Renewal Application Information - T25056295

Submission Date and Time August 26, 2022 16:00

Program Information
Programs being renewed SNAP (Food Assistance)

Basic Information
Applicant Details
First Name Tareeq
Last Name Walke
Middle Initial L
Suffix
Date of Birth On-File
Gender Male
Language English
City/County Virginia Beach City
Is the Person a Resident of Virginia? Yes
Marital Status Single-Never Married
Physical Address
Address Line 1 2436 Deepwater Way
Address Line 2
City Virginia Beach
State VA
Zip Code 23456
Mailing Address
Address Line 1
Address Line 2
City
State
Zip Code
Living Arrangement
Living Arrangement Type Private Residence
Contact Information
Home Phone (757) 581-2230
Work Phone
Work Phone Extension
Cell/Message Phone (757) 581-2230
Email Address speedoftareeq@gmail.com
Preferred Contact Method Email
Preferred Method of Correspondence Information
Preferred Method of Correspondence:
Cell/Message Phone:
Service Provider
Email Address

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People in your Home - Tareeq L Walke
Personal Information
First Name Tareeq
Last Name Walke
Middle Initial L
Suffix
Date of Birth On-File
Gender Male
Marital Status Single-Never Married
Are you an American Indian or Alaskan Native?
Programs Selected SNAP (Food Assistance), Medical Assistance
Plan First Selection
Is the Person a Resident of Virginia? Yes
Name of Tribe
Race Black or African American
Ethnicity
How does this person file their taxes? Non-filer
Is this person, his or her spouse, or a parent a veteran or an active No
duty member in the U.S. military?
Managed Care Organization
Living Arrangement
Living Arrangement Type Private Residence
Temporarily Absent No
Citizenship Information
SSN On-File
If this person does not have a Social Security number, please
provide a reason:
If you do not have a Social Security number but have applied,
please provide the date you submitted your application:
US Citizen On-File
Alien Number
Alien Status
Document Type
Date of Entry to US
Does this person require dialysis?

People in your Home - Sarita T Walke

Personal Information
First Name Sarita
Last Name Walke
Middle Initial T
Suffix
Date of Birth On-File
Gender Female
Marital Status Single-Never Married
Are you an American Indian or Alaskan Native?
Programs Selected
Plan First Selection
Is the Person a Resident of Virginia? Yes
Name of Tribe
Race Black or African American
Ethnicity
How does this person file their taxes? Taxpayer
Is this person, his or her spouse, or a parent a veteran or an active No
duty member in the U.S. military?

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Managed Care Organization
Living Arrangement
Living Arrangement Type Private Residence
Temporarily Absent No
Citizenship Information
SSN On-File
If this person does not have a Social Security number, please
provide a reason:
If you do not have a Social Security number but have applied,
please provide the date you submitted your application:
US Citizen On-File
Alien Number
Alien Status
Document Type
Date of Entry to US
Does this person require dialysis?

Relationship Information - Tareeq L Walke

Relationships is the Son of Sarita
Relationship Information - Sarita T Walke
Relationships is the Mother of Tareeq

Disability Or Blindness Details - Tareeq L Walke

Disability Status Disabled
Disability Status Begin Date 09/07/2020
Disability Status End Date
Disability or Blindness
Has Tareeq applied for SSI/SSDI?
What is the date that Tareeq applied to SSI/SSDI?
What is the status of Tareeq's SSI/SSDI Application?

