Fill in Your Mississippi Snap Application Template
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
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) APPLICATION
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) APPLICATION
Name SSN Date of Birth
Residence Address
City State Zip
Mailing Address
City State Zip
Alternate Person
Phone Cell
❑ Yes ❑No 2
nd
Phone Cell ❑ Yes ❑No Contact Phone Cell ❑ Yes ❑No
Would you like to receive paperless notices? ❑ Yes ❑ No
If yes, email address Text phone number
What benefits are you applying to receive? ❑ SNAP ❑ TANF Before we can determine your eligibility, you must be interviewed.
You may file a joint application for both SNAP and TANF or may file a separate application for both programs.
SNAP
You may file your application immediately by submitting this form to the local county office either in person, through an authorized
representative, by fax, online, 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 combined 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.
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.
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 non-citizens or non-qualified aliens may be left off your
application for assistance. Such persons will not be reported to the Immigration and Customs Enforcement agency. Non-citizens
included in your application will have eligibility determined under SNAP rules. The income and resources of all persons in your
household will be considered in determining eligibility for persons included in the SNAP application.
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
Date
Signature of witness if signed by mark
Signature of Authorized Representative or
Date
Signature of witness if signed by mark
Second Parent in TANF
SNAP Outreach Agency Code
MISSISSIPPI
MDHS-EA-900
Revised 7-1-2026
Page 1
FOR OFFICE USE ONLY:
Date
Case Number:
Received:
Appointment Date:
Time:
303B:
❑
Initials:
530:
❑ Initials:
MISSISSIPPI
MDHS-EA-900
Revised 7-1-2026
Page 2
Income
•
Have you or anyone you are applying for received any type of earned income this month such as: wages, tips, bonuses, self-
employment, or any other earned income? ❑ Yes ❑ No If yes, how much? $
•
Have you or anyone you are applying for received any type of unearned income this month such as: social security/railroad retirement,
other disability, VA income, pensions, unemployment, child support, alimony, money from other people (cash gifts), worker’s
compensation? ❑ Yes ❑ No If yes, how much? $
•
Do you or anyone you are applying for expect to receive income later this month? ❑Yes ❑No If yes, how much? $
•
Is your household’s only income from migrant or seasonal farm work? ❑ Yes ❑ No
Resources
•
Do you or anyone you are applying for have any type of resources such as: cash on hand, checking, savings account, or savings
certificates? ❑ Yes ❑ No If yes, how much? $
Please note, at the interview, you will need to disclose any IRA account, valuable coins, stocks or bonds, nonrecurring lump sum payments,
recreational vehicles (boat, 4-wheeler, off road vehicles), personal property, buildings and certain land, recreational properties belonging
to you or anyone you are applying for.
Expenses
•
Give the actual expense amounts you pay: Rent/Mortgage $ Electricity $ Gas $ Water $ Phone $
•
Do you or anyone you are applying for pay for care of a dependent child or a disabled household member? ❑Yes ❑No
•
Does anyone 60 years of age or older or disabled have medical expenses that exceed $35 such as: doctor visits, hospital visits,
prescriptions, Medicare premiums, health insurance premiums, glasses, dentures, hearing aids, part D prescription premiums,
transportation expenses to and from doctor or hospital; pharmacy pick-ups? ❑ Yes ❑ No
Additional Questions
1.
Are you deaf, hearing impaired, or in need of interpreter services? ❑Yes ❑No
2.
Is anyone in your household currently serving a SNAP disqualification due to fraud? ❑ Yes ❑ No
3.
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
4.
Are you or any member of your household a resident of a commercial boarding home (establishment that offers meals and lodging
compensation with the intent of making a profit)? ❑Yes ❑No
5.
Are you or any member of your household on strike? ❑Yes ❑No
6.
Have you or any member of your household been convicted of any of the following after 08/22/96 (select all that apply):
❑trading SNAP benefits for drugs ❑ receiving duplicate SNAP benefits in any State
❑ buying or selling SNAP benefits over $500 ❑trading SNAP benefits for guns, ammunitions, or explosives
7.
Have you or any member of your household been convicted of any of the following after 02/07/14 (select all that apply):
❑aggravated sexual abuse ❑sexual exploitation and other abuse of children
❑sexual assault ❑murder
8.
If you are not registered to vote where you live now, would you like to apply to register to vote here today? ❑ Yes ❑ No
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. If you decline to register
to vote, this fact will remain confidential. If you do register to vote, the office where your application was submitted will be kept
confidential, and it 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.
