APPLICATION FOR BENEFITS WHO MAY APPLY

COMMONWEALTH OF PENNSYLVANIA ANYONE WHO WISHES TO APPLY FOR MEDICAL ASSISTANCE (MA)
DEPARTMENT OF PUBLIC WELFARE MUST BE GIVEN THE OPPORTUNITY TO DO SO.
1. When a person requests an application, he or she may request medical assistance for
him/herself only or for him/herself and other family members who wish to be included.
PROVIDER INSTRUCTIONS The application is for all medical services covered under the MA program For this
reason, the application must contain information about the applicant and all other family
members who wish to apply. In addition, the CAO may use income and resource
Before completing this application, access the Eligibility Verification System (EVS) using
information from other family members to compute eligibility.
client's date of birth and social security number to determine if the client is already receiving
benefits. If they are not receiving benefits, the Department encourages medical facilities to 2. Any person, agency or institution may complete and/or submit an application form for
take applications so that the facility will not bear expenses for medical care for which public medical assistance on behalf of an applicant. The applicant should, if at all possible,
funds are available. Delays in applications can mean delays in payments for medical complete and sign the form. If someone else completes and signs the form, the applicant
services or total denial of payment. The following forms are needed to apply for medical remains responsible for any fraudulent statements made on the application.
assistance:
3. If another person signs for the applicant, enter the name and address of that person on
PA 600 - Application for Benefits, Including the Provider Addendum the address line beneath the signature lines.
MA 314 - Eligibility Determination Form (For Inpatient Care Only)
4. An application for a deceased person will be accepted if the person died during the
If the PA 600 (including the Provider Addendum, when needed) contains the necessary month of application or during the 3 calendar months before the month of application. A
information and verification, the CAO can determine eligibility for medical assistance and relative, friend or official of the institution or agency which provided the service may
authorize either partial of full payment for medical services. If the PA 600 and Addendum are complete and sign the application.
not complete, the CAO will not be able to determine eligibility until the client is interviewed.
This may delay payment or result in denial.
When there is a pregnant woman or a child under the age of 21 in the household, the shorter
application form, PA 600CH (Medicaid/CHIP application), may be used. WHEN APPLICATION SHOULD BE MADE
Complete the application for medical assistance benefits as follows:
1. Remove this page and complete the Addendum on the reverse side. When a person indicates that he/she wishes to apply for medical assistance, have the
2. Complete the “PROVIDER USE ONLY” section on page 1 of the Application For person immediately sign and date Page 1 and complete the PA 600. After the provider’s
Benefits (PA 600). Give the remaining booklet to the applicant for completion of all representative has reviewed the form for completeness, he/she will witness the client’s or
information. representative’s signature on Page 16. If the application is approved, medical assistance
3. After the applicant has completed the booklet, review for completeness and have the coverage begins on the date of the signature on the front of the booklet. Payment may be
applicant sign the affidavit on page 16. available for a service given prior to this date, if the service was given in the month of
4. The applicant’s signature must be witnessed by the provider or the provider’s application or during the 3 calendar months before the month of application. Delay in
employee. obtaining the applicant’s signature may cause the applicant to be liable for medical services
5. Complete and attach the reverse of this page to the back of this booklet. that may have been covered by the MA program.
If you have any questions about the completion of the application form, phone
1-800-692-7462.

PA 600 COMPLETION CHECKLIST

If any sections are left blank or completed inaccurately, the county assistance office cannot
immediately process the request for payment for medical services, and a face-to-face RETROACTIVE COVERAGE
interview in the CAO may be necessary.
The application should include: The Department will pay for certain medical services provided up to three months before the
calendar month of application if the applicant is eligible. If payment is being requested for
Page 1 - Name and address of applicant and signature of applicant, or someone on medical services provided during this retroactive period, use the provider addendum to
his/her behalf, and date. provide necessary information.
Pages 2-13 - As much information as possible for the applicant and other family
members who are applying.
- Yes or No answers to all questions. If Yes, additional information should
be entered. VERIFICATION
Affidavit - The date and signature of the applicant or someone on his/her behalf. Applications must have necessary verification of income, resources, medical expenses, and
(Page 16) any other information needed, or a county assistance office interview may be required
before benefits are authorized.
- The form is signed and dated by the provider or the provider’s employee.

i PA 600P 7/08
 APPLICANT INFORMATION
PROVIDER ADDENDUM Name Date

THIRD PARTY LIABILITY RESOURES INSTRUCTIONS INCOME INSTRUCTIONS

Complete if anyone in the applicant group (including absent Complete this section if anyone in the applicant group had unpaid medical expenses during the 3 calendar months before the month of application
spouse or parent) is covered by an HMO, or health or accident and anyone in the applicant group had income during those 3 months.
insurance. Use a second addendum if there are more than Use a separate line for each type/source of income each person received. If the income from a particular source varied during the period covered
three sources. Items are self-explanatory except for the (e.g., wages often vary from pay period to pay period), use a separate line for each amount received:
following:
Contract/Policy/Agreement Number Employer/Source Enter the name of the employer or other source of income (e.g., name of union providing benefits).
Enter the number as shown on the insurance card or other Gross Amount Enter the amount earned before deductions or the actual amount received if the income is unearned.
document. This number is often the Social Security number Begin Date Enter the date the income started.
or HIB number of the insured person.
Group Name/Group Number Date Received Enter the last date the income was received. If the income varies, enter each date received. If the income
ended, circle the date.
Enter the Group Name or the Group Number and any
designation number (local, shop, etc.) Attach verification of the income, if available.

THIRD PARTY LIABILITY RESOURCES

INSURANCE CARRIERS, HMO, PRIMARY CARE PHYSICIAN OF FCN CLAIM OFFICE ADDRESS (INCLUDE CITY, STATE, ZIP CODE) CONTRACT/POLICY/AGREEMENT NO. GROUP NAME/GROUP NUMBER
1.
2.
3.
POLICYHOLDER NAME POLICYHOLDER SSN POLICYHOLDER ADDRESS (IF NOT APPLICANT)
1.
2.
3.
EMPLOYER NAME EMPLOYER ADDRESS
FREQUENCY CODES
1.
01 ONE TIME ONLY 04 SEMI-MONTHLY 07 QUARTERLY
2. 02 WEEKLY 05 MONTHLY 08 SEMI-ANNUALLY
3. 03 BI-WEEKLY 06 BI-MONTHLY 09 ANNUALLY

INCOME TYPE OF INCOME CODES

NAME TYPE OF 1 FULL-TIME EMPLOYMENT 18 BLACK LUNG
GROSS FREQ BEGIN DATE
INCOME EMPLOYER/SOURCE
AMOUNT CODE DATE REC’D 2 PART-TIME EMPLOYMENT 19 RAILROAD RETIREMENT
LAST FIRST MI CODE
3 ROOM/BOARD OR RENT 20 OTHER PENSIONS (FEDERAL
IRA, KEOGH, ETC)
4 SELF EMPLOYMENT
21 SICK BENEFITS
10 UNEMPLOYMENT
COMPENSATION 22 UNION BENEFITS
11 WORKER’S COMPENSATION 23 DIVIDENDS/INTEREST
12 SOCIAL SECURITY DISABILITY 24 COURT ORDERED SUPPORT
13 SOCIAL SECURITY SURVIVORS 25 SUPPORT FROM RELATIVES
OR RETIREMENT (LRR) LIVING IN HOUSEHOLD
14 SUPPLEMENTAL SECURITY 26 SUPPORT FROM RELATIVES
INCOME (LRR) LIVING OUTSIDE THE
HOUSEHOLD
15 VETERANS COMPENSATION
(DISABILITY) 31 SCHOLARSHIPS, GRANTS, AND
LOANS
16 VETERANS PENSION
(RETIREMENT) 32 VOLUNTARY SUPPORT FROM
PUTATIVE FATHERS
17 UNITED MINE WORKERS
BENEFITS 99 OTHER INCOME

PA 600P 7/08 ii
P E N N S Y LVA N I A
Application for Benefits
This is an application for cash, Medical Assistance and Food Stamp benefits. If you need
this application in another language or someone to interpret, please contact your local
county assistance office. Language assistance will be provided free of charge.

PA 600P 7/08
 APPLICATION FOR BENEFITS
• Read the entire application form.
• Print the requested information in the unshaded sections.
• If you need help completing this application, another person of your choosing can help you; you can get help from your
county assistance office (CAO) or you can call the HELPLINE at 1-800-692-7462. If you are hearing impaired, call TDD 1-800-451-5886.
• We will accept your application during normal business hours.

You may apply for cash, Medical Assistance and/or Food Stamp benefits using this form. If you are not eligible for cash and/or Medical Assistance
benefits, you will not need to file a new application to receive or continue to receive Food Stamp benefits. If you or any of your children do not
qualify for Medical Assistance, you or they may qualify for healthcare coverage through the Children’s Health insurance Program (CHIP) or the
adultBasic program. You will not need to file a new application. A copy of this application will be provided to the Department of Insurance or to
a CHIP or adultBasic contractor.
We will start your application once you complete your name, address and signature. (Questions not marked optional must be answered
before we can make a decision on your eligibility.)
You should complete the form, sign and date it. Bring it, have someone else bring it or mail it to the CAO. Medical Assistance providers or other
agencies approved by our Department may submit applications for Medical Assistance. If you return your application by mail, you will receive
further instructions for completing the application process. We will tell you if a face-to-face interview is needed. You must prove your identity. If
necessary, the CAO can help you to obtain this proof.
We will tell you within 30 days after we receive your completed application whether or not you are eligible. Food Stamp benefit eligibility starts
from the date your application is received. If eligible for cash assistance, your benefits will begin on the date we receive all the information we
requested. If an interview is required, and you do not appear or contact us within 30 days of application, your application will be denied.
The Department issues cash and Food Stamp benefits through the Electronic Benefits Transfer (EBT) system. This
system allows you to use your EBT ACCESS card to obtain your cash benefits from certain Automatic Teller
Machines (ATMs) 24 hours a day, or to buy items at stores that accept the card. The Food Stamp benefits on the
EBT ACCESS card can be used for buying food or seeds and plants to grow food for personal consumption.
If you are applying for cash assistance, you and the caseworker who interviews you will complete an Agreement of Mutual Responsibility (AMR).
The AMR stresses the temporary nature of cash assistance and describes the steps you agree to take that will help you support yourself and
your family without welfare.
Your information is kept confidential; it is used only to administer the programs for which you may be eligible. Pages 14 and 17 of this document
list your rights and responsibilities. Pages 17 and 18 will be given to you.

