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Print Reset Form 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)