Individual Non-Financial Summary - Tareeq L Walke

Probation / Parole Violation No
Individual Non-Financial Summary - Sarita T Walke
Probation / Parole Violation No

Liquid Assets Information

Bank Account Details - Tareeq L Walke
Cash Amount in Financial Account $52.00
Type of Account Savings Account
Name of Bank Navy Federal
Bank Address
Bank Account Number
Account for School Expenses No
Reason for Account Savings Account
Account used for business, trade or farming purpose No
Acquired Date 11/10/2015

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Other Owner's Name
Bank Account Details - Sarita T Walke
Cash Amount in Financial Account
Type of Account Checking Account
Name of Bank chartway
Bank Address
Bank Account Number
Account for School Expenses No
Reason for Account
Account used for business, trade or farming purpose
Acquired Date 01/01/2017
Other Owner's Name
Bank Account Details - Sarita T Walke
Cash Amount in Financial Account
Type of Account Savings Account
Name of Bank chartway FCU
Bank Address
Bank Account Number
Account for School Expenses No
Reason for Account
Account used for business, trade or farming purpose
Acquired Date 03/01/2004
Other Owner's Name
Bank Account Details - Sarita T Walke
Cash Amount in Financial Account
Type of Account Checking Account
Name of Bank Chartway FCU
Bank Address
Bank Account Number
Account for School Expenses No
Reason for Account
Account used for business, trade or farming purpose
Acquired Date 03/01/2004
Other Owner's Name

School Enrollment Information - Tareeq L Walke

School Enrollment Status Not in school
School Name
Highest Grade Completed GED
School Enrollment Information - Sarita T Walke
School Enrollment Status Not in school
School Name
Highest Grade Completed Second year college

Other Changes
Do you want to appoint an authorized representative or, make No
changes to an existing authorized representative?
Do you want to apply for any new program? No

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Signing Your Application Details
Commonwealth of Virginia Voter Registration Agency Certification No, I do not want to register to vote.
Consent to Exchange Information Do not allow my User Profile to be shared.
Electronically Signed Yes
Authorization to Use Income Data to Renew Coverage
Signed By Tareeq L Walke
Applicant Physically or Mentally Incapacitated

