Content Overview
The Mississippi SNAP Application form is a crucial document for individuals and families seeking assistance through the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF). This form collects essential information about the applicant, including personal details such as name, Social Security Number, and contact information. It also requires applicants to specify which benefits they are applying for, either TANF or SNAP. An interview is a necessary step in the application process, although certain circumstances may allow for a telephonic interview instead of a face-to-face meeting. The form outlines eligibility criteria, emphasizing that benefits can be accessed quickly under specific conditions, such as having a gross monthly income below $150 or facing significant housing costs. Additionally, the application gathers information on household income, expenses, and the composition of the household, including details about individuals not included in the application. It is important to note that only U.S. citizens and qualified aliens are eligible for SNAP benefits, and the form includes a certification section where applicants affirm the accuracy of the information provided. Understanding these key aspects of the Mississippi SNAP Application form is vital for applicants to navigate the assistance process effectively.
Mississippi Snap Application Preview
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FOR OFFICE USE ONLY:
DATE
CASE NUMBER:_________________________________RECEIVED:________________
Appointment Date:_______________ Time:___________ 303B: ❑ Initials:____________
InterviewedTelephonic
By:_______________________________ Interview:__________________ 530: ❑Initials:
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) APPLICATION
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) APPLICATION
Name___________________________________SSN_______________________________Date of Birth______________________
Residence Address_______________________________________________________________ Phone______________________
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Mailing Address__________________________________________________________________ 2nd Phone____________________ |
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Would you like to receive notices by email? ❑Yes ❑No |
If yes, email address:_________________________________________ |
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What benefits are you applying to receive? |
❑TANF |
❑SNAP |
Before we can determine your eligibility, you must be |
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interviewed. Due to household hardship, a
TANF
To begin your application, complete the above section and sign below. We are required to take action within 30 days from the day you give us this form.
SNAP
You may file your application immediately by submitting the forms to the local county office either in person, through an authorized representative, by fax, or by mail as long as we have your name, address and the signature of a responsible household member or your authorized representative. The application filing date is considered the day we receive this form in our office, and benefits are provided from that day, if determined eligible. However, when a resident of an institution jointly applies for SSI and SNAP prior to leaving the institution, the application filing date must be considered the day of your release from the institution. We are required to verify information you provide and take action within 30 days from the date your application is received, unless you are entitled to receive benefits within 7 days. YOU MAY GET SNAP WITHIN 7 DAYS if your household’s gross monthly income is less than $150 and your household’s resources such as cash, checking or savings accounts are $100 or less; or if your rent/mortgage and utilities are more than your household’s co mbined gross monthly income and liquid resources; or if you are a migrant or seasonal farm worker household; and you verify your identity. All SNAP applications, regardless of whether they are joint applications or separate applications, will be processed according to SNAP regulations and timeframes and will not be affected if TANF is denied.
For information regarding services provided by Families First for Mississippi, contact
By signing and dating this application, I am giving consent for the attendance records of the children identified on this application to be disclosed by the Mississippi Department of Education to the Mississippi Department of Human Services for use by the Department of Human Services to determine compliance with school attendance requirements of the Temporary Assistance for Needy Families (TANF) Program.
Only US citizens and qualified aliens are eligible for SNAP benefits. Any
I certify that each applicant included in my household is a U.S. citizen or alien in lawful immigration status and that the information provided is true to the best of my knowledge. I give permission for the Department of Human Services to make a full review of my case and any necessary contacts to verify my statements. I give consent for the release of income verification to MDHS for all household members that are 18 or above. I know that if I give false or incorrect information, I could be penalized, my case may be denied, and I may be subject to criminal prosecution. I certify that I received the Rights and Responsibilities handout from this agency.
Signature of Applicant |
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Signature of witness if signed by mark |
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Signature of Authorized Representative or |
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Signature of witness if signed by mark |
Second Parent in TANF |
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SNAP Outreach |
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Agency Code |
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Has anyone in your household received any income (money, checks, gifts, etc.) this month? ❑Yes ❑No. If yes, how much? $_______ |
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Does anyone expect to receive income later this month? ❑Yes ❑No. If yes, how much? $_________ |
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How much money does your household have in cash, checking account and savings account? $_______________ |
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Give the actual expense amounts: Rent/Mortgage $________Electricity $________Gas $_______Water $_______Phone $________ |
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Is your household’s only income from migrant or seasonal farm work? ❑Yes ❑No |
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Does any household member age 60 or above or disabled have any out of pocket medical expenses that exceed $35? ❑Yes ❑No |
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Is anyone in your household currently serving a SNAP disqualification due to fraud? ❑Yes ❑No |
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Have you or any member of your household been convicted of trading SNAP benefits for drugs after 08/22/96? ❑Yes ❑No |
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Have you or any member of your household been convicted of a |
10. Have you or any member of your household been convicted of buying or selling SNAP benefits over $500 after 08/22/96? ❑Yes ❑No
11.Have you or any member of your household been convicted of fraudulently receiving duplicate SNAP benefits in any State after 08/22/96? ❑Yes ❑No
12.Have you or any member of your household been convicted of trading SNAP benefits for guns, ammunitions, or explosives after 08/22/96? ❑Yes ❑No
13.Are you or any member of your household hiding or running from the law to avoid prosecution, being taken into custody, or going to
jail, for a felony crime or attempted felony crime, or violating a condition or parole or probation? ❑Yes ❑No
14. Are you or any member of your household a resident of a commercial boarding home (establishment that offers meals and lodging for
compensation with the intent of making a profit)? ❑Yes |
❑No |
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15. Are you or any member of your household on strike? ❑Yes ❑No |
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List who you are applying for beginning with the Head of Household |
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Name (First, Last) |
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RELATIONSHIP |
SOCIAL SECURITY |
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**OPTIONAL |
US |
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*SEE DISCUSSION |
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HISPANIC |
RACE |
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BELOW |
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Y or N |
(***Choose |
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one or more) |
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**Information pertaining to Ethnicity and Race is not required and will not be used in determining your eligibility or benefit level. This information will be used to help |
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determine how effective the program is in reaching the eligible population. |
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***Race Codes: |
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List anyone in your household who you are not including in this application
Name (First, Last)
Relationship to Head of Household
Age
Name (First, Last)
Relationship to Head of Household
Age
SNAP Authorized Representative
You may appoint someone outside your household to act for your household to make an application and to be interviewed. This person should know your household’s situation well enough to give any information needed to determine your eligibility for SNAP. You are responsible for the information that anyone acting as your authorized representative gives, including any information that may be incorrect.