You can apply online at: www.compass.state.pa.us

PA 600P 7/08 I
 FOOD STAMPS NOW!
• Does your household have • Are you a migrant or • Are your monthly gross
$100 or less in available seasonal farm worker? income and cash on
cash and bank accounts hand less than your
and expect to receive less rent/mortgage and utility
than $150 in income this costs for this month?
month?
IF THE ANSWER TO ANY OF THESE QUESTIONS IS YES, YOU MAY HAVE A RIGHT TO EXPEDITED FOOD STAMPS.
This means you can get Food Stamps within five calendar days. Ask for more information by contacting the local
county assistance office.

FILE YOUR FOOD STAMP APPLICATION TODAY! It is YOUR RIGHT to file an application today at ANY TIME before
5 p.m. The person at the county assistance office should date-stamp your application while you watch.

If you are denied expedited food stamps, you have the right to an agency conference within two working days
with a supervisor at the county assistance office.

If you believe you are being denied your rights or services, or if the county assistance office does not take your
application when you hand it in, or date-stamp it while you watch, ask to talk to a supervisor or call the HELPLINE
toll free at 1-800-692-7462.

YOU CAN GET FREE LEGAL HELP AT THE LOCAL LEGAL SERVICES OFFICE.

This is an equal opportunity program. If you believe you have been discriminated against because of race,
color, national origin, age, sex, disability, political beliefs or religion, write:

USDA, Director, Office of Civil Rights,

1400 Independence Avenue, SW PLEASE READ AND
Washington, DC 20250-9410 REMOVE THIS PAGE
or call (866) 632-9992 or (202) 401-0216 (TDD).
BEFORE COMPLETING
APPLICATION

II PA 600P 7/08
 FAMILY SAFETY
Information About Your Benefits and Domestic Violence

Domestic violence happens when someone in your life harms you physically, sexually or emotionally, including:

 Physically hurting you or your children  Controlling where you go and who you see
 Threatening or trying to hurt you, your children or  Not allowing you or your children to have food, clothing
your property or medical care
 Forcing you to have sex  Keeping you from going to work or school
 Sexually abusing your children  Following or stalking you

If you are or have been a victim of domestic violence or are at risk of further violence, your caseworker can:

 Help you find local programs where you can get counseling, safety planning, shelter, legal services and
other help.

 Excuse you from requirements for cash assistance if domestic violence prevents you from complying:
Sometimes people cannot safely follow welfare requirements because they fear that they or their children will be abused if they
do so. These include:

 Support cooperation  Requirements that teen parents live at home

 Work (RESET)  Verification
 Time limits  Other requirements on a case-by-case basis

If you need to be excused from welfare requirements because of domestic violence, tell your caseworker.
You can ask to speak to your caseworker in private. You may not want to share this information with your caseworker or you may decide to
discuss it with your worker later. Your caseworker and the staff at the county assistance office will keep your personal information confidential.
However, the Department of Public Welfare is required by law to report child abuse to the local Children and Youth Agency.

COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE

PA 600P 7/08 III

 CHECK WHICH BENEFITS YOU WANT TO RECEIVE CHECK IF YOU ARE INTERESTED IN:
 CASH ASSISTANCE  FOOD STAMP BENEFITS  MEDICAL ASSISTANCE  Housing Assistance  Lifeline (Reduced price
 Receiving an application for phone service)
 OTHER ____________________________________________________________
Energy Assistance (LIHEAP)  Family Planning/
 YES  NO Do you understand English?  Food Banks Birth Control
If no, what language do you understand? __________________  Free or reduced cost  Well Baby Clinic
 YES  NO Are you a migrant or seasonal farm worker? school meals  Women, Infants and
 Employment and Training Children Program
 YES  NO Do you have a permanent home?
 Special Allowance for  Immunizations (Shots)
 YES  NO Do you receive housing assistance? If yes, what type? employment or training  Child Care
 Public Housing  Rent (Please check one) (Clothing, etc.)  Child Support Services
 YES  NO Have you ever been disqualified or agreed to be disqualified for  Supplemental Security  Head Start
food stamps or cash assistance in another state? Income (Kids age 3 through 6)
 YES  NO If you are applying for food stamps and are elderly, an SSI recipient
or the spouse of the elderly or SSI recipient or homeless, do you PROVIDER USE ONLY
want to use your food stamps to purchase meals in restaurants? PROVIDER NAME PROVIDER NUMBER
If you are applying for only food stamps, medical assistance, or for food stamps and
medical assistance, provide a telephone number where you can be reached during the
 Inpatient  Outpatient  Emergency
day for a telephone interview. ______________________________________________
If you have a welfare case number in Pennsylvania - write it here __________________  Non-Applicable

LAST NAME FIRST NAME MIDDLE INITIAL COUNTY ASSISTANCE OFFICE USE
FILE CLEAR BY/DATE SCREEN BY/DATE
 Mail  Walk In
ADDRESS HOW LONG AT THIS ADDRESS
Years Months COUNTY DISTRICT APPLICATION REG # DATE STAMP CAT
CITY STATE ZIP CODE PLUS 4
WORKER ID CASELOAD RECORD NUMBER 2ND DATE CAT
SCHOOL DISTRICT TOWNSHIP (CIVIL SUBDIVISION) TELEPHONE NUMBER
NAME
PREVIOUS ADDRESS (Street, City, State)
APPOINTMENT DATE/TIME  AM
 PM
 YES  NO Are you or anyone you are applying for currently receiving Food
Stamp benefits or Medical Assistance in another state?  APPLICATION  ADD ON  REDETERMINATION
State______ County __________________ Record # ____________________
AUTHORIZED NOT AUTHORIZED
 YES  NO Have you ever received cash benefits in another state?
If yes, complete Date: From __________________ To ________________ DATE

 YES  NO Have you ever applied for benefits using a different name or social BY
security number?
Name ________________________ Social Security # ____________________
CAT
SIGNATURE OF APPLICANT OR REPRESENTATIVE

REASON
X ______________________________________ Date ____________ CODE

1 PA 600P 7/08
 COMPLETE THIS PAGE FOR YOURSELF AND EVERYONE WHO LIVES AT YOUR ADDRESS, EVEN IF THEY ARE NOT APPLYING
Name any person who lives with you but is temporarily staying somewhere else.
If you are applying for this person, list the person in the section below also.
FOR EDUCATION
TELL US THE HIGHEST GRADE LEVEL
COMPLETED BY EACH PERSON
* You must provide or apply for a Social Security Number (SSN) as follows: 01-11 = ACTUAL GRADE LEVEL COMPLETED
If you are applying for: 12 = HIGH SCHOOL DIPLOMA,
GED OR NEDP
• Cash Assistance: You must provide or apply for a SSN for you or anyone for whom you are applying, and you must provide a
13 = ASSOCIATE DEGREE
SSN for anyone whose income or resources may affect the eligibility or benefit amount of you or anyone for whom you are
applying. 14 = BACHELOR’S DEGREE
15 = GRADUATE DEGREE
• Food Stamp benefits: You must provide or apply for a SSN for you or anyone for whom you are applying. (MASTER’S OR HIGHER)
• Medical Assistance: You must provide or apply for a SSN for 16 = OTHER DEGREES, CERTIFICATES
you or anyone for whom you are applying unless the person If you do not qualify for a SSN because of your immigration OR DIPLOMAS
is an alien seeking emergency Medical Assistance only. status, and you are not applying for assistance for yourself, 98 = NO FORMAL EDUCATION

your income and resources must still be considered in

SSNs for any other individuals are not required. If
determining eligibility or benefit amount of the persons for
you have any questions about providing a SSN, USE 98 FOR CHILDREN WHO HAVE
contact the county assistance office. whom you are responsible. NOT COMPLETED FIRST GRADE

PLEASE PRINT ALL INFORMATION

COUNTY
OFFICE PRINT YOUR NAME FIRST ARE YOU OTHER NAME,

EDUCATION
USE APPLYING SUCH AS A
FOR MAIDEN NAME OR BIRTH HOW IS EACH
LINE # LAST NAME FIRST NAME
MIDDLE JR./SR. THIS FORMER MARRIED DATE SEX * SOCIAL SECURITY PERSON RELATED
INITIAL I, II PERSON? NAME MM DD YYYY M/F NUMBER TO YOU?