Rights and Responsibilities

General Information
U.S. Citizens: By federal law, documentation of U.S. citizenship and identity must be obtained for Medical Assistance applicants and
recipients who declare they are United States (U.S.) citizens. Certain groups of people do not have to prove their U.S. citizenship or
identity: people currently receiving Supplemental Security Income (SSI); people who receive Social Security benefits on the basis of a
disability; people entitled or receiving Medicare; children in foster care or who are classified as Title IV-E Adoption Assistance; and
children born in the United States to mothers who were covered by Medical Assistance at the time of the birth.
You will be enrolled in coverage if you meet all other eligibility requirements. A data match will be conducted with the Social Security
Administration (SSA) to verify your claim of U.S. citizenship. If the SSA cannot verify your claim of U.S. citizenship, you will receive a
written request from your eligibility worker at your local department of social services to provide a document that proves you are a U.S.
citizen and a photo identification card or document that identifies you.
If applying for Medical Assistance for aged, blind, or disabled adults or medically needy children, also provide resource information for
the spouse or parents. Include any resources anyone owns, is currently buying, or is heir to. Include any resources jointly owned with
someone else, even if that person does not live with you. List the names of all joint owners.
If applying for TANF, in order to receive TANF, you are required to assign all of your rights to financial support paid to you and to
everyone else for whom you are receiving TANF. After your case is approved, you must give any support payments you receive to
Division of Child Support Enforcement (DCSE).
Your household may qualify for Expedited Service and receive SNAP benefits within 7 days if you are eligible and if your gross
monthly income is less than $150 and liquid resources are $100 or less; or your monthly shelter bills are higher than your household's
gross monthly income plus your liquid resources; or if someone in your household is a migrant or seasonal farm worker with little or no
income and resources.
The local department may not release information about you without your written consent except for purposes directly connected with
the administration of social service programs or by court order.
If you are not satisfied with a local department's decision about your case, you have the right to ask for an appeal by means of a
conference or a hearing. A conference is administered by the local department and should be arranged by your worker. This request
must be made within 30 days after receiving written notice of the local agency's decision. If you request a conference within 10 days
from the effective date of the notice, your service or service payment will continue until a decision is made.
If you are not satisfied with the outcome of the conference, you may request a hearing. A hearing is an evaluation by staff from the
office of the Director of the Division of Appeals and Fair Hearings at the Virginia Department of Social Services for financial assistance
and SNAP or by the Department of Medical Assistance Services for Medical Assistance. A request for a hearing on your appeal must
be made within 30 days after receiving written notice of the local agency's decision. If you ask for a hearing within 10 days of the
effective date of the notice, your service or service payment will continue until a decision is made.
Send a written request for financial assistance and SNAP benefits appeals to the Virginia Department of Social Services,
Attention: Hearing and Legal Services Manager, 801 East Main Street, Richmond, Virginia 23219-2901 or call 1-833-5CALLVA.
For Medical Assistance you can find out how to appeal by calling the Department of Medical Assistance Services at 1-804-371-8488,
or you can visit the website at www.dmas.virginia.gov and click on Client Services on the left, and then select Appeals Information or
go to coverva.org.
SNAP NONDISCRIMINATION STATEMENT
This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases
religion or political beliefs.
The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin, sex, religious creed, disability,
age, political beliefs or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape,
American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf,
hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027), found online
at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in
the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your
completed form or letter to USDA by:
(1) mail: U.S. Department of Agriculture
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 Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) fax: (202) 690-7442; or
(3) email: program.intake@usda.gov.
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the
USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline
Numbers (click the link for a listing of hotline numbers by State); found online at:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health
and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington,
D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-7697 (TTY).
This institution is an equal opportunity provider.
Your SNAP Rights
In accordance with federal law and US Department of Agriculture policy, the Virginia Department of Social Services is prohibited from
discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability.
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC
20250-9410 or call (800) 795-3272 or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
Application Processing
The process of determining eligibility for assistance must be explained to you. You will be asked to verify certain information.
The local department of social services may have to ask for such things as pay stubs or permission to contact agencies or individuals
to get proof of your income. If you give incorrect information, you could be prosecuted for perjury, larceny, or welfare fraud, and may
no longer be eligible for assistance. You must repay any money paid on your behalf to which you were not entitled.
You must apply in the city or county in which you live. You do not have to have lived in the county or city for any specific length of
time.
You have a right to see the information in your record.
VERIFICATION AND USE OF INFORMATION
Information you give on this application, including Social Security numbers (SSN), may be matched against federal, state, and local
records. These records include:
Virginia Employment Commission (VEC)
Internal Revenue Service (IRS)
Social Security Administration (SSA)
Department of Motor Vehicles (DMV)
US Citizenship and Immigration Services (USCIS)
Income and Eligibility Verification System (IEVS)*
*Information received through IEVS will be requested, used and may be verified through collateral contacts when discrepancies are
found. The information may affect the amount of benefits and/or your continued receipt of benefits.
Child Care Applicants - Rights and Responsibilities
You have the right to receive and complete a Child Care Service Application on the day you request child care services. If you need
help filling out the application, someone will assist you.
Anyone may apply for child care services. The child (ren) for whom the child care service application is submitted must be a citizen of
the United States or have legal alien status. You must provide proof of their citizenship or legal alien status.
All children receiving services under the Child Care and Development Fund (CCDF) must be age-appropriately immunized, according
to the current "Recommended Childhood Immunization Schedule, United States." You may be required to provide your child care
worker with documentation of immunization, a physician's statement that the required immunizations may be detrimental to the child's
health, or a statement of religious exemption (on the CRE-1 form entitled "Certification of Religious Exemption" ), within 30 days of
receiving child care that will be paid for with CCDF funds.
The local department of social services (local department) will decide on your application within 30 days. If this is impossible, you
must be told why. The local department must send you a written Notice of Action if you are not eligible or if there is a delay.
If you are determined eligible, you have a right for child care services to begin within 30 days after the local department gets your
signed and completed application unless the local department has a Fee Subsidy Waiting List for child care services. If your name is
placed on this waiting list, the child care worker will explain the reason why and the waiting list process. The local department must
send written notification explaining their decision to add you to the waiting list. You may request that your name be removed from the
waiting list at any time.
You have the right to mandated child care services for which you meet eligibility requirements, for which there is funding and for which
a legally operating provider is available. Your right to other services depends on meeting eligibility requirements and on whether or not
the local department offers the service. This application is for child care assistance only.
Reporting Changes

