A digital services project by FlexionWisconsin FoodShare (SNAP) Application
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{
"id": "spec-wisconsin-foodshare-snap-application-3",
"title": "Wisconsin FoodShare (SNAP) Application",
"description": "",
"groups": [
{
"id": "group-new-192f8be6",
"title": "Application Information and Signature",
"requirements": [
{
"id": "application-date",
"fieldName": "application_date",
"label": "Application Date",
"fieldType": "date",
"required": true,
"helpText": "The date this application is being submitted"
},
{
"id": "perjury-certification",
"fieldName": "i_certify_under_penalty_of_perjury_that_",
"label": "I certify under penalty of perjury that all information provided in this application is true and complete to the best of my knowledge",
"fieldType": "boolean",
"required": true,
"control": "checkbox"
},
{
"id": "benefit-use-understanding",
"fieldName": "i_understand_that_i_must_use_foodshare_b",
"label": "I understand that I must use FoodShare benefits only to purchase eligible food for my household",
"fieldType": "boolean",
"required": true,
"control": "checkbox"
},
{
"id": "false-info-understanding",
"fieldName": "i_understand_that_providing_false_inform",
"label": "I understand that providing false information is subject to prosecution under state and federal law",
"fieldType": "boolean",
"required": true,
"control": "checkbox"
},
{
"id": "rights-responsibilities-ack",
"fieldName": "i_acknowledge_that_i_have_received_and_u",
"label": "I acknowledge that I have received and understand my rights and responsibilities under the FoodShare program",
"fieldType": "boolean",
"required": true,
"control": "checkbox"
},
{
"id": "verification-authorization",
"fieldName": "i_authorize_the_state_agency_to_verify_t",
"label": "I authorize the State agency to verify the information I have provided through collateral contacts, computer matches, and other means permitted by law",
"fieldType": "boolean",
"required": true,
"control": "checkbox"
},
{
"id": "applicant-printed-name",
"fieldName": "applicant_full_name_(print)",
"label": "Applicant Full Name (Print)",
"fieldType": "text",
"required": true,
"helpText": "Print the full name of the person signing this application"
},
{
"id": "applicant-signature",
"fieldName": "applicant_signature",
"label": "Applicant Signature",
"fieldType": "text",
"required": true,
"helpText": "Digital signature of the applicant or authorized representative. By typing your name here, you are providing your electronic signature."
},
{
"id": "signature-date",
"fieldName": "signature_date",
"label": "Signature Date",
"fieldType": "date",
"required": true,
"helpText": "Date the application was signed"
},
{
"id": "is-authorized-rep",
"fieldName": "is_this_application_being_signed_by_an_a",
"label": "Is this application being signed by an authorized representative on behalf of the household?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "auth-rep-name",
"fieldName": "authorized_representative_name",
"label": "Authorized Representative Name",
"fieldType": "text",
"required": false,
"helpText": "Full name of the authorized representative if different from applicant"
},
{
"id": "auth-rep-relationship",
"fieldName": "relationship_to_household",
"label": "Relationship to Household",
"fieldType": "text",
"required": false,
"helpText": "How is the authorized representative related to or connected to the household?"
},
{
"id": "auth-documentation",
"fieldName": "authorization_documentation",
"label": "Authorization Documentation",
"fieldType": "longText",
"required": false,
"helpText": "Describe the documentation provided establishing authority to act for the household (signed statement, power of attorney, court documentation, etc.)"