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: Mississippi Secretary of State, Elections Divisions, P.O. Box 136, Jackson, MS 39205-0136.
FOR OFFICE USE ONLY:
DATE
CASE NUMBER: RECEIVED:
MISSISSIPPI
MDHS-EA-900
Revised 7-1-2026
Page 3
List who you are applying for beginning with the Head of Household
Name (First, Last)
RELATIONSHIP SOCIAL SECURITY
NUMBER
*SEE DISCUSSION
BELOW
DATE
of
BIRTH
AGE SEX **OPTIONAL US
CITIZEN
Y or N
HISPANIC
Y or N
RACE
(***Choose
one or more)
1.
2.
3.
4.
5.
6.
**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 determine how effective the program is in reaching the eligible population.
***Race Codes: AL-American Indian/Alaska Native; AS-Asian; BL-Black or African American; HP-Hawaiian or Other Pacific Islander; WH-White;
OT-Other
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
Phone Number
2. Name Phone Number
SNAP Benefit Representative
You may appoint someone outside your household access to your household’s SNAP benefits in the Electronic Benefit Transfer (EBT) Account.
This person will be issued an EBT card which allows them total use of your account without your immediate consent. Benefits misused by this
individual (s) cannot be replaced.
I would like to appoint: 1. Name
Phone Number
2. Name Phone Number
FOR OFFICE USE ONLY:
DATE
CASE NUMBER: RECEIVED:
MISSISSIPPI
MDHS-EA-900
Revised 7-1-2026
Page 4
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
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.
Information available through the Income and Eligibility Verification System (IEVS) will be used to verify statements you provide on this
application regarding household income. Information available through IEVS will be requested, used and may be verified through collateral
contacts when discrepancies are found by MDHS. Additionally, information you provide regarding household income, expenses, or
financial resources are subject to verification through third party electronic databases. Such information may affect your household’s
eligibility and level of benefits.
Information you provide on this application regarding the alien status of household members may be subject to verification by the United States
Citizenship and Immigration Services (USCIS) through use of the Systematic Alien Verification and Entitlements (SAVE) System. Submitted
information from USCIS may affect your household’s eligibility and level of benefits.
I understand that I can receive a copy of this completed SNAP application. I choose paper electronic or I decline a copy.
*PENALTY WARNING*
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, and 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.
I certify under penalty of perjury that my answers to all questions about each household member, including those about
citizenship or alien status, are correct and complete.
Household member signature or mark (X): Date:
Witness if signed by mark: Date:
FOR OFFICE USE ONLY:
DATE
CASE NUMBER: RECEIVED:
MISSISSIPPI
MDHS-EA-900
Revised 7-1-2026
Page 5
USDA Nondiscrimination Statement
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies,
this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including gender identity
and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity.
Program information may be made available in languages other than English. Persons with disabilities who require alternative
means of communication to obtain program information (e.g., Braille, large print, audiotape, American Sign Language),
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.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program
Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-
3027.pdf, from any USDA office, by calling (833) 620-1071, or by writing a letter addressed to USDA. The letter must
contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in
sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights
violation.
The completed AD-3027 form or letter must be submitted to:
1) mail:
Food and Nutrition Service, USDA
1320 Braddock Place, Room 334
Alexandria, VA 22314; or
2) fax: (833) 256-1665 or (202) 690-7442; or
3) email: FNSCIVILRIGHTSCOMPLAINTS@usda.gov
This institution is an equal opportunity provider.
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: SNAP Hotline.
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).
FOR OFFICE USE ONLY:
DATE
CASE NUMBER: RECEIVED:
MISSISSIPPI
MDHS-EA-900
Revised 7-1-2026
Page 3A
List who you are applying for beginning with the Head of Household
Name (First, Last)
RELATIONSHIP SOCIAL SECURITY
NUMBER
*SEE DISCUSSION
BELOW
DATE
of
BIRTH
AGE SEX **OPTIONAL US
CITIZEN
Y or N
HISPANIC
Y or N
RACE
(***Choose
one or more)
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
**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 determine how effective the program is in reaching the eligible population.
***Race Codes: AL-American Indian/Alaska Native; AS-Asian; BL-Black or African American; HP-Hawaiian or Other Pacific Islander; WH-White;
OT-Other
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
FOR OFFICE USE ONLY:
DATE
CASE NUMBER: RECEIVED:
File Features
| Fact Name | Details |
|---|---|
| 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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