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Child Care Services: You must report all required changes to the local department of social services within 10 days after they occur.
You are required to report the following changes:
1) Your gross (before taxes) monthly family wages or other family income if the total amount exceeds the maximum monthly income
level
2) Your family no longer has income
3) A change in education/training activity, including class days/hours and curriculum
4) A change in the number of household members or head of household
5) A child receiving child care services reaches his/her 13th birthday
6) A change of address
7) A change of provider
8) A change in the number of hours child(ren) need child care
9) A change in employment, including schedule, employer and/or income
Medical Assistance Programs: You must report a change in your mailing/home address, the number of people living with you, the
disability status of anyone in the home, if you get married, separated, or divorced and if your income (such as pay or a pension) or
resources (such as bank accounts) change. Changes must be reported within 10 days of the change. You can call 1-855-242-8282 or
visit coverva.org or CommonHelp at https://commonhelp.virginia.gov to report any changes. You need to understand that a change in
your information might affect whether someone in your household qualifies for coverage.
SNAP: You must report changes that occur for SNAP but, what you must report is tied to how long you are determined eligible for
benefits, the certification period. You must report changes that occur during the certification period within 10 days, but no later than the
10th day of the month after the change occurs.
Changes that need to be reported during the certification period for SNAP depend on the length of the certification period. "Simplified
Reporting" applies to households that are eligible for SNAP benefits for five (5) months or longer. "Change Reporting" applies to
households that are eligible for one (1) month to four (4) months. Changes that need to be reported for each category are listed below.
Interim Report Filing
In addition to reporting changes when they occur during the SNAP certification period, Simplified Reporting households may be
required to submit an Interim Report in the sixth or twelfth month. The Interim Report is used to determine the amount of SNAP
benefits households will receive for the second half of the certification period. The Interim Report provides a snapshot of household
circumstances that were presented at the time of application. We will ask for proof of income changes and changes in legal obligations
to pay child support. If households fail to return the completed Interim Report by the fifth of the month, SNAP benefits for the seventh
or thirteenth month may be delayed or closed. Assistance for filling the Interim Report is available by calling the telephone number
printed on the form.
TANF: Report these changes within 10 days, but no later than the 10th day of the month after the changes occur:
1) Change in household income that exceeds 130% of the Federal poverty level. See the Change Report or the Notice of Action for
amount.
2) Change in address.
3) An eligible child or parent leaves or enters the home.
4) Changes needed for VIEW (TANF work program).
Penalties for SNAP Violations
You must not give false information or hide information to get SNAP benefits. You must not trade or sell EBT cards. You must not use
SNAP benefits to buy non-food items, such as alcohol, tobacco or paper products. You must not use someone else's, EBT card for
your household.
If you intentionally break any of these rules you could be barred from getting SNAP benefits for 12 months (1st violation), 24 months
(2nd violation), or permanently (3rd violation); subject to $250,000 fine, imprisoned up to 20 years, or both; and suspended for an
additional 18 months and further prosecuted under other Federal and State laws.
If you intentionally give false information or hide information about identity or residence to get SNAP benefits in more than one locality
at the same time, you could be barred for 10 years.
If you are convicted in court of trading or selling SNAP benefits of $500.00 or more, you could be barred permanently.
If you are convicted in court of trading SNAP benefits for a controlled substance, you could be barred for 24 months for the 1st
violation, permanently for the 2nd violation.
If you are convicted in court of trading SNAP benefits for firearms, ammunition, or explosives, you could be barred permanently for the
first violation.
Penalties for TANF Violations
You must not knowingly give false information, hide information, or fail to report changes on time in order to receive TANF or to receive
supportive or transitional services such as child care or assistance with transportation.
If you are found guilty of intentionally breaking these rules, you will be ineligible to receive TANF for yourself for 6 months (1st
violation), 12 months (2nd violation), or permanently (3rd violation). In addition, you may be prosecuted under Federal or State law.
Anyone convicted of misrepresenting his or her residence to get TANF, Medical Assistance, SNAP benefits or SSI in two or more
states is ineligible for TANF for 10 years.
Anyone convicted of a drug-related felony for actions that occurred after August 22, 1996, could be barred permanently.
Penalties for Child Care Fraud
Fraud is larceny. Fraud involving more than $200 is a felony. The Code of Virginia (§63.2-522) deems any person who obtains
assistance or benefits by means of a willful false statement or who knowingly fails to notify of changes in circumstances that could
affect eligibility for assistance as guilt of larceny. Upon conviction, the Code of Virginia authorizes punishment according to State law.
Repayment - In addition to any criminal punishment as set forth in the Code of Virginia, anyone who causes the Department of Social
Services to make an improper vendor payment by withholding any of the above changes will be required to repay the amount of the
improper payment. Repayment will be in either a lump sum or according to a written repayment plan between the responsible person
and the local Department of Social Services.
Medical Assistance Fraud/Abuse
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You must not deliberately withhold or hide information or give false information to get Medical Assistance or FAMIS Plus. Medical