}
]
},
{
"id": "group-new-d2a399b5",
"title": "Household Information",
"requirements": [
{
"id": "household-name",
"fieldName": "household_name",
"label": "Household Name",
"fieldType": "text",
"required": true,
"helpText": "Primary name for this household application",
"sensitivity": "pii"
},
{
"id": "street-address",
"fieldName": "street_address",
"label": "Street Address",
"fieldType": "text",
"required": true,
"helpText": "Street address where the household resides",
"sensitivity": "pii"
},
{
"id": "city",
"fieldName": "city",
"label": "City",
"fieldType": "text",
"required": true
},
{
"id": "state",
"fieldName": "state",
"label": "State",
"fieldType": "text",
"required": true
},
{
"id": "zip-code",
"fieldName": "zip_code",
"label": "ZIP Code",
"fieldType": "text",
"required": true
},
{
"id": "county",
"fieldName": "county",
"label": "County",
"fieldType": "text",
"required": true,
"helpText": "County where the household resides"
},
{
"id": "phone-number",
"fieldName": "phone_number",
"label": "Phone Number",
"fieldType": "phone",
"required": false,
"helpText": "Primary contact phone number for the household",
"sensitivity": "pii"
},
{
"id": "email-address",
"fieldName": "email_address",
"label": "Email Address",
"fieldType": "email",
"required": false,
"helpText": "Email address for household communications",
"sensitivity": "pii"
},
{
"id": "household-size",
"fieldName": "total_number_of_people_in_household",
"label": "Total Number of People in Household",
"fieldType": "number",
"required": true,
"helpText": "Total number of people who live together and purchase and prepare meals together"
},
{
"id": "has-elderly",
"fieldName": "is_anyone_in_the_household_60_years_of_a",
"label": "Is anyone in the household 60 years of age or older?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "has-disabled",
"fieldName": "is_anyone_in_the_household_disabled?",
"label": "Is anyone in the household disabled?",
"fieldType": "boolean",
"required": true,
"control": "radio",
"helpText": "Includes anyone receiving disability benefits or unable to work due to disability"
},
{
"id": "has-different-mailing",
"fieldName": "does_the_household_have_a_current_mailin",
"label": "Does the household have a current mailing address different from the home address?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "mailing-address",
"fieldName": "mailing_address_(if_different)",
"label": "Mailing Address (if different)",
"fieldType": "longText",
"required": false,
"helpText": "Complete mailing address if different from home address",
"sensitivity": "pii",
"condition": {
"field": "has-different-mailing",
"operator": "equals",
"value": true
}
},
{
"id": "monthly-gross-income",
"fieldName": "monthly_gross_income_(before_taxes_and_d",
"label": "Monthly Gross Income (before taxes and deductions)",
"fieldType": "currency",
"required": true,
"helpText": "Total monthly gross income for all household members from all sources",
"sensitivity": "high"
},
{
"id": "liquid-resources",
"fieldName": "cash_on_hand,_checking_and_savings_accou",
"label": "Cash on hand, checking and savings accounts",
"fieldType": "currency",
"required": true,
"helpText": "Total liquid resources available to the household",
"sensitivity": "high"
}
]
},
{
"id": "group-new-1c3a17f7",
"title": "Employment and Income",
"requirements": [
{
"id": "currently-employed",
"fieldName": "are_you_currently_employed?",
"label": "Are you currently employed?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "job-title",
"fieldName": "what_is_your_job_title_or_type_of_work?",
"label": "What is your job title or type of work?",
"fieldType": "text",
"required": false
},
{
"id": "employer-name",
"fieldName": "employer_name",
"label": "Employer name",
"fieldType": "text",
"required": false
},
{
"id": "hours-per-week",
"fieldName": "how_many_hours_per_week_do_you_work?",
"label": "How many hours per week do you work?",
"fieldType": "number",
"required": false,
"helpText": "Enter the average number of hours you work per week"
},
{
"id": "gross-monthly-earned-income",
"fieldName": "what_is_your_gross_monthly_income_from_e",
"label": "What is your gross monthly income from employment? (before taxes and deductions)",
"fieldType": "currency",
"required": true,
"helpText": "Include wages, salaries, tips, and commissions before any deductions"
},
{
"id": "self-employed",
"fieldName": "are_you_self-employed?",
"label": "Are you self-employed?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "net-self-employment-income",
"fieldName": "what_is_your_net_monthly_income_from_sel",
"label": "What is your net monthly income from self-employment? (after allowable business expenses)",
"fieldType": "currency",
"required": false,
"helpText": "Enter your self-employment income after deducting allowable business expenses"
},
{
"id": "receives-unemployment",
"fieldName": "do_you_receive_unemployment_compensation",
"label": "Do you receive unemployment compensation?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "unemployment-amount",
"fieldName": "monthly_unemployment_compensation_amount",
"label": "Monthly unemployment compensation amount",
"fieldType": "currency",
"required": false
},
{
"id": "receives-social-security",
"fieldName": "do_you_receive_social_security_benefits?",
"label": "Do you receive Social Security benefits?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "social-security-amount",
"fieldName": "monthly_social_security_benefits_amount",
"label": "Monthly Social Security benefits amount",
"fieldType": "currency",
"required": false
},
{
"id": "receives-ssi",
"fieldName": "do_you_receive_ssi_(supplemental_securit",
"label": "Do you receive SSI (Supplemental Security Income)?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "ssi-amount",
"fieldName": "monthly_ssi_amount",
"label": "Monthly SSI amount",
"fieldType": "currency",
"required": false
},
{
"id": "receives-veterans-benefits",
"fieldName": "do_you_receive_veterans'_benefits?",
"label": "Do you receive veterans' benefits?",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "veterans-benefits-amount",
"fieldName": "monthly_veterans'_benefits_amount",
"label": "Monthly veterans' benefits amount",
"fieldType": "currency",
"required": false
},
{
"id": "receives-other-income",
"fieldName": "do_you_receive_any_other_income?_(tanf,_",
"label": "Do you receive any other income? (TANF, General Assistance, pensions, rental income, interest, dividends, child support, etc.)",
"fieldType": "boolean",
"required": true,
"control": "radio"
},
{
"id": "other-income-details",
"fieldName": "list_all_other_sources_of_income_and_mon",
"label": "List all other sources of income and monthly amounts",
"fieldType": "longText",
"required": false,
"helpText": "Please list each source of income and the monthly amount (e.g., TANF $200, Rental income $500, etc.)"
