource value, description/location and use.

OTHER RESOURCES: Applicant checks (√) "yes" or "no" if any EU member(s) own or are purchasing a prepaid burial, a vehicle, real property, or personal property.

EARNED INCOME: Applicant checks (√) "yes" or "no" if any EU member(s) are receiving income from employment. If "yes", the applicant lists the name of the EU member(s) who are employed, the employers' name, start date, frequency of payment, amount earned, and if the income is from tips, bonus, or commission.

EMPLOYMENT CHANGES: Applicant checks (√) "yes" or "no" if any EU member(s) is on strike. Applicant checks (√) "yes" or "no" if any EU member(s) ages 16-60 quit a job in the last 60 days or reduced their work hours in the last 60 days. 

SELF EMPLOYMENT: Applicant checks (√) "yes" or "no" if any EU member(s) operate or own a business. If "yes", applicant lists the name of the EU member(s) who operate or own a business, the source of the business, start date of the business, frequency of payment, and amount earned.

EXPENSES OF SELF EMPLOYMENT: Applicant enters the expenses of self employment. The applicant lists the type of the expense, frequency of payment, and the amount of payment.

OTHER INCOME: Applicant checks (√) "yes" or "no" if any EU member(s) receive income from another source. If "yes", applicant lists the name of the EU member(s), source of the other income, start date, frequency of payment, and amount received.

MEDICAL EXPENSES: Applicant checks (√) "yes" or "no" if any EU member(s) incur medical expenses. If "yes", applicant lists the name of the EU member(s) who incur medical expenses, type of expense, frequency of payment, amount paid, and number of miles driven from home to receive medical care.

SHELTER EXPENSES: Applicant checks (√) "yes" or "no" if the EU received energy assistance at the current address in the last 12 months. Applicant checks (√) "yes" or "no" if any EU member(s) incur shelter expenses and if the EU is receiving housing assistance or help paying the expenses. If "yes", applicant lists the name of the EU member(s) who incur a shelter expense, type of expense, amount paid, frequency of payment, and if the expense is a primary heating or cooling expense.

DEPENDENT CARE EXPENSES: Applicant checks (√) "yes" or "no" if any EU member(s) pays someone outside of the home for dependent care expenses. If yes, applicant lists the name of EU member(s) paying the expense, who the care is paid for, amount paid, frequency, and number of miles driven from home to the provider.

COURT ORDERED EXPENSES: Applicant checks (√) "yes" or "no" if any EU member(s) pays someone a court-ordered expense. If yes, applicant lists the name of EU member(s) paying the expense, type of expense, who the expense is paid for, amount of the legal obligation, amount paid, and frequency.

NON-DISCRIMINATION AND FAIR HEARING RIGHTS / NOTIFICATION AND ACKNOWLEDGMENT OF FRAUD PROVISIONS: Before the form is signed, the applicant must read the statements under each category. These statements are important in prosecution of individuals suspected of fraud and misrepresentation.

SIGNATURE OF APPLICANT: Applicant signs his/her name (in ink) in the same way it is entered on page one of the form.

DATE: Enter the date applicant signs the FS-1.

10.01.2012