Assistance fraud also occurs when a provider bills for services that were not delivered to a Medical Assistance recipient, or when a
recipient shares the Medical Assistance number with another person to get medical services.
If you are convicted of Medical Assistance fraud in a criminal court, you must repay the program for all losses (paid claims or managed
care premiums) and cannot get Medical Assistance for one year after conviction. In addition, the sentence could include a fine up to
$25,000 and up to 20 years in prison. You may also have to repay any claims and managed care premiums paid when you were not
eligible for Medical Assistance due to acts that are not considered criminal. Fraud and abuse should be reported to your local social
services office or to the Department of Medical Assistance Services Recipient Audit Unit at 1-804-785-0156.
Energy Penalty Information
I understand that I or any member of my household cannot sell merchandise purchased on my behalf through the program unless the
local department of social services has granted permission to sell. Any benefits received must be used for the purpose approved.
If I give false information, withhold information, fail to report changes promptly, or obtained assistance for which I am not eligible, I may
be breaking the law and could be prosecuted for perjury, larceny and/or fraud; subject to imprisonment of up to 20 years and further
prosecuted under other Federal and State laws.
Signature Declaration
BY MY SIGNATURE, I DECLARE:
. I understand and agree to abide by all the information in the Responsibilities, Rights, Penalties, Additional Information, and Signature
Declaration sections of this application.
. I understand that if I refuse to cooperate with any review of my eligibility including review by Quality Assurance, my benefits may be
denied until I cooperate.
. I understand that my signature on this application certifies, under penalty of perjury, that I am a U.S. Citizen or alien in lawful
immigration status (unless applying for emergency services only).
. I understand that I have the right to file a complaint if I believe I have been discriminated against because of race, color, national
origin, sex, age, disability, or religious or political beliefs.
. I understand the Department of Social Services may use information on this application or that I may be contacted for the purposes of
research, evaluation and analysis to the extent allowed by state and federal law.
. I understand that I have the right to appeal and have a fair hearing if I am (1) not notified in writing of the decision regarding my
application within specified time frames; (2) denied benefits from the programs for which I applied; or (3) dissatisfied with any other
decision that affects my receipt of assistance. For FAMIS/ FAMIS MOMS, there will be no opportunity for review of a negative action if
the sole basis for the action is exhaustion of funding.
. I have given true and correct information on this application to the best of my knowledge and belief.
. I understand that if I give any false information, withhold information, fail to report a change promptly or on purpose, or obtained
assistance for which I am not eligible or use my Medical Assistance number for anyone else to get medical care, I may be breaking the
law and could be prosecuted for perjury, larceny, and/or welfare fraud; subject to imprisonment of up to 20 years and further
prosecuted under other Federal and State laws.
. If I completed, or assisted in completing this application form and aided and abetted the applicant to obtain assistance for which
he/she is not eligible, I may be breaking the law and could be prosecuted.
. I understand that I or any member of my household cannot sell merchandise purchased on my behalf through the Energy program
unless the local department of social services has granted permission to sell.
. I understand that the Department of Social Services, DMAS, and DMAS contractors may exchange information relating to my
coverage or my child's coverage to assist with application, enrollment, administration, and billing services. I understand that I can
revoke the consent to disclose information at any time.
. I understand that to receive benefits from the Medical Assistance/FAMIS PLUS/Plan First/FAMIS programs, I must agree to assign
my rights and the rights of anyone for whom I am applying to medical support and other third-party payments to the Department of
Medical Assistance Services. If I do not agree to assign my rights, I will be ineligible for Medical Assistance.
. I understand that all money I receive for diagnosis or treatment of any injury, disease, disability, or medical care support must be sent
to the Third-Party Liability Section, Department of Medical Assistance Services, Suite 1300, 600 East Broad Street, Richmond, VA
23219.
. I understand that I must report ownership of all annuities my spouse or I have. I also understand that my spouse and I may have to
name the Commonwealth of Virginia as the beneficiary on any annuities we may have in order for Medical Assistance to pay long-term
care costs.
. If I am applying for Medical Assistance, I understand that I must cooperate in establishing paternity and obtaining medical support for
my children. I understand that failure to cooperate may cause my ineligibility for Medical Assistance.
If I am applying for Medicaid, I understand that I have the right to appeal and have a fair hearing if the Department of Social Services
or Cover Virginia does not determine Medicaid eligibility with reasonable promptness within the 45/90 day timeframe.
. I authorize the Department of Social Services and the Department of Medical Assistance Services to obtain any verification
necessary to both determine and review financial or medical assistance eligibility or to give information in my case record to other
organizations from which I have or may request assistance. This authorization includes the release of any medical or psychological
information obtained from any source to any state or local agency that may review this application and the release to the Department
of Medical Assistance Services of any information in any medical records pertaining to any services received by me or anyone for
whom I applied. This authorization applies as long as my medical assistance case is open.
. I understand that if my application is for SNAP benefits, failure to report or verify any of my expenses will be seen as a statement by
my household that I do not want to receive a deduction for these expenses.