 YES
 NO SELF
 YES
 NO

 YES
 NO

 YES
 NO

 YES
 NO

 YES
 NO

 YES
 NO

 YES
 NO

 YES
 NO

PA 600P 7/08 2
COMPLETE THIS PAGE FOR YOURSELF AND EVERYONE WHO LIVES AT YOUR ADDRESS, EVEN IF THEY ARE NOT APPLYING

*You must sign this statement for each person for whom you are applying who is a By signing my name, I certify that, subject to penalties provided by law, these persons are
U.S. citizens or aliens in satisfactory immigration status.
citizen of the U.S. or an alien in satisfactory immigration status. An alien who is
applying only for treatment of an emergency medical condition is not required to
sign this certification or provide a Social Security Number.
SIGNATURE DATE

CITIZENSHIP STATUS*
Use one of the following codes:
RACE Individuals may fit more than one group. Check all groups that apply.
(optional) Your benefits will not be affected if you do not answer.
1. U.S. Citizen 4. Refugee/Asylee/Parolee
2. Perm. Alien 5. Other - Not Eligible for
(Qualified Alien or Benefits Except for
PRUCOL) Emergency Medical HISPANIC Check this box for each person whose ethnic background is primarily Hispanic,
3. Temp. Alien Benefits ORIGIN regardless of race. Your benefits will not be affected if you do not answer
6. Unaccompanied minor (optional)
Enter number code for anyone for whom you are applying

*If born in a U.S. territory, or outside the U.S., list the territory or county of birth.

VETERAN STATUS MARITAL STATUS RACE DOES THIS

PERSON IF BORN OUTSIDE U.S.
1 3 4 5 7 2
CITIZENSHIP

VETERAN HAVE A PA SPECIFY WHERE

NA HAWAIIAN
NON-VETERAN SINGLE MARRIED ACCESS
OR ALASKA

OR PACIFIC
AM. INDIAN
AMERICAN
BLACK OR

NAME ON BIRTH
STATUS

ISLANDER
*STATE COUNTY CITY MOTHER’S FULL

HISPANIC
AFRICAN

ACTIVE MILITARY COMMON LAW MARRIAGE CARD?

ORIGIN
NATIVE

CERTIFICATE OF OF MAIDEN NAME PA DRIVER’S OR

WHITE
ASIAN

NATIONAL GUARD/ SEPARATED DIVORCED OF

WIDOWED YES NO Last, First, MI BIRTH BIRTH BIRTH Last, First, MI STATE I.D. NUMBER
RESERVES

3 PA 600P 7/08
 MEDICAL COVERAGE INFORMATION
 YES  NO DO YOU OR ANYONE FOR WHOM YOU ARE APPLYING HAVE MEDICAL COVERAGE? THIS INCLUDES INSURANCE
COVERAGE PROVIDED BY INDIVIDUALS LIVING IN OR OUTSIDE OF THE HOUSEHOLD. IF YES, PROVIDE THE FOLLOWING INFORMATION:
COVERAGE BY OTHER MEDICAL INSURANCE WILL NOT AFFECT YOUR ELIGIBILITY FOR BENEFITS.
MEDICAL ASSISTANCE IS ALWAYS THE PAYER OF LAST RESORT.

POLICY HOLDER NAME POLICY HOLDER ADDRESS POLICY HOLDER NAME POLICY HOLDER ADDRESS

INSURANCE COMPANY NAME POLICY NUMBER GROUP NAME/NUMBER INSURANCE COMPANY NAME POLICY NUMBER GROUP NAME/NUMBER

INSURANCE COMPANY PHONE NUMBER INSURANCE TYPE INSURANCE COMPANY PHONE NUMBER INSURANCE TYPE

MEDICARE A DENTAL MEDICARE A DENTAL

INSURANCE COMPANY ADDRESS INSURANCE COMPANY ADDRESS

MAJOR MAJOR
MEDICARE B MEDICARE B
MEDICAL MEDICAL

BASIC HOSP / BASIC HOSP /

WHO IS COVERED? VISION WHO IS COVERED? VISION
PHYSICIAN PHYSICIAN

HOSPITAL WORKERS’ HOSPITAL WORKERS’

ONLY COMP ONLY COMP
IS THIS COURT ORDERED? IS THIS COURT ORDERED?
HMO HMO
 YES  NO PRESCRIPTION (INCLUDES  YES  NO PRESCRIPTION (INCLUDES
MEDICARE) MEDICARE)
POLICY HOLDER NAME POLICY HOLDER ADDRESS POLICY HOLDER NAME POLICY HOLDER ADDRESS

INSURANCE COMPANY NAME POLICY NUMBER GROUP NAME/NUMBER INSURANCE COMPANY NAME POLICY NUMBER GROUP NAME/NUMBER

INSURANCE COMPANY PHONE NUMBER INSURANCE TYPE INSURANCE COMPANY PHONE NUMBER INSURANCE TYPE

MEDICARE A DENTAL MEDICARE A DENTAL

INSURANCE COMPANY ADDRESS INSURANCE COMPANY ADDRESS

MAJOR MAJOR
MEDICARE B MEDICARE B
MEDICAL MEDICAL

BASIC HOSP / BASIC HOSP /

WHO IS COVERED? VISION WHO IS COVERED? VISION
PHYSICIAN PHYSICIAN

HOSPITAL WORKERS’ HOSPITAL WORKERS’

ONLY COMP ONLY COMP
IS THIS COURT ORDERED? IS THIS COURT ORDERED?
HMO HMO
 YES  NO PRESCRIPTION (INCLUDES  YES  NO PRESCRIPTION (INCLUDES
MEDICARE) MEDICARE)

PA 600P 7/08 4
 VOTER REGISTRATION (Optional)
If you or any other adult in your household is not registered to vote where you live now, would you like to register to vote? __Yes __No
If yes, enter names below. IF YOU DO NOT CHECK ‘YES’ OR ‘NO’, you are choosing not to register to vote at this time.
To register you must: 1) Be at least age 18 on the day of the next election; 2) Be a citizen of the United States for at least one month PRIOR
TO THE NEXT ELECTION; 3) Reside in Pennsylvania and the voting district at least 30 days prior to the next election.
LINE NO LINE NO
CAO ONLY LAST NAME FIRST NAME CAO ONLY LAST NAME FIRST NAME

YOUR BENEFITS WILL NOT BE AFFECTED IF YOU REGISTER OR DO NOT REGISTER.

If you need help filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.
Please contact the county assistance office if you need help. If you believe that someone has interfered with your right to register to vote, or to decline to register to vote, your right to
privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the
Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-free telephone number 1-800-552-VOTE.)
DO NOT COMPLETE - COUNTY ASSISTANCE OFFICE USE
 Given to client ___/___/____  Sent to voter registration ___/___/____  Mailed to client ___/___/____
 Declined, not interested ___/___/____  Not a U.S. citizen ___/___/____  Declined, already registered ___/___/____

CRIMINAL HISTORY INQUIRY - MANY PEOPLE WITH CRIMINAL RECORDS CAN STILL GET BENEFITS, BUT WILL NEED
TO BE IN COMPLIANCE WITH COURT ORDERS, PROBATION AND PAROLE AND CURRENT ON FINE PAYMENTS
If you are applying for:
• Cash assistance or Food Stamp benefits you must answer all of the following questions for yourself and anyone for whom you are applying.
• Medical Assistance only, you must answer question #1 for yourself and anyone else for whom you are applying.
If you answer “yes” to a question, name the household member(s) to whom the answer applies.
Have you or anyone for whom you are applying:
1.  Yes  No ever been issued a summons or warrant to appear as a defendant at criminal court? Household member(s)

2.  Yes  No ever been convicted for a felony or misdemeanor offense? Household member(s)

3.  Yes  No been convicted of a felony offense committed after Aug. 22, 1996 related to possession, distribution and/or use of a controlled
substance? Household member(s)

4.  Yes  No ever been convicted of welfare fraud? Household member(s)

5.  Yes  No ever received a court order to pay fines, costs or restitution related to a criminal conviction? Household member(s)

6.  Yes  No ever been on probation or parole or in an Accelerated Rehabilitative Disposition (ARD) program? Household member(s)

7.  Yes  No ever fled or are currently fleeing from law enforcement officials? Household member(s)

5 PA 600P 7/08
 ANSWER ALL YES AND NO QUESTIONS - FOR YES ANSWERS, COMPLETE THE UNSHADED BLOCKS
The following information will be used to determine eligibility for benefits only; it will not be released to any other parties.
 YES  NO Is anyone applying who is not a U.S. Citizen? SKIP THIS BLOCK IF THIS APPLICATION IS FOR EMERGENCY MEDICAL BENEFITS ONLY RFUG
NAME OF PERSON WHO IS NOT A CITIZEN DATE ENTERED THE U.S. FROM WHAT COUNTRY ALIEN REGISTRATION NUMBER INS SECTION
MONTH DAY YEAR

 YES  NO Does anyone listed above have a sponsor?

SPONSOR NAME (Last, First, Middle) PERSON / ORGANIZATION NAME SPONSOR OR ORGANIZATION ADDRESS (Street, City, State, Zip Code)

TYPE / SOURCE HOW MUCH HOW OFTEN

SPONSOR’S INCOME / RESOURCES

 YES  NO Is anyone a student? (School Type: E=Elementary, M=Middle, H=High School, C=College, T=Training, V=Vocational) SCH
SCHOOL PART TIME EXPECTED GRAD. DATE
NAME NAME OF SCHOOL TYPE GRADE FULL TIME MONTH DAY YEAR

P F

P F
P F

 YES  NO Is anyone a veteran or active in the military, national guard or reserves? VET/SVI
NAME SOCIAL SECURITY NUMBER BRANCH OF SERVICE DATE ENTERED DATE LEFT VETERAN CLAIM #
MONTH DAY YEAR MONTH DAY YEAR

 YES  NO Is anyone a widow, parent, spouse or minor child of a veteran?

