PURPOSE: Food stamp applications are taken in FAMIS when the applicant is available in person. Use the Spanish translation FS-1 as the food stamp application form, as appropriate, in the following situations:
For mail-out applications, include the IM-31F (Spanish) with the Spanish FS-1.
Do not use an FS-1 for all food stamp applications. If the applicant is available in person and can stay for the interview, complete the application in FAMIS and do not use the FS-1 form.
If an individual wishes to download the FS-1 from the Internet, instruct the individual to go to http://www.dss.mo.gov/fsd/fstamp/index.htm. Both the English and Spanish translations are on the website.
NUMBER OF COPIES AND DISPOSITION: The original is completed and filed in the case record following registration of the application.
NOTE: When a person(s) is added to an open food stamp case, an FS-1 is not necessary. Register the individual application in FAMIS.
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 handicap 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 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 county office. If the FS-1 is faxed after normal working hours, the date of application is the next business day.
If the applicant cannot stay to meet with the eligibility specialist 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. Register the application 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 county office.
FOR FSD USE ONLY/PARA USO EXCLUSIVO DE LA FSD
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.
DATE RECEIVED/APPLICATION DATE: Enter the date the FS-1 is received in the office either in the mail, by fax, 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. Check to ensure that a case number has not previously been assigned.
NOMBRE COMPLETO: Enter the full 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 name.
TELEFONO PARTICULAR/TELEFONO PARA MENSAJES: Space is provided for both a home telephone number and a message telephone number. Complete both blanks, if applicable.
DOMICILIO PARTICULAR: 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.
DOMICILIO POSTAL: Enter the mailing address if it is different from resident address (the mailing address can be: the county 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. If the legal guardian resides in one county and the applicant resides in another, the legal guardian must appoint an authorized representative who resides in the applicant's county. The complete address of the authorized representative is then entered.
FIRMA DEL SOLICITANTE: 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.
If an applicant has a legal guardian, the signature should be that of the guardian. For example, Ralph Owen, Guardian for Ruth Otis.
If the application is made for the EU by an authorized representative, the signature should be that of the authorized representative. For example, Ralph Owen, Authorized Representative for Ruth Otis.
NOTE: If the applicant is a resident of a drug or alcohol treatment center, the center is the authorized representative. A representative of the center must sign the application.
FECHA: Enter the date applicant signs the FS-1.
INTEGRANTES DELGRUPO FAMILIAR:
NOMBRE: The applicant lists each person in the EU with the applicant's name entered on line one.
SEXO (M/F): The applicant enters his/her gender.
RELACION: The applicant enters the relationship of each EU member to herself/himself.
FECHA DE NACIMIENTO: The applicant enters the birth date for each EU member.
NO. DE SEGURO SOCIAL: The applicant enters the social security number for each EU member.
HISPANO/LATINO SI/NO: The applicant enters “si” (yes) or “no” if any EU member is Hispanic.
RAZA (SELECCIONE TODAS QUE LE CORRESPONDEN): The applicant selects and enters the race code as shown at the bottom of the EU members section. (Select all that apply)
CUIDADANO/A (SI/NO): The applicant enters “si” (yes) or “no” to attest to his/her United States citizenship and the United States citizenship of all EU members.
COMPRA/COCINA DE MANERA CONJUNTA: Place a check ( ) mark if the EU member listed buys and cooks food together.
DECLARACION DE DATOS DEL HOGAR:
Applicant checks (√) “si” (yes) or “no” if any EU member has been convicted of trafficking food stamp benefits. If “si” (yes), applicant lists the name of the EU member(s) who has been convicted.
Applicant checks (√) “si” (yes) or “no” if any EU member is fleeing to avoid prosecution, custody or jail for a crime that is a felony. If “si” (yes), applicant lists the name of the EU member(s).
Applicant checks (√) “si” (yes) or “no” if any EU member is violating a condition of probation or parole. If “si” (yes), applicant lists the name of the EU member(s).
Applicant checks (√) D. Applicant checks (?) “si” (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 “si” (yes), applicant lists the name of the EU member(s).
Applicant checks (√) “si” (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 “si” (yes), applicant lists the name of the EU member(s).
Applicant checks (√) “si” (yes) or “no” if any EU member has ever been found by a state agency or convicted in court of having made fraudulent statements or misrepresentation with respect to identity or place of residence for the purpose of receiving food stamp benefits in two or more places at the same time. If “si” (yes), applicant lists the name of the EU member(s).
SERVICIO DE CURSO RAPIDO: This section notifies the EU of the expedited service qualifications.
DERECHO A NO SER DISCRIMINADO Y A UNA AUDIENCIA JUSTA/ AVISO Y RECONOCIMIENTO SOBRE LAS DISPOSICIONES DE FRAUDE: 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.
FIRMA: Applicant signs his/her name (in ink) in the same way it is entered on page one of the form.
Signature of Applicant: Robert T. (X) (his mark) Cummins
Witnesses: Jane Harris, 627 N. Euclid St., St. Louis, MO 63108
Ralph Owen, 3428 Shenandoah Blvd., St. Louis, MO 63104
When the applicant has a legal guardian, the signature should be that of the guardian. For example, Ralph Owen, Guardian for Ruth Otis.
If the application is made for the EU by an authorized representative, the signature should be that of the authorized representative. For example: Ralph Owen, Authorized Representative for Ruth Otis.
NOTE: If the applicant is a resident of a drug or alcohol treatment center, the center is the authorized representative. A representative of the center must sign the application.
If someone else (including the eligibility specialist) helped the applicant complete the form or completed it for the applicant, that person must sign his/her name and enter the date.
FECHA: Enter the date applicant signs the FS-1.