Download Food Benefit Filing Form SDS 539F 10/13

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Food Benefit Filing Form
Aging and People with Disabilities
Agency use only
Date received:
Expedited services:
Yes
Client name:
Program:
Branch code:
Worker initials:
MA notice
No
Date sent:
Case number:
Worker ID:
Worker phone:
Let us know if you need:
An interpreter
Language I speak:
A sign language interpreter
Written materials translated (what language):
Materials in:
Braille
Large print
Computer disk
Oral presentation
Date of birth:
Audio tape
If you are not registered to vote where you live now, would you like to apply to vote today?
Yes
No
Applying to register to vote, or declining to register, will not affect the amount of assistance you
will be provided by this agency.
Important to file this form as soon as possible
1
Complete this filing form first if you are applying for food benefits and return it today. You may be eligible
to receive benefits within seven days. Otherwise, fill out the application form and turn it in at the time of
your interview.
Client
Last name:
First name:
Address:
City:
Telephone:
Mailing address: (if different)
City:
I need a phone interview because I am:
2
MI:
elderly
State:
ZIP code:
State:
ZIP code:
disabled
SDS 539F (10/13)
other hardship:
Expedited food benefit information
3
Does anyone have income of more than $150 a month?
Does anyone have more than $100 in cash or in their checking or savings account?
Are your monthly rent and utility payments more than your monthly income, cash
and money in your bank accounts?
Is anyone a migrant or seasonal farm worker?
If “yes” answer the following questions:
Did you get paid before you applied for food benefits?
Will you get paid in the next 10 days?
Will your pay be more than $25?
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
Yes
No
No
No
All of the above information is true and correct to the best of my knowledge.
Client signature
Date:
Remarks/interview questions:
SDS 539F (10/13)