NAME NAME OF VETERAN BRANCH OF SERVICE DATE ENTERED DATE LEFT VETERAN CLAIM #
MONTH DAY YEAR MONTH DAY YEAR

 YES  NO Is anyone disabled, seriously ill or in need of medical attention?  YES  NO Did anyone’s SSI stop because of an increase in or DIS/INC
 YES  NO Is anyone receiving treatment or in need of help to overcome a drug or receipt of Social Security benefits?
alcohol problem?  YES  NO Does a parent have a physical or mental disability that
 YES  NO Does anyone require health sustaining medication? affects the ability to care for a child?
 YES  NO Has anyone applied for or received, or is anyone currently receiving  YES  NO Is or has anyone been a victim of domestic violence?
RSDI (Social Security) or Supplemental Security Income (SSI)?
NAME DESCRIBE THE DISABILITY DATE DISABILITY BEGAN
MONTH DAY YEAR

PA 600P 7/08 6
 IF YOU ARE APPLYING FOR FOOD STAMPS ONLY, SKIP PAGES 7 AND 8.
USE THIS PAGE FOR ANY PARENT AND/OR SPOUSE NOT LIVING IN YOUR HOUSEHOLD
 YES  NO Does any unmarried child under age 21 have a mother or father who is not living with you or who is deceased? ABS/REL
 YES  NO Does anyone have a husband or wife who is not living with you or who is deceased?

If you answered yes to either or both questions, give the following information for each relative. Complete a separate section for each relative.
NAME OF RELATIVE (Last, First, Middle)  IF DECEASED SEX RACE BIRTHDATE (MM/DD/YYYY) SOCIAL SECURITY NUMBER HOW IS THIS PERSON RELATED TO YOU
M
F
ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

NAME OF RELATIVE’S EMPLOYER (Current or most recent) EMPLOYER’S ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

1 NAMES FROM PAGE 2 THAT THIS PERSON IS RESPONSIBLE FOR

IF THE RELATIVE HAS MEDICAL INSURANCE FOR THESE DEPENDENTS, PROVIDE INFORMATION ON PAGE 4.

IF THIS RELATIVE PAYS SUPPORT OR IF HE SHOULD BE PAYING SUPPORT - COMPLETE THE FOLLOWING
HOW MUCH HOW OFTEN LAST DATE PAID (MM/DD/YYYY) PAID TO WHOM
FOR VOLUNTARY
SUPPORT $
WHAT ARE THE
FOR COURT COURT ORDER # AMOUNT HOW OFTEN IT IS PAID DATE OF ORDER (MM/DD/YYYY) SPECIAL TERMS - IF ANY COUNTY COURT NAME
ORDERED
SUPPORT
$
NAME OF RELATIVE (Last, First, Middle)  IF DECEASED SEX RACE BIRTHDATE (MM/DD/YYYY) SOCIAL SECURITY NUMBER HOW THIS PERSON IS RELATED TO YOU
M
F
ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

NAME OF RELATIVE’S EMPLOYER (Current or most recent) EMPLOYER’S ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

2 NAMES FROM PAGE 2 THAT THIS PERSON IS RESPONSIBLE FOR

IF THE RELATIVE HAS MEDICAL INSURANCE FOR THESE DEPENDENTS, PROVIDE INFORMATION ON PAGE 4.

IF THIS RELATIVE PAYS SUPPORT OR IF HE SHOULD BE PAYING SUPPORT - COMPLETE THE FOLLOWING
HOW MUCH HOW OFTEN LAST DATE PAID (MM/DD/YYYY) PAID TO WHOM
FOR VOLUNTARY
SUPPORT $
WHAT ARE THE
FOR COURT COURT ORDER # AMOUNT HOW OFTEN IT IS PAID DATE OF ORDER (MM/DD/YYYY) SPECIAL TERMS - IF ANY COUNTY COURT NAME
ORDERED
SUPPORT
$

7 PA 600P 7/08
 USE THIS PAGE FOR ADDITIONAL PARENTS OR A SPOUSE NOT LIVING IN YOUR HOUSEHOLD

If you answered yes to either question on page 7, give the following information for each relative. Complete a separate section for each relative.
NAME OF RELATIVE (Last, First, Middle)  IF DECEASED SEX RACE BIRTHDATE (MM/DD/YYYY) SOCIAL SECURITY NUMBER HOW THIS PERSON IS RELATED TO YOU
M
F
ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

NAME OF RELATIVE’S EMPLOYER (Current or most recent) EMPLOYER’S ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

3 NAMES FROM PAGE 2 THAT THIS PERSON IS RESPONSIBLE FOR

IF THE RELATIVE HAS MEDICAL INSURANCE FOR THESE DEPENDENTS, PROVIDE INFORMATION ON PAGE 4.

IF THIS RELATIVE PAYS SUPPORT OR IF HE SHOULD BE PAYING SUPPORT - COMPLETE THE FOLLOWING
HOW MUCH HOW OFTEN LAST DATE PAID (MM/DD/YYYY) PAID TO WHOM
FOR VOLUNTARY
SUPPORT $
WHAT ARE THE
FOR COURT COURT ORDER # AMOUNT HOW OFTEN IT IS PAID DATE OF ORDER (MM/DD/YYYY) SPECIAL TERMS - IF ANY COUNTY COURT NAME
ORDERED
SUPPORT
$
NAME OF RELATIVE (Last, First, Middle)  IF DECEASED SEX RACE BIRTHDATE (MM/DD/YYYY) SOCIAL SECURITY NUMBER HOW THIS PERSON IS RELATED TO YOU
M
F
ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

NAME OF RELATIVE’S EMPLOYER (Current or most recent) EMPLOYER’S ADDRESS (Street, City, State) ZIP CODE PHONE NUMBER

4 NAMES FROM PAGE 2 THAT THIS PERSON IS RESPONSIBLE FOR

IF THE RELATIVE HAS MEDICAL INSURANCE FOR THESE DEPENDENTS, PROVIDE INFORMATION ON PAGE 4.

IF THIS RELATIVE PAYS SUPPORT OR IF HE SHOULD BE PAYING SUPPORT - COMPLETE THE FOLLOWING
HOW MUCH HOW OFTEN LAST DATE PAID (MM/DD/YYYY) PAID TO WHOM
FOR VOLUNTARY
SUPPORT $
WHAT ARE THE
FOR COURT COURT ORDER # AMOUNT HOW OFTEN IT IS PAID DATE OF ORDER (MM/DD/YYYY) SPECIAL TERMS - IF ANY COUNTY COURT NAME
ORDERED
SUPPORT
$

IF YOU HAVE MORE RELATIVES TO LIST - ASK FOR AN EXTRA PAGE OR PROVIDE
THE INFORMATION ON A SEPARATE SHEET OF PAPER
PA 600P 7/08 8
 ANSWER ALL YES AND NO QUESTIONS - FOR YES ANSWERS, COMPLETE THE UNSHADED BLOCKS
 YES  NO Is anyone in your household working, including self-employment? WRK HST
 YES  NO Did you or anyone else in your household have a reduction in the number of hours worked?
 YES  NO Has anyone in your household worked in the last five years?
If you answered yes to any of the above questions, complete below.
START DATE END DATE # OF HOURS
NAME EMPLOYER’S NAME EMPLOYER’S ADDRESS (Street, City, State, Zip) PHONE WORKED PER
MO / DAY / YR MO / DAY / YR WEEK

 YES  NO Is anyone on strike? If yes, who?________________________________________ When did the strike start? mm_____ dd_____ yyyy______

IF YOU ARE APPLYING FOR FOOD STAMP BENEFITS ONLY, SKIP THIS BLOCK
 YES  NO If you or anyone else in your household is employed, is medical insurance available through an employer for you or anyone in your family? HIPP
 YES  NO Did the loss of a job within the last 30 days cause the loss of medical insurance for anyone in your household? If yes, provide
 YES  NO Is there someone in your family who is pregnant? the date the
 YES  NO Is there someone in your family who is seriously ill? coverage ended:____________

NAME ILLNESS PREGNANCY DUE DATE

IF YOU ARE APPLYING FOR MEDICAL ASSISTANCE ONLY AND ARE PREGNANT,
UNDER AGE 21 OR HAVE A DEPENDENT CHILD UNDER AGE 21 LIVING WITH YOU, SKIP THIS BLOCK
Does anyone have any of the following resources? MISC
 YES  NO Cash on hand (01)  YES  NO Savings Certificate (26)  YES  NO Trust Fund (06)
 YES  NO Savings Account (02)  YES  NO U.S. Savings Bonds (05)  YES  NO Boat / Snowmobile / Camper (14)
 YES  NO Checking Account (03)  YES  NO Christmas or Vacation Club (04)  YES  NO Family Savings Account (FSA)
 YES  NO Certificate of Deposit (26)  YES  NO Stocks or Bonds (05)  YES  NO IRA, KEOGH or other retirement plan (27)
NAME OF OWNER TYPE/ACCOUNT #/LOCATION OF THE RESOURCE CURRENT VALUE

 YES  NO Is anyone expecting money or any type of resource such as, but not limited to, an accident settlement, inheritance, trust fund or other resource?
If yes, type of resource __________________________________________ Value ________________________ When to be received, date __________________
 YES  NO Has anyone sold, transferred or given away a home, land, personal property or other resource in the past 36 months?
If yes, describe the type of property ____________________________________________________ Value ______________________ Date __________________

9 PA 600P 7/08
 IF YOU ARE APPLYING FOR MEDICAL ASSISTANCE ONLY AND ARE PREGNANT,
UNDER AGE 21 OR HAVE A DEPENDENT CHILD UNDER AGE 21 LIVING WITH YOU, SKIP THIS PAGE
ANSWER ALL YES AND NO QUESTIONS - FOR YES ANSWERS, COMPLETE THE UNSHADED BLOCKS
 YES  NO Does anyone own or is anyone buying a car, truck or motorcycle? MV
If you have a recreational vehicle such as a camper, boat or motor home, list it as a MISC. RESOURCE on page 9.