},
{
"id": "total-monthly-gross-income",
"fieldName": "what_is_your_total_monthly_gross_income_",
"label": "What is your total monthly gross income from all sources?",
"fieldType": "currency",
"required": true,
"helpText": "This is used for expedited service screening and benefit calculation"
}
]
},
{
"id": "group-new-e5fd9e9d",
"title": "Resources and Assets",
"requirements": [
{
"id": "cash-on-hand",
"fieldName": "total_cash_on_hand_(including_money_in_c",
"label": "Total cash on hand (including money in checking and savings accounts)",
"fieldType": "currency",
"required": true,
"helpText": "Include cash, checking accounts, savings accounts, and any other liquid resources available to your household",
"sensitivity": "medium"
},
{
"id": "investments",
"fieldName": "savings_certificates,_stocks,_bonds,_or_",
"label": "Savings certificates, stocks, bonds, or other investments",
"fieldType": "currency",
"required": true,
"helpText": "Enter the current value of any savings certificates, stocks, bonds, or other investments",
"sensitivity": "medium"
},
{
"id": "vehicle-value",
"fieldName": "value_of_vehicles_owned_(exclude_one_veh",
"label": "Value of vehicles owned (exclude one vehicle per adult household member)",
"fieldType": "currency",
"required": true,
"helpText": "Enter the fair market value minus any loans owed on vehicles that exceed the state exclusion limits",
"sensitivity": "medium"
},
{
"id": "work-property",
"fieldName": "property_used_for_work_or_self-employmen",
"label": "Property used for work or self-employment",
"fieldType": "currency",
"required": true,
"helpText": "Enter the value of property, tools, or equipment essential to your employment or business",
"sensitivity": "medium"
},
{
"id": "other-resources",
"fieldName": "other_resources_not_listed_above",
"label": "Other resources not listed above",
"fieldType": "currency",
"required": true,
"helpText": "Include any other countable resources such as land that is not your home, additional real estate, etc.",
"sensitivity": "medium"
},
{
"id": "owns-home",
"fieldName": "do_you_own_your_home?",
"label": "Do you own your home?",
"fieldType": "boolean",
"required": true,
"control": "radio",
"helpText": "Your home and surrounding property are excluded from resource limits"
},
{
"id": "lump-sum-received",
"fieldName": "have_you_received_any_lump-sum_payments_",
"label": "Have you received any lump-sum payments in the past 12 months?",
"fieldType": "boolean",
"required": true,
"control": "radio",
"helpText": "Include tax refunds, insurance settlements, retroactive Social Security or SSI payments, etc."
},
{
"id": "lump-sum-details",
"fieldName": "describe_the_lump-sum_payment(s)_and_amo",
"label": "Describe the lump-sum payment(s) and amount(s)",
"fieldType": "longText",
"required": true,
"helpText": "Provide details about each lump-sum payment including source, amount, and date received",
"sensitivity": "medium",
"condition": {
"field": "lump-sum-received",
"operator": "equals",
"value": true
}
}
]
},
{
"id": "group-new-cb66747f",
"title": "Housing and Shelter Costs",
"requirements": [
{
"id": "shelter-rent-mortgage",
"fieldName": "monthly_rent_or_mortgage_payment",
"label": "Monthly rent or mortgage payment",
"fieldType": "currency",
"required": true,
"helpText": "Enter the amount you pay each month for rent or mortgage payments. If you own your home free and clear, enter $0."
},
{
"id": "shelter-property-taxes",
"fieldName": "property_taxes_(monthly_amount)",
"label": "Property taxes (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "If you pay property taxes, enter the monthly amount. If paid annually, divide by 12."
