Summary

• You have been honest on this application.
• Getting these benefits will not affect your or your family’s immigration status. Immigration information is private and confidential.
• If you do not agree with these terms you can use other online applications found elsewhere.

Details

• I read, or had read to me, the information in the official application and my answers to the questions in this application.

• My answers to the questions are true and complete to the best of my knowledge.

• I read or had read to me and I understand and agree to the Rights and Responsibilities for this program and the Program Rules and Penalties.

• I understand that my county office may verify the information in this application with Federal, State and local officials to determine if it is accurate.

• I understand that giving false or misleading statements or misrepresenting, hiding or withholding facts to establish eligibility for this program is fraud. Fraud can cause a criminal case to be filed against me and/or I may be barred for a period of time (or life) from getting these benefits.

• I understand that illegally using or trafficking these benefits is subject to the same penalties as above.

• I understand that Social Security Numbers or immigration status for household members applying for benefits may be shared with the appropriate government agencies as required by federal law.

• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting the website.

• I’m giving to the benefits agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I’m also giving to the the benefits agency rights to pursue and get medical support from a spouse or parent.

• I know that information on this form will be used only to determine eligibility for health coverage and/for food assistance, help paying for coverage (if requested), and for lawful purposes of the benefits programs that help pay for coverage.

• We need this information to check your eligibility for help paying for food assistance and health coverage if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

• I know that I must tell the benefits agency within 30 days if anything changes (and is different than) what I wrote on this application. I can visit the office or call to report any changes. I understand that a change in my information could affect my eligibility as well as eligibility for member(s) of my household.

What should I do if I think my eligibility results are wrong?

If you don’t agree with what you qualify for, in many cases, you can ask for an appeal. Please review your eligibility notice to find appeals instructions specific to each person in your household who applies for coverage, including how many days you have to request an appeal. Here’s important information to consider when requesting an appeal:

• You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or other individual. Or, you can request and participate in your appeal on your own.
• If you request an appeal, you may be able to keep your eligibility for coverage while your appeal is pending.
• The outcome of an appeal could change the eligibility of other members of your household. To appeal your benefits eligibility results, visit the website, local office, call or via mail.