NAME(S) OF OWNER LICENSE AMOUNT MONTHLY

YEAR MAKE MODEL LICENSED
PLATE NUMBER OWED CAR PAYMENT
 YES  NO

 YES  NO

 YES  NO

 YES  NO

 YES  NO

 YES  NO

 YES  NO Does anyone have a life insurance policy? (IF YOU ARE APPLYING FOR FOOD STAMP BENEFITS ONLY, SKIP THIS BLOCK) INS

POLICY OWNER NAME OF INSURANCE COMPANY / POLICY NUMBER FACE VALUE CASH VALUE WHO IS COVERED?

 YES  NO Is anyone covered by an accident policy? (DO NOT LIST MEDICAL OR CAR INSURANCE HERE - COMPLETE PAGE 4)
Insurance Company Type of Policy (Accident, Dismemberment, Disability, etc.)
IF YES

 YES  NO Does anyone own a burial space or plot? BRL

OWNER OF SPACES NUMBER VALUE AMOUNT OWED NAME OF CEMETERY

OF SPACES
$ $

$ $

 YES  NO Does anyone have a burial agreement with a bank or funeral home?

OWNER OF AGREEMENT BANK / FUNERAL HOME BANK / FUNERAL HOME ADDRESS (Street, City, State, Zip)

PA 600P 7/08 10
 IF YOU ARE APPLYING FOR MEDICAL ASSISTANCE ONLY AND ARE PREGNANT,
UNDER AGE 21, OR HAVE A DEPENDENT CHILD UNDER AGE 21 LIVING WITH YOU, SKIP THIS BLOCK

 YES  NO Does anyone own or is anyone buying a non-resident property or a non-resident mobile home? PROP
If yes, complete the unshaded blocks.

NAME DATE PURCHASED MARKET VALUE NAMES ON DEED / AGREEMENT

MONTH DAY YEAR
$

PROPERTY ADDRESS (Street, Township, City, State, Zip)

NAME DATE PURCHASED MARKET VALUE NAMES ON DEED / AGREEMENT

MONTH DAY YEAR
$

PROPERTY ADDRESS (Street, Township, City, State, Zip)

List any UNPAID medical bills. MED EXP

AMOUNT TO WHO PROVIDED TYPE OF BILL

NAME OF PERSON WITH BILL FREQUENCY DATE OF SERVICE
BE PAID SERVICE? (Doctor, Hospital, Prescriptions, etc.)
MONTH DAY YEAR
$

List any medical bills PAID in the last three months prior to the month of the application and/or any paid in the month of the application.

WHO PROVIDED TYPE OF BILL

NAME OF PERSON WHO PAID BILL FREQUENCY AMOUNT DATE PAID
SERVICE? (Doctor, Hospital, Prescriptions, etc.)
MONTH DAY YEAR
$

11 PA 600P 7/08
 ANSWER ALL YES AND NO QUESTIONS - FOR YES ANSWERS, COMPLETE THE UNSHADED BLOCKS
EXPENSES SHEL
 YES  NO Do you pay for heating or air conditioning?
 YES  NO Is the bill for heating or air conditioning mailed to someone living in your household?
 YES  NO Did you receive Energy Assistance (LIHEAP) since last October 1st?
 YES  NO Do you have utility costs other than heating, or air conditioning, such as electric, water, sewer or phone?
 YES  NO Do you live in public or subsidized housing (Section-8 or HUD)?
 YES  NO Do you receive a utility allowance? If yes, list the amount. $___________________
 YES  NO Are your meals included in your rent?
 YES  NO Do you share expenses? If yes, with whom? __________________________What expenses are shared (rent/utilities or both)___________.
How much do you contribute?____________________________________________________________________________________________.
LIST YOUR OUT OF POCKET HOUSEHOLD EXPENSES (SEE PAGE 16 FOR ADDITIONAL INFORMATION
FOR FAILURE TO VERIFY THESE EXPENSES)
EXPENSES HOW MUCH HOW OFTEN EXPENSES YES NO EXPENSES YES NO

RENT OR MORTGAGE $ TELEPHONE WATER

PROPERTY TAXES (City, County, School) $ ELECTRIC SEWERAGE

HOMEOWNER’S PROPERTY INSURANCE $ GAS GARBAGE

OTHER SUCH AS LOT RENT, OIL/COAL/WOOD UTILITY INSTALLATION

CONDO FEES, KEROSENE, ETC. $

 YES  NO Does anyone outside your household pay any of your expenses?
If so, what? ____________________________________ How much? $ __________________________To whom? ________________________

 YES  NO DOES ANYONE IN YOUR HOUSEHOLD HAVE ANY INCOME? INCOME

If yes, list any income you have already received this month or expect to receive this month.
Income includes,
WAGES ROOM AND BOARD SSI UNEMPLOYMENT OR WORKER’S COMPENSATION PENSIONS
but is not SELF EMPLOYMENT RENT SUPPORT MONEY FOR TRAINING COMMISSIONS
limited to: BABYSITTING SOCIAL SECURITY SICK BENEFITS DIVIDENDS OR INTEREST UNION PAY

DATE RECEIVED
NAME TYPE / SOURCE OF INCOME HOW MUCH HOW OFTEN
MO / DAY / YR

PA 600P 7/08 12
 INCOME AND EXPENSES

List benefits anyone has applied for but has not received such as Unemployment Compensation, Workers’ Compensation, Social Security or SSI. INCOME

NAME TYPE / SOURCE OF INCOME DATE RECEIVED HOW MUCH WHEN YOU EXPECT IT
MO / DAY / YR

$
List the expenses related to the care of a child or disabled adult in your household, incurred by anyone who is working, looking for work or going to school or training.

NAME OF PERSON WHO NEEDS CARE NAME OF CARE GIVER HOW MUCH HOW OFTEN

List information about child support that you or another household member pays to a person who does not live with you.

AMOUNT OF AMOUNT
NAME OF PERSON WHO PAYS NAME OF CHILD HOW OFTEN
SUPPORT ORDER ACTUALLY PAID

$ $

$ $

$ $
List the expenses that you or another household member has in order to receive income, such as transportation or legal fees.

NAME ROUND TRIP MILES TO WORK OTHER TRANSPORTATION COSTS LEGAL FEES BANK OR OTHER FEES

CAO OFFICE USE ONLY

EXPEDITED INITIALS DATE
1.  YES  NO Is anyone in the application group receiving food stamps and not living in a certified shelter for battered REVIEW
women and children?
2.  YES  NO Is there any postponed verification from a previous expedited issuance that the household must provide?  ELIGIBLE  DENIED -- CLIENT
NOTIFIED
3.  YES  NO Are the household liquid resources equal to or less than $100? REASON FOR DENIAL:
4.  YES  NO Is the countable monthly gross income less than $150?
5.  YES  NO Is this a migrant or seasonal farm worker household?
6.  YES  NO Is the household destitute?
7.  YES  NO Are combined monthly gross income and liquid resources less than monthly shelter expenses? REGISTERED
FOR CATEGORIES