},
{
"id": "shelter-insurance",
"fieldName": "home_insurance_(monthly_amount)",
"label": "Home insurance (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "Enter monthly homeowner's or renter's insurance premium. If paid annually, divide by 12."
},
{
"id": "shelter-condo-fees",
"fieldName": "condominium_or_cooperative_fees_(monthly",
"label": "Condominium or cooperative fees (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "Enter monthly condo fees or cooperative housing fees, if applicable."
},
{
"id": "utility-choice-method",
"fieldName": "do_you_want_to_claim_actual_utility_cost",
"label": "Do you want to claim actual utility costs or use the standard utility allowance?",
"fieldType": "choice",
"required": true,
"control": "radio"
},
{
"id": "utility-electricity",
"fieldName": "electricity_costs_(monthly_amount)",
"label": "Electricity costs (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "Enter your average monthly electricity bill. Only complete if claiming actual utility costs."
},
{
"id": "utility-gas-heating",
"fieldName": "gas/heating_costs_(monthly_amount)",
"label": "Gas/heating costs (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "Enter your average monthly gas or heating bill. Only complete if claiming actual utility costs."
},
{
"id": "utility-water-sewer",
"fieldName": "water_and_sewer_costs_(monthly_amount)",
"label": "Water and sewer costs (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "Enter your average monthly water and sewer bill. Only complete if claiming actual utility costs."
},
{
"id": "utility-telephone",
"fieldName": "telephone_costs_(monthly_amount)",
"label": "Telephone costs (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "Enter your average monthly telephone bill (landline and/or cell phone). Only complete if claiming actual utility costs."
},
{
"id": "utility-other",
"fieldName": "other_utility_costs_(monthly_amount)",
"label": "Other utility costs (monthly amount)",
"fieldType": "currency",
"required": false,
"helpText": "Enter any other utility costs such as trash collection, internet, or cable. Only complete if claiming actual utility costs."
}
]
},
{
"id": "group-new-a56f8163",
"title": "Medical and Dependent Care Expenses",
"requirements": [
{
"id": "has-medical-expenses",
"fieldName": "do_you_or_any_household_member_have_medi",
"label": "Do you or any household member have medical expenses that exceed $35 per month?",
"fieldType": "boolean",
"required": true,
"control": "radio",
"helpText": "Medical expenses include prescription drugs, medical supplies, health insurance premiums, and transportation to medical appointments. Only expenses for elderly (60+) or disabled members can be deducted."
},
{
"id": "medical-expenses-amount",
"fieldName": "monthly_medical_expenses_amount_(only_am",
"label": "Monthly medical expenses amount (only amount over $35)",
"fieldType": "currency",
"required": false,
"helpText": "Enter only the portion of medical expenses that exceeds $35 per month. Include prescription drugs, medical supplies, health insurance premiums, and transportation to medical appointments for elderly or disabled members."
},
{
"id": "has-dependent-care",
"fieldName": "do_you_or_any_household_member_have_depe",
"label": "Do you or any household member have dependent care costs?",
"fieldType": "boolean",
"required": true,
"control": "radio",
"helpText": "Dependent care costs include expenses for child care or care for disabled adults when necessary for a household member to work, seek employment, or attend training or education."
},
{
"id": "dependent-care-amount",
"fieldName": "monthly_dependent_care_costs",
"label": "Monthly dependent care costs",
"fieldType": "currency",
"required": false,
"helpText": "Enter the actual monthly cost for dependent care when necessary for work, job training, or education. Include care for children or disabled adults."
},
{
"id": "dependent-care-provider",
"fieldName": "name_of_dependent_care_provider",
"label": "Name of dependent care provider",
"fieldType": "text",
"required": false
},
{
"id": "dependent-care-address",
"fieldName": "dependent_care_provider_address",
"label": "Dependent care provider address",
"fieldType": "text",
"required": false
},
{
"id": "dependent-care-recipient",
"fieldName": "who_receives_the_dependent_care?",
"label": "Who receives the dependent care?",
"fieldType": "text",
"required": false,
"helpText": "Name of the household member(s) who receive dependent care services."
}
]
},
{
"id": "group-new-f5847b49",
"title": "Student and Work Requirements",
"requirements": []
},
{
"id": "group-new-fd543e9e",
"title": "Authorized Representative",
"requirements": []
},
{
"id": "group-new-dd5d95ee",
"title": "Rights and Responsibilities",
"requirements": []
}
]
}