STATE OF MARYLAND DEPARTMENT OF HUMAN RESOURCES LDSS 006 - Customer Care Unit , MD Phone: Program : 4434234456 Food Stamps

(FS) BENEFIT SUMMARY The information listed below is a summary of the information given by you for your household. Case Name :
Home Address : Apt# : City, State & Zip: Jonathan M Lipscomb
21 acorn circle 304 towson, MD 21286

Control ID Date Printed : Submission Date :

S443585821 6/15/2011

You provided information for benefits for the people listed below : Name Jonathan M Lipscomb You have reported the following information regarding income, expenses, and resources. Household Resources : Gross Earned Income: Gross Unearned Income: Child/Dependent Care Expenses : Child Support/Alimony Paid: Shelter Costs : $0.00 $0.00 $0.00 $0.00 $0.00 $550.00 SSN Date Of Birth Applying For Person? Roomer/Boarder? N

Collecting application information, including the social security number (SSN) of each household member, is authorized under the Food Stamp Act of 1977, as amended, U.S.C.2011_2036, Social Security Act S1137(f) and 42 U.S.C S1320b-7(d). We use the information to find out if your household is eligible.

STATE OF MARYLAND DEPARTMENT OF HUMAN RESOURCES

Your Control ID :

S443585821

This number helps us identify you. Print this page or write this number down. You must put this number on everything you send to your local office. That helps us keep your information together. If you leave the screens and come back later you will need this number. I have read or someone has read and explained the entire application to me. I swear or affirm under penalty of perjury, that all the information I gave is true, correct, and complete to the best of my ability, belief and knowledge. I certify, under penalty of perjury, that all persons for whom I am applying are U.S. citizens or lawfully admitted immigrants. I understand that any information I provide in electronic form shall be admissible in judicial or administrative proceedings, the same as information I provide in printed form. I am voluntarily choosing to apply for benefits through SAIL instead of filing a paper application. By sending my information via the Internet, I agree to these terms. Please type the head of household's name exactly as it appears on the first page of this document. Complete all boxes that apply to you. Print this page, sign and mail, fax, or bring it to your local department. Use the navigation bar from the HOMEPAGE to locate an address for your local office. Please fax your signed application to Name of Head of Household Name of Spouse (if any) Name of Authorized Representative (if any) 4434234018

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