13 PA 600P 7/08
 CLIENT’S RIGHTS CLIENT RESPONSIBILITIES
RIGHT TO NONDISCRIMINATION RESPONSIBILITY TO ACKNOWLEDGE LIABILITY OF REAL OR PERSONAL PROPERTY
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited If you are applying for cash assistance and have non-resident real property and/or personal property, we
from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or may require you to sign an agreement to repay benefits that you, your spouse and your children have
disability. received.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence If you are age 55 or older and receive Medical Assistance to pay for nursing facility services, home and
Avenue, SW, Washington, D.C. 20250-9410 or call (866) 632-9992 or (202) 401-0216 (TDD). USDA is community-based waiver services and any related hospital and prescription drug service, you will be
an equal opportunity provider and employer. required to repay the cost of these services from your probate estate.
RIGHT TO APPEAL RESPONSIBILITY TO PROVIDE INFORMATION
You have the right to ask for a Pennsylvania Department of Public Welfare hearing to appeal a You must give true, correct and complete information. You must cooperate in documenting or proving the
decision of or failure to act by the Department which affects your benefits or that you believe is unfair information you give. Cash assistance may be denied if you fail to provide certain verification. If you cannot
or incorrect. You may file the appeal at the county assistance office (CAO). At the appeal hearing, you provide proof, you should ask the CAO to help. You must cooperate fully with persons or investigators of the
may represent yourself, or someone else, such as a lawyer, friend or relative may represent you. Department or the Office of Inspector General conducting investigations.
RIGHT TO AN AGENCY CONFERENCE RESPONSIBILITY TO REPORT CHANGES
If you appeal, you may have an agency conference before the hearing. If you appeal because the For cash assistance and Medical Assistance, you must report changes in: the number of people in your
Department decided that you are not eligible for expedited Food Stamp service, you have a right to an household, address, new unearned income, real property or other resources (such as bank accounts or life
agency conference with a supervisor within two work days. insurance). However, for Medical Assistance, if you are pregnant, under 21 years of age or have a
RIGHT TO A WRITTEN NOTICE dependent child under 21 years of age living with you, you are not required to report changes in resources.
We will give you a written notice explaining your benefits. If we deny, change, suspend or stop You must report any plans to leave the state, even temporarily. If you have no earned income, you must
benefits, we will explain the reason on the notice. You have 30 days (90 days for food stamps) from the report new employment or new income from self-employment. If you have earned income, you must report
mailing date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons if your gross monthly earned income increases by more than $100 than the estimated gross monthly earned
given. income used to determine your benefit. If you have unearned income, you must report if your gross monthly
unearned income increases by more than $50 than the amount used to determine your benefit. You must
RIGHT TO A CERTIFICATE OF CREDITABLE COVERAGE report changes within the first 10 days of the month following the month of the change.
You have the right to ask the Department to provide you with a Certificate of Creditable Coverage to
For Food Stamp households that are not participating in Semiannual Reporting (SAR), you must report
verify your Medical Assistance coverage. Federal law limits when health coverage may be denied or
changes as described for cash assistance with three exceptions. If you have unearned income, you must
limited for a pre-existing condition. If you enroll in a group health plan that excludes treatment for a pre-
report increases or decreases in gross monthly unearned income of more than $50. Additionally, changes
existing condition, you can be credited for the time you received Medical Assistance. You may request
in life insurance and temporary absences from the state or county do not need to be reported.
a certificate to verify your Medical Assistance coverage. Contact your case worker to request this
certificate For Food Stamp households that are participating in SAR, you must report if your household's total gross
monthly income exceeds 130 percent of the Federal Income Poverty Guidelines (FPIGs) for your household
RIGHT TO CONFIDENTIALITY size. The report must be made within 10 calendar days from the end of the month in which the gross monthly
We keep information you give confidential and use it only to administer the programs you apply for income exceeds the 130 percent FPIGs. Your caseworker will explain your specific income reporting
and/or may be eligible for, such as the school lunch program, the Children's Health Insurance Program requirement.
(CHIP) or adultBasic. Any person knowingly violating any of the rules and regulations of this Department
shall be guilty of a misdemeanor, and, upon conviction thereof, shall be sentenced to pay a fine, not In addition, for Food Stamp households that contain an Able-Bodied Adult Without Dependents (ABAWD)
exceeding one hundred dollars ($100), or to undergo imprisonment, not exceeding six months, or both that are participants in SAR, the household must report if the ABAWD work hours fall below an average of
(62 P.S. Section 483). The CAO, when requested, must provide federal, state and local law 20 hours weekly. An ABAWD means that you are able to work, you are age 18 through 49 and you have no
enforcement officials with the address, Social Security Number and photograph (if available) of an children under age 18 who live with you.
individual who is fleeing to avoid prosecution, custody or confinement for a felony or violating probation If you are proven to have failed, without good cause, to report earned income in a timely manner, you
or parole. may not receive an earned income deduction on the unreported income. This may reduce the amount of
cash assistance and/or Food Stamps to which you are entitled and increase the amount of the overpayment
RIGHT TO CLAIM GOOD CAUSE claim.
The law requires you to cooperate in establishing paternity for any child born out of marriage and get
any support owed to you and/or any child(ren) for whom you want cash and/or Medical Assistance. The You can report changes to the CAO in person, by telephone, by fax or by mail.
Department will excuse you from cooperating with the support requirements if you prove that it would RESPONSIBILITY TO USE THE PA ACCESS CARD LAWFULLY
not be in the best interest of you or the child(ren) for whom assistance is claimed. If you are not exempt You may use the PA ACCESS card for services only during the period you are eligible. You must use the
from employment and training requirements, you must comply unless you have good cause. You must card only for the person who is eligible and you may get only the services that are needed and reasonable.
meet Semiannual Reporting requirements unless you have good cause.
RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERS
For cash, Medical Assistance and/or Food Stamp benefits, you must provide a Social Security Number
(SSN) for each person for whom you are applying. If you do not have an SSN you must apply for one.
Refusal or failure to provide an SSN may result in disqualification. For cash benefits, we will also ask you to
supply an SSN for anyone else whose income and/or resources affect your eligibility or amount of benefits.
Your SSN is used to verify your identity and to prevent duplication of state and federal benefits. Your SSN
is used for computer matches to verify income and resources that may affect your eligibility and/or benefits.
An alien who is applying for emergency Medical Assistance only, is not required to provide an SSN. (42
U.S.C. §1320b-7).

PA 600P 7/08 14
 PROHIBITIONS AND PENALTIES
You must not: An individual is ineligible for cash assistance for a Stamps. Before a disqualification is imposed, you will
• give false, incorrect or incomplete information; period of 10 years if he is convicted of fraudulent receive a notice and will have the right to appeal and
• trade, sell or alter your Electronic Benefit Transfer misrepresentation of residence for the purpose of have a fair hearing.
(EBT) Card or your PA ACCESS Card; receiving additional benefits in two or more states. The minimum disqualification periods are as
• use someone else’s EBT or PA ACCESS Card; Cash assistance will be reduced by amounts follows: for the first violation, one month and thereafter
• use your Food Stamp benefits to buy ineligible items received by cashing an assistance check at a until the failure to comply ceases; the second violation
such as alcoholic drinks or tobacco; gambling casino, race track, bingo hall or other is three months and thereafter until the failure to
• use your Food Stamp benefits to buy drugs or establishment that derives more than 50 percent of its comply ceases; and for the third and subsequent
controlled substances, firearms, ammunition or gross revenues from gambling. violations, six months and thereafter until the failure to
explosives; or
If you do not report changes as required, your comply ceases.
• use your Food Stamp benefits to pay for food already
received, or use your Food Stamp benefits to purchase benefits may be reduced or stopped. If you purpose-
food on credit. ly fail to give correct information or report changes, CASH ASSISTANCE WORK
you may be tried and if found guilty, fined and/or be REQUIREMENTS/PENALTIES
Any member of your household who is found guilty put in jail for theft by deception. Improper use of the A mandatory participant who fails to cooperate with
by a court or an Administrative Disqualification hearing PA ACCESS Card for medical services and/or cash the work requirement, accept a bona fide offer of
of breaking any of the above rules or who signs a and Food Stamp electronic benefit transfers may employment; or who terminates employment, reduces
voluntary disqualification consent agreement or waiver result in a fine or imprisonment, or both. earnings or fails to apply for work, without good cause,
of Administrative Disqualification hearing will be barred
from getting cash assistance or Food Stamp benefits is ineligible for cash assistance.
for up to: The period of the penalty is:
If you are found guilty of violating these rules, First occurrence - 30 days or until the failure to
• 12 months for the first violation; or committing fraud, you also may be:
• 24 months for the second violation; and comply ceases, whichever is longer.
• fined up to $250,000 for Food Stamps and up Second occurrence - 60 days or until the failure to
• permanently for the third violation. to $15,000 for cash;
comply ceases, whichever is longer.
• jailed up to 20 years for Food Stamps and up Third occurrence - permanently.
Any household member found guilty by a court of using to seven years for cash;
Food Stamp benefits to buy controlled substances will be and/or
disqualified for: If an individual fails to report for an initial
• required to repay the benefits you received.
appointment with a contracted work activity, or fails to
• 24 months for the first violation, and
complete a partial determiniation related to
• permanently for the second violation. FOOD STAMP WORK non-cooperation with a work activity, the entire
REQUIREMENTS/SANCTIONS assistance group is ineligible.
Any household member found guilty by a court of
buying or selling Food Stamp benefits or other benefit If you are physically and mentally fit, over 15 years of If the reason for the penalty occurs in the first 24
instruments for cash or consideration other than food for age and under 60 years of age, and not otherwise months of receipt of cash assistance, whether
the exchange of firearms, ammunition, explosives or exempt, you may not refuse to register for consecutive or interrupted, the penalty applies only to
controlled substances in the amount of $500 or more in employment; participate in an approved employment the individual.
Food Stamp benefits will be disqualified permanently. and training program unless you have good cause; If the reason for penalty occurs after the first
Any household member found by a court or accept employment unless you have good cause; 24 months of receipt of cash assistance, whether
an Administrative Disqualification hearing of
misrepresenting his identity or residence to receive provide sufficient information to your county consecutive or interrupted, the sanction applies to the
multiple Food Stamps will be disqualified for 10 years. assistance office about your employment status and entire assistance group.
Any household member fleeing to avoid job availability unless you have good cause or comply In place of the penalties above, if an employed
prosecution, custody or confinement for a felony with workfare. Additionally, you must not voluntarily individual voluntarily, without good cause, reduces his
or attempted felony, or violating a condition of probation and without good cause quit your job or reduce the earnings by not fulfilling the work requirement, the
or parole will be ineligible for cash assistance and number of hours you work if, after the reduction, you cash grant is reduced by the dollar value of the income
Food Stamps until the situation is rectified.
Any individual who has been sentenced for a are employed less than 30 hours per week. that would have been earned if the recipient would
felony or a misdemeanor offense and who has not If you or another member of your household have fulfilled his work requirement, until the
satisfied the penalty imposed by the court is ineligible for violates any of the above work requirements, you or requirement is met.
cash assistance. that person may be disqualified from receiving Food