I would like to appoint: 1. Name |
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2. Name |
As part of the eligibility process for SNAP, I understand that certain household members including myself will be eligible to receive SNAP benefits only by following requirements to register for work, seek employment, and/or accept suitable employment, unless a work exemption is met by that household member. I understand that job seeking services are available through the MS Department of Employment Security, and that I may be required to complete job seeking requirements at a later date. I will accept an offer of suitable employment whether it was received through my own effort or through an employment and training referral. I understand that failure to comply with work registration
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requirements may result in disqualification of a household member or the entire household from SNAP, and that I will explain these work requirements to my household.
I understand that the information included on this application may be disclosed to other Federal and State agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law.
I understand that if a SNAP/TANF claim arises against my household, the information on this application, including all SSNs, may be referred to Federal and State agencies, as well as private claims collections agencies, for claims collection.
PENALTY WARNING: *A Social Security Number (SSN) must be provided or applied for each person for whom assistance is requested per the Food and Nutrition Act of 2008. SSNs will be verified and used for Federal and State data matches, including but not limited to, Social Security, Internal Revenue Service, VA, MS Department of Employment Security, resource/income verifications, program disqualifications, and for collection of fraud debts. State and federal laws provide for fines, imprisonment or both for any person guilty of obtaining assistance to which he/she is not entitled by willfully withholding or giving false information. Information may be verified through collateral contacts when discrepancies are found. Alien status of persons requesting benefits is subject to verification with United States Citizenship and Immigration Services (USCIS) and will require submission of certain information from this application to USCIS.
SNAP PENALTY WARNING: If your household receives SNAP, it must follow the rules listed below. Any member of your household who breaks any of these rules on purpose can be barred from SNAP for 1 year for first offense, 2 years for second offense, and permanently for third offense; fined up to $250,000, imprisoned up to 20 years or both; and subject to prosecution under other federal laws.
DO NOT give false information, or hide information to get or continue to get SNAP benefits. DO NOT trade or sell EBT cards. DO NOT alter EBT cards to get SNAP benefits you are not entitled to receive. DO NOT use SNAP benefits to buy ineligible items such as alcohol and tobacco or to pay food credit accounts. DO NOT use someone else’s SNAP benefits or EBT card for your household.
Individuals determined by a court to have committed the following program violations will be subject to the following penalties:
-If you are found to have used or received benefits in a transaction involving the sale of a controlled substance, you will be ineligible to receive SNAP benefits for a period of two years for the first offense and permanently upon the second such offense.
-If you are found to have used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you will be permanently ineligible to receive SNAP benefits upon the first occasion of such violation.
-If you have been found guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently ineligible to receive SNAP benefits upon the first occasion of such violation.
-If you have been found to have made a fraudulent statement or representation with respect to your identity or place of residence in order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the Program for a period of 10 years.
In accordance with the U.S. Department of Agriculture (USDA) Office of Civil Rights, this institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex, and in some cases religion and political beliefs.
The USDA also prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, disability, age, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or activities.)
If you wish to file a Civil Rights program complaint of discrimination with USDA, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_ filing_ cust.html, or any USDA office, or call (866)
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877- 8339; or (800)
For any other information dealing with SNAP issues, persons should either contact the USDA SNAP Hotline Number at (800) 221
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
USDA and HHS are equal opportunity providers and employers.
File Features
| Fact Name | Details |
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| Governing Law | The Mississippi SNAP application is governed by the Food and Nutrition Act of 2008 and state regulations under the Mississippi Department of Human Services. |
| Application Form Number | The form is officially designated as MDHS-EA-900, revised on August 1, 2013. |
| Eligibility Criteria | To qualify for SNAP, households must meet specific income and resource limits, including gross monthly income under $150 and resources under $100. |
| Interview Requirement | An interview is necessary for eligibility determination. In some cases, this can be conducted over the phone rather than in person. |
| Benefit Timing | Benefits may begin from the date the application is received, assuming eligibility is confirmed. In some cases, benefits can be issued within 7 days. |
| Social Security Number Requirement | A Social Security Number (SSN) is mandatory for each individual listed on the application, as per federal regulations. |
| Disqualification Penalties | Individuals found guilty of program violations, such as fraud or trafficking benefits, may face severe penalties, including disqualification from receiving SNAP benefits. |
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