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. I will report any changes in my situation within the time frames specified to my local department of social services. I can visit
CommonHelp at https://commonhelp.virginia.gov to report any changes. For the Medical Assistance Program, I can also call 1-855-
242-8282 or visit coverva.org. I understand that a change in my information might affect whether someone in my household qualifies
for coverage.
. My signature authorizes the release to the local department of social services all information necessary to both determine and review
my eligibility for services. I authorize the release of any employment, medical, or child care information obtained from any source to
the state or local department that may review this application for benefit assistance. This authorization is valid during the eligibility
period of my case. I understand that this time limit does not apply to investigations regarding possible fraud.
Child Care Services Signature Declaration
. I further understand that I must remove my child from child care if I stop going to the activity or work for which I am approved.
. I understand that it will be necessary to release certain information to my child care provider.
. I understand that the Virginia Department of Social Services (VDSS) has limited funding available for the purchase of Fee Child Care
services. The funding for Fee Child Care changes from year to year. I further understand that the availability of funding for child care
services cannot be guaranteed. I understand that, if this funding ends or runs out, I will receive at least 10 days written advance notice
of this action, and my name may be placed on the local department's waiting list at my request.
. I understand that to qualify for these funds I must have a current need for child care services; I must be working or participating in an
approved educational or training program; and my total household gross monthly income must not exceed the maximum monthly
household income determined by VDSS.
. I must give complete and accurate information needed for determining initial and on-going eligibility for child care services.

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