15 PA 600P 7/08
 AFFIDAVIT
WHEN I SIGN THIS FORM I AGREE THAT: WHEN I SIGN THIS FORM I UNDERSTAND THAT:
• I have read this application in full or someone has read it to me, and I understand the questions asked. • The Office of Inspector General may visit my residence within 7 to 10 days from the date I signed the
• I received a copy of my rights and responsibilities, and have read them or someone has read them to me; application for benefits to confirm information I provided to the County Assistance Office.
I understand, and agree to abide by them. • The state operates a fraud control program under which local, state and federal officials may verify the
information I have given. Verification will include confirmation through the Pennsylvania State Police
• I will provide or cooperate in getting any information needed to prove my statements.
Criminal Record Files, the Administrative Office of Pennsylvania Court files and other records that are
• I must report any changes in my circumstances within the first 10 calendar days of the month following
available.
the month of the change, unless I am in Semiannual reporting for Food Stamp benefits.
• The state may obtain information about my circumstances from other sources, including computer
• I will cooperate with the requirements of the child support enforcement program as directed by the matches and the U.S. Citizenship and Immigration Services except for persons applying for emergency
Department of Public Welfare (DPW). Medical Assistance only.
• If I receive cash and/or Medical Assistance benefits, I give the state and/or the Domestic Relations • I must report changes in my circumstances within the first 10 calendar days of the month following the
Section the right to pursue and collect cash and/or medical support for me and others for whom I am month of the change, unless I am in Semiannual reporting for Food Stamp benefits. (See pages 17 and
applying. 18 for reporting requirements.)
• If I receive a check for my cash benefits, the worker has read the certification on the back of the check; • My benefits may be reduced or terminated or I can be penalized (including charged with fraud) for giving
and every time I sign a check, I am signing the certification. false or misleading information or for not reporting changes that would affect my benefits.
• I am responsible for any fraudulent statements made on this application even if the application is • I am giving the state the right to seek, with or without legal action, payment from private or public health
submitted by someone acting on my behalf. insurance or liable third party. The amount recovered will not exceed the amount paid by Medical
• I consent to, and will fully cooperate in the finger, photo and signature imaging process. I understand that Assistance.
refusal to cooperate may result in the denial of benefits. • The state Domestic Relations Section has the right to review all records of medical services paid for by
• I certify that, subject to penalties provided by law, the information I gave is true, correct and complete to Medical Assistance.
the best of my knowledge • Payment for medical services will be made directly to the provider, not to me. This includes payments
• I am authorizing the DPW to release to the appropriate agency, information regarding my receipt of cash from Medical Assistance.
assistance, Food Stamp benefits and/or Medical Assistance as necessary to qualify my employer to • The law provides for automatic assignment of support rights for myself and others for whom I am
receive federal and/or state Tax Credits. accepting cash assistance and/or Medical Assistance to the state.
• If I receive cash assistance, I will be required to sign an Agreement of Mutual Responsibility which defines • If I receive cash benefits, all support including arrears will be paid to the state. When cash benefits stop,
my plan to achieve self sufficiency. arrears may be paid to the state to repay the amount of cash and other reimbursable assistance that I
• If contacted by Quality Control about information I provided on this application, I will cooperate with their received for my family. The amount of arrears paid to the state will not exceed the arrears assigned to
inquiry. the state or the total reimbursable assistance I received for my family, whichever is less. The total amount
of reimbursement from child support and other sources will not exceed the total amount of reimbursable
assistance received. If I receive medical benefits, medical support may be paid to the state. Medical
support retained by the state will not be more than the amount paid under the Medical Assistance
program.
• Failure to report or provide proof of household expenses will be regarded as my statement that I do
not want to receive a deduction for unreported or unproven expenses (Authority; U.S. Department of
Agriculture, Food and Nutrition Service, Mid-Atlantic region, Administrative Note 6-99, issued Jan. 4,
1999). I understand that I have the right to receive credit for household expenses at the time I report and
that I may be asked to provide proof of them at any time during my food stamp certification period.

CLIENT OR AUTHORIZED REPRESENTATIVE SIGNATURES DATE ID EMPLOYEE/WITNESS SIGNATURES DATE

ADDRESS OF REPRESENTATIVE (Street, City, Zip) PHONE NUMBER

SECOND WITNESS IF AN (X) IS SIGNED ABOVE ADDRESS OF WITNESS DATE

PA 600P 7/08 16
 CLIENT RIGHTS CLIENT RESPONSIBILITIES
RIGHT TO NONDISCRIMINATION RESPONSIBILITY TO ACKNOWLEDGE LIABILITY OF REAL OR PERSONAL PROPERTY
In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited If you are applying for cash assistance and have non-resident real property and/or personal property, we
from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or may require you to sign an agreement to repay benefits that you, your spouse and your children have
disability. received.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence If you are age 55 or older and receive Medical Assistance to pay for nursing facility services, home and
Avenue, SW, Washington, D.C. 20250-9410 or call (866) 632-9992 or (202) 401-0216 (TDD). USDA is community-based waiver services and any related hospital and prescription drug service, you will be
an equal opportunity provider and employer. required to repay the cost of these services from your probate estate.
RIGHT TO APPEAL RESPONSIBILITY TO PROVIDE INFORMATION
You have the right to ask for a Pennsylvania Department of Public Welfare hearing to appeal a You must give true, correct and complete information. You must cooperate in documenting or proving the
decision of or failure to act by the Department which affects your benefits or that you believe is unfair information you give. Cash assistance may be denied if you fail to provide certain verification. If you cannot
or incorrect. You may file the appeal at the county assistance office (CAO). At the appeal hearing, you provide proof, you should ask the CAO to help. You must cooperate fully with persons or investigators of the
may represent yourself, or someone else, such as a lawyer, friend or relative may represent you. Department or the Office of Inspector General conducting investigations.

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RIGHT TO AN AGENCY CONFERENCE RESPONSIBILITY TO REPORT CHANGES
If you appeal, you may have an agency conference before the hearing. If you appeal because the For cash assistance and Medical Assistance, you must report changes in: the number of people in your
Department decided that you are not eligible for expedited Food Stamp service, you have a right to an household, address, new unearned income, real property or other resources (such as bank accounts or life
agency conference with a supervisor within 2 work days.

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insurance). However, for Medical Assistance, if you are pregnant, under 21 years of age or have a
RIGHT TO A WRITTEN NOTICE dependent child under 21 years of age living with you, you are not required to report changes in resources.
We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop You must report any plans to leave the state, even temporarily. If you have no earned income, you must

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benefits, we will explain the reason on the notice. You have 30 days (90 days for Food Stamps) from report new employment or new income from self-employment. If you have earned income, you must report
the mailing date of the notice to ask for a hearing if you disagree with the action taken and/or the if your gross monthly earned income increases by more than $100 than the estimated gross monthly earned

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reasons given. income used to determine your benefit. If you have unearned income, you must report if your gross monthly
unearned income increases by more than $50 than the amount used to determine your benefit. You must
RIGHT TO A CERTIFICATE OF CREDITABLE COVERAGE report changes within the first 10 days of the month following the month of the change.
You have the right to ask the Department to provide you with a Certificate of Creditable Coverage to

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For Food Stamp households that are not participating in Semiannual Reporting (SAR), you must report
verify your medical assistance coverage. Federal law limits when health coverage may be denied or
changes as described for cash assistance with three exceptions. If you have unearned income, you must
limited for a pre-existing condition. If you enroll in a group health plan that excludes treatment for a pre-
report increases or decreases in gross monthly unearned income of more than $50. Additionally, changes
existing condition, you can be credited for the time you received Medical Assistance. You may request
in life insurance and temporary absences from the state or county do not need to be reported.

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a certificate to verify your medical assistance coverage. Contact your case worker to request this
certificate For Food Stamp households that are participating in SAR, you must report if your household's total gross
monthly income exceeds 130 percent of the Federal Income Poverty Guidelines (FPIGs) for your household
RIGHT TO CONFIDENTIALITY size. The report must be made within 10 calendar days from the end of the month in which the gross monthly
We keep information you give confidential and use it only to administer the programs you apply for income exceeds the 130 percent FPIGs. Your caseworker will explain your specific income reporting
and/or may be eligible for, such as the school lunch program, the Children's Health Insurance Program requirement.
(CHIP) or adultBasic. Any person knowingly violating any of the rules and regulations of this Department
shall be guilty of a misdemeanor, and, upon conviction thereof, shall be sentenced to pay a fine, not In addition, for Food Stamp households that contain an Able-Bodied Adult Without Dependents (ABAWD)
exceeding one hundred dollars ($100), or to undergo imprisonment, not exceeding six months, or both that are participants in SAR, the household must report if the ABAWD work hours fall below an average of
(62 P.S. Section 483). The CAO, when requested, must provide federal, state and local law 20 hours weekly. An ABAWD means that you are able to work, you are age 18 through 49 and you have no
enforcement officials with the address, Social Security Number and photograph (if available) of an children under age 18 who live with you.
individual who is fleeing to avoid prosecution, custody or confinement for a felony or violating probation If you are proven to have failed, without good cause, to report earned income in a timely manner, you
or parole. may not receive an earned income deduction on the unreported income. This may reduce the amount of
cash assistance and/or Food Stamps to which you are entitled and increase the amount of the overpayment
RIGHT TO CLAIM GOOD CAUSE claim.
The law requires you to cooperate in establishing paternity for any child born out of marriage and get
any support owed to you and/or any child(ren) for whom you want cash and/or Medical Assistance. The You can report changes to the CAO in person, by telephone, by fax or by mail.
Department will excuse you from cooperating with the support requirements if you prove that it would RESPONSIBILITY TO USE THE PA ACCESS CARD LAWFULLY
not be in the best interest of you or the child(ren) for whom assistance is claimed. If you are not exempt You may use the PA ACCESS card for services only during the period you are eligible. You must use the
from employment and training requirements, you must comply unless you have good cause. You must card only for the person who is eligible and you may get only the services that are needed and reasonable.
meet Semiannual Reporting requirements unless you have good cause.
RESPONSIBILITY TO PROVIDE SOCIAL SECURITY NUMBERS
For cash, Medical Assistance and/or Food Stamp benefits, you must provide a Social Security Number
(SSN) for each person for whom you are applying. If you do not have an SSN you must apply for one.
Refusal or failure to provide an SSN may result in disqualification. For cash benefits, we will also ask you to
supply an SSN for anyone else whose income and/or resources affect your eligibility or amount of benefits.
Your SSN is used to verify your identity and to prevent duplication of state and federal benefits. Your SSN
is used for computer matches to verify income and resources that may affect your eligibility and/or benefits.
An alien who is applying for emergency Medical Assistance only, is not required to provide an SSN. (42
U.S.C. §1320b-7).

