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": "group-new-e5fd9e9d",
"title": "Resources and Assets",
"requirements": []
},
{
"id": "group-new-cb66747f",
"title": "Housing and Shelter Costs",
"requirements": []
},
{
"id": "group-new-a56f8163",
"title": "Medical and Dependent Care Expenses",
"requirements": []
},
{
"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": []
}
]
}