A digital services project by FlexionWisconsin FoodShare (SNAP) Application
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9 groups13 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
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 |
|---|
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 |
|---|