17 PA 600P 7/08
 AFFIDAVIT - CLIENT’S COPY
WHEN I SIGN THIS FORM I AGREE THAT: WHEN I SIGN THIS FORM I UNDERSTAND THAT:
• I have read this application in full or someone has read it to me, and I understand the questions • The Office of Inspector General may visit my residence within 7 to 10 days from the date I signed the application for benefits
asked. to confirm information I provided to the County Assistance Office.
• I received a copy of my rights and responsibilities, and have read them or someone has read them • The state operates a fraud control program under which local, state, and federal officials may verify the information I have given.
to me; I understand, and agree to abide by them. Verification will include confirmation through the Pennsylvania State Police Criminal Record Files, the Administrative Office of
• I will provide or cooperate in getting any information needed to prove my statements. Pennsylvania Court files and other records that are available.
• I must report any changes in my circumstances within the first 10 calendar days of the month • The state may obtain information about my circumstances from employers and other sources, including computer matches and
following the month of the change, unless I am in Semiannual Reporting for Food Stamp benefits. the U.S. Citizenship and Immigration Services except for persons applying for emergency Medical Assistance only.
• I will cooperate with the requirements of the child support enforcement program as directed by the • I must report changes in my circumstances within the first 10 calendar days of the month following the month of the change,
Department of Public Welfare (DPW). unless I am in Semiannual reporting for Food Stamp benefits. (See pages 16 and 17 for reporting requirements.)
• If I receive cash and/or Medical Assistance benefits, I give the state and/or the Domestic Relations • My benefits may be reduced or terminated or I can be penalized (including charged with fraud) for giving false or misleading
Section the right to pursue and collect cash and/or medical support for me and others for whom I am information or for not reporting changes that would affect my benefits.
applying.
• I am giving the state the right to seek, with or without legal action, payment from private or public health insurance or liable third
• If I receive a check for my cash benefits, the worker has read the certification on the back of the party. The amount recovered will not exceed the amount paid by Medical Assistance.
check; and every time I sign a check, I am signing the certification.

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• The state Domestic Relations Section has the right to review all records of medical services paid for by Medical Assistance.
• I am responsible for any fraudulent statements made on this application even if the application is
submitted by someone acting on my behalf. • Payment for medical services will be made directly to the provider, not to me. This includes payments from Medical Assistance.
• I consent to, and will fully cooperate in the finger, photo and signature imaging process. I understand • The law provides for automatic assignment of support rights for myself and others for whom I am accepting cash assistance
and/or Medical Assistance to the state.

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that refusal to cooperate may result in the denial of benefits.
• I certify that, subject to penalties provided by law, the information I gave is true, correct and complete • If I receive cash benefits, all support including arrears will be paid to the state. When cash benefits stop, arrears may be paid
to the state to repay the amount of cash and other reimbursable assistance that I received for my family. The amount of arrears
to the best of my knowledge paid to the state will not exceed the arrears assigned to the state or the total reimbursable assistance I received for my family,
• I am authorizing the DPW to release to the appropriate agency, information regarding my receipt of

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whichever is less. The total amount of reimbursement from child support and other sources will not exceed the total amount of
cash assistance, Food Stamp benefits and/or Medical Assistance as necessary to qualify my reimbursable assistance received. If I receive medical benefits, medical support may be paid to the state. Medical support
employer to receive federal and/or state Tax Credits. retained by the state will not be more than the amount paid under the Medical Assistance program.

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• If I receive cash assistance, I will be required to sign an Agreement of Mutual Responsibility which • Failure to report or provide proof of household expenses will be regarded as my statement that I do not want to receive a
defines my plan to achieve self sufficiency. deduction for unreported or unproven expenses (Authority; U.S. Department of Agriculture, Food and Nutrition Service,
Mid-Atlantic region, Administrative Note 6-99, issued Jan. 4, 1999). I understand that I have the right to receive credit for
• If contacted by Quality Control about information I provided on this application, I will cooperate with household expenses at the time I report and that I may be asked to provide proof of them at any time during my food stamp

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their inquiry. certification period.
You must not:
• give false, incorrect or incomplete information; An individual is ineligible for cash assistance for a period of 10 from receiving Food Stamps. Before a disqualification is imposed,
years if he is convicted of fraudulent misrepresentation of residence you will receive a notice and will have the right to appeal and have a

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• trade, sell or alter your Electronic Benefit Transfer (EBT) Card or your PA ACCESS
Card; for the purpose of receiving additional benefits in two or more states. fair hearing.
Cash assistance will be reduced by amounts received by cashing The minimum disqualification periods are as follows: for the first
• use someone else’s EBT or PA ACCESS Card;
an assistance check at a gambling casino, race track, bingo hall or violation, one month and thereafter until the failure to comply ceases;
• use your Food Stamp benefits to buy ineligible items such as alcoholic drinks or other establishment that derives more than 50 percent of its gross the second violation is three months and thereafter until the failure to
tobacco; revenues from gambling. comply ceases; and for the third and subsequent violations, six
• use your Food Stamp benefits to buy drugs or controlled substances, firearms, If you do not report changes as required, your benefits may be months and thereafter until the failure to comply ceases.
ammunition or explosives; or reduced or stopped. If you purposely fail to give correct information or
• use your Food Stamp benefits to pay for food already received, or use your Food CASH ASSISTANCE WORK REQUIREMENTS/PENALTIES
report changes, you may be tried and if found guilty, fined and/or be A mandatory participant who fails to cooperate with the work activity
Stamp benefits to purchase food on credit. put in jail for theft by deception. Improper use of the PA ACCESS
Any member of your household who is found guilty by a court or an requirement, accept a bona fide offer of employment; or who
Card for medical services and/or cash and Food Stamp electronic terminates employment, reduces earnings or fails to apply for work,
Administrative Disqualification hearing of breaking any of the above rules or who signs benefit transfers may result in a fine or imprisonment, or both. without good cause, is ineligible for cash assistance.
a voluntary disqualification consent agreement or waiver of Administrative The period of the penalty is:
Disqualification hearing will be barred from getting cash assistance or Food Stamp If you are found guilty of violating these rules, or committing fraud, First occurrence - 30 days or until the failure to comply ceases,
you also may be:
benefits for up to: whichever is longer.
• fined up to $250,000 for Food Stamps and up to $15,000 for
• 12 months for the first violation; cash; Second occurrence - 60 days or until the failure to comply
• 24 months for the second violation; and ceases, whichever is longer.
• jailed up to 20 years for Food Stamps and up to seven years for
• permanently for the third violation. cash; and/or Third occurrence - permanently.
• required to repay the benefits you received. If an individual fails to report for an initial appointment with a
Any household member found guilty by a court of using Food Stamp benefits to
contracted work activity, or fails to complete a partial determination
buy controlled substances will be disqualified for: related to non-cooperation with a work activity, the entire assistance
• 24 months for the first violation, and FOOD STAMP WORK REQUIREMENTS/SANCTIONS - If you are group is ineligible.
• permanently for the second violation. physically and mentally fit, over 15 years of age and under 60 years If the reason for the penalty occurs in the first 24 months of receipt
Any household member found guilty by a court of buying or selling Food Stamp of age, and not otherwise exempt, you may not refuse to register for of cash assistance, whether consecutive or interrupted, the penalty
benefits or other benefit instruments for cash or consideration other than food for the employment; participate in an approved employment and training applies only to the individual.
exchange of firearms, ammunition, explosives or controlled substances in the amount of program unless you have good cause; accept employment unless If the reason for penalty occurs after the first 24 months of receipt
$500 or more in Food Stamp benefits will be disqualified permanently. you have good cause; provide sufficient information to your county
Any household member found by a court or an Administrative Disqualification of cash assistance, whether consecutive or interrupted, the penalty
assistance office about your employment status and job availability applies to the entire assistance group.
hearing of misrepresenting his identity or residence to receive multiple Food Stamps will unless you have good cause or comply with workfare. Additionally,
be disqualified for 10 years. In place of the penalties above, if an employed individual
Any household member fleeing to avoid prosecution, custody or confinement for a you must not voluntarily and without good cause quit your job or voluntarily, without good cause, reduces his earnings by not fulfilling
felony or attempted felony, or violating a condition of probation or parole will be reduce the number of hours you work if, after the reduction, you are the work requirement, the cash grant is reduced by the dollar value of
ineligible for cash assistance and Food Stamps until the situation is rectified. employed less than 30 hours per week. the income that would have been earned if the recipient would have
Any individual who has been sentenced for a felony or a misdemeanor offense and If you or another member of your household violates any of the fulfilled his work requirement, until the requirement is met.
who has not satisfied the penalty imposed by the court is ineligible for cash assistance. above work requirements, you or that person may be disqualified

18 PA 600P 7/08