A digital services project by FlexionWisconsin FoodShare (SNAP) Application
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9 groups28 fields9 pages0 low confidence
Pages
1.Application Information and Signature
- Application Information and Signature
- Application Datedate
- I certify under penalty of perjury that all information provided in this application is true and complete to the best of my knowledgeboolean
- I understand that I must use FoodShare benefits only to purchase eligible food for my householdboolean
- I understand that providing false information is subject to prosecution under state and federal lawboolean
- I acknowledge that I have received and understand my rights and responsibilities under the FoodShare programboolean
- I authorize the State agency to verify the information I have provided through collateral contacts, computer matches, and other means permitted by lawboolean
- Applicant Full Name (Print)text
- Applicant Signaturetext
- Signature Datedate
- Is this application being signed by an authorized representative on behalf of the household?boolean
- Authorized Representative Nametext
- Relationship to Householdtext
- Authorization DocumentationlongText
2.Household Information
- Household Information
- Household Nametext
- Street Addresstext
- Citytext
- Statetext
- ZIP Codetext
- Countytext
- Phone Numberphone
- Email Addressemail
- Total Number of People in Householdnumber
- Is anyone in the household 60 years of age or older?boolean
- Is anyone in the household disabled?boolean
- Does the household have a current mailing address different from the home address?boolean
- Mailing Address (if different)longText
- Monthly Gross Income (before taxes and deductions)currency
- Cash on hand, checking and savings accountscurrency
3.Employment and Income
4.Resources and Assets
5.Housing and Shelter Costs
6.Medical and Dependent Care Expenses
7.Student and Work Requirements
9.Rights and Responsibilities
Groups
Application Information and Signature
| Field | Type | Required | Conditions | Status |
|---|---|---|---|---|
| Application Date The date this application is being submitted | Date | Yes | — | |
| I certify under penalty of perjury that all information provided in this application is true and complete to the best of my knowledge | Boolean | Yes | — | |
| I understand that I must use FoodShare benefits only to purchase eligible food for my household | Boolean | Yes | — | |
| I understand that providing false information is subject to prosecution under state and federal law | Boolean | Yes | — | |
| I acknowledge that I have received and understand my rights and responsibilities under the FoodShare program | Boolean | Yes | — | |
| I authorize the State agency to verify the information I have provided through collateral contacts, computer matches, and other means permitted by law | Boolean | Yes | — | |
| Applicant Full Name (Print) Print the full name of the person signing this application | Text | Yes | — | |
| Applicant Signature Digital signature of the applicant or authorized representative. By typing your name here, you are providing your electronic signature. | Text | Yes | — | |
| Signature Date Date the application was signed | Date | Yes | — | |
| Is this application being signed by an authorized representative on behalf of the household? | Boolean | Yes | — | |
| Authorized Representative Name Full name of the authorized representative if different from applicant | Text | No | — | |
| Relationship to Household How is the authorized representative related to or connected to the household? | Text | No | — | |
| Authorization Documentation Describe the documentation provided establishing authority to act for the household (signed statement, power of attorney, court documentation, etc.) | LongText | No | — |
Household Information
| Field | Type | Required | Conditions | Status |
|---|---|---|---|---|
| Household Name Primary name for this household application | Text | Yes | — | |
| Street Address Street address where the household resides | Text | Yes | — | |
| City | Text | Yes | — | |
| State | Text | Yes | — | |
| ZIP Code | Text | Yes | — | |
| County County where the household resides | Text | Yes | — | |
| Phone Number Primary contact phone number for the household | Phone | No | — | |
| Email Address Email address for household communications | No | — | ||
| Total Number of People in Household Total number of people who live together and purchase and prepare meals together | Number | Yes | — | |
| Is anyone in the household 60 years of age or older? | Boolean | Yes | — | |
| Is anyone in the household disabled? Includes anyone receiving disability benefits or unable to work due to disability | Boolean | Yes | — | |
| Does the household have a current mailing address different from the home address? | Boolean | Yes | — | |
| Mailing Address (if different) Complete mailing address if different from home address | LongText | No | When has-different-mailing equals true | |
| Monthly Gross Income (before taxes and deductions) Total monthly gross income for all household members from all sources | Currency | Yes | — | |
| Cash on hand, checking and savings accounts Total liquid resources available to the household | Currency | Yes | — |
Employment and Income
| Field | Type | Required | Conditions | Status |
|---|
Resources and Assets
| Field | Type | Required | Conditions | Status |
|---|
Housing and Shelter Costs
| Field | Type | Required | Conditions | Status |
|---|
Medical and Dependent Care Expenses
| Field | Type | Required | Conditions | Status |
|---|
Student and Work Requirements
| Field | Type | Required | Conditions | Status |
|---|
Authorized Representative
| Field | Type | Required | Conditions | Status |
|---|
Rights and Responsibilities
| Field | Type | Required | Conditions | Status |
|---|