Application Information - T28328655

Submission Date and Time January 8, 2024 13:18

Applying On Your Behalf

Self

Program Information
Programs SNAP (Food Assistance)

Basic Information
Applicant Details
First Name Randall
Last Name whitlock
Middle Initial
Suffix
Date of Birth 10/26/1990
Preferred Spoken Language English
Preferred Reading Language English
Gender Male
City/County Fluvanna County
Is the Person a Resident of Virginia?
Marital Status Single-Never Married
Do you require any special accommodation?
Physical Address
Address Line 1 907 jefferson dr
Address Line 2
City palmyra
State Virginia
Zip Code 22963
Is this physical address for a nursing, medical, correctional, or No
assisted living facility?
Mailing Address
Address Line 1 907 Jefferson dr
Address Line 2
City Palmyra
State Virginia
Zip Code 22693
Living Arrangement
Living Arrangement Type Private Residence
Contact Information
Home Phone (727) 564-4594
Work Phone
Work Phone Extension
Cell/Message Phone

Application (T28328655) Commonwealth of Virginia -

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Email Address therealraw@outlook.com
Preferred Contact Method Email
Preferred Method of Correspondence Information
Preferred Method of Correspondence:
Cell/Message Phone:
Service Provider
Email Address

Getting Faster Service For SNAP Benefits

Total Money Expected this Month Before Deductions 1,000.00
Resources/Assets 0.00
Amount Paid for Rent or Mortgage 0.00
Utilities Paid Other
Amount Paid for Utilities 0.00
Migrant or Seasonal Farm Worker No

People in your Home - Randall whitlock

Personal Information
First Name Randall
Last Name whitlock
Middle Initial
Suffix
Date of Birth 10/26/1990
Gender Male
Marital Status Single-Never Married
Programs Selected SNAP (Food Assistance)
Are you an American Indian or Alaskan Native? No
Race White
Ethnicity
Temporarily Absent No
How does this person file their taxes?
Living Arrangement
Living Arrangement Type Private Residence
SSN Information
Social Security number 594-04-3992
If you do 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:
Citizenship Information
US Citizen Yes
U.S. Veteran status Not applicable

Number of People in Your Home 1

School Enrollment Information - Randall whitlock

School Enrollment Status Not in school
Expected Graduation Date
School Name
Highest Grade Completed Vocational training

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Individual Non-Financial Summary - Randall whitlock
Blindness or Disability No
Other Felonies No
Probation / Parole Violation No
Current/Past Social Services Assistance No
Head of the Household for SNAP Yes
Roomer / Boarder No

Liquid Resources - Randall whitlock

Cash No
Financial Account No
Other Liquid Resources No
Money from Legal Suit No
Sold, Given Away or Transferred Resources No

Employment Income Information - Randall whitlock

Current/New Jobs No
Self-Employment No
Past Jobs No
Change In Income No

Money From Other Sources - Randall whitlock

Child Support No
Supplemental Security Income (SSI) No
Social Security Administration (SSA) No
Other Income No

Housing and Utility Bills - Randall whitlock

Housing Bills No
Utility Bills No
Shelter Expense For Home Temporarily Not Lived In No

Standard Utility Expense

Does anyone have or expect to have an expense for heating or No
cooling the home? Or has anyone received assistance from the
Fuel Assistance program during this year?
If yes, please indicate whether you would like your SNAP benefits Utility Standard
determined using your Actual Utility Expense or a Standard
amount we use for these expenses?
Does anyone living in your home but not Included on your SNAP No
application help you pay your Heating or Cooling Bill?
Homeless Shelter Expense
Date Moved In
Please indicate whether you would like your SNAP benefits
determined using your Actual Shelter Expenses or Standard
amount we use for these expenses?

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Other Bills - Randall whitlock
Legally Obligated Child Support Payments No
Dependent Care Bills No
Medical Bills No
Medicare Part A, Part B, Part C or Part D No

Additional Information Details

Currently staying in a friend's house. I'm looking for work actively.

Signing Your Application Details

Consent to Exchange Information My User Profile can be shared with the specified agencies, but do
not include Social Security Number when creating my User Profile.
Commonwealth of Virginia Voter Registration Agency Certification
Electronic Signature Details
Electronically Signed Yes
Signed By randall A Whitlock
Applicant Physically or Mentally Incapacitated

Rights and Responsibilities

GENERAL INFORMATION
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 agency processing your application 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 the decision about your case, you have the right to request a conference administered by the local
department and arranged by your worker. If you do not agree with the result or don't want to have a conference, you may ask
someone else to look at your request for help. This is called an appeal. Within 30 days of getting a "notice" (written decision) from your
worker, you must send a letter saying you want someone else to let you know if you can get the help you requested. A friend, relative
or other person can send the letter for you. If the letter is sent in less than 10 days, and you were already getting help, you will
continue getting help while the appeal is going on, but you might have to pay the Medicaid program back if you lose your appeal.
Send a written request for financial assistance and SNAP benefits appeals to the Virginia Department of Social Services,
Attention: Hearing and Legal Services Manager, 5600 Cox Road Glen Allen, VA 23060-9266 or call 1-833-5CALLVA. To file your
appeal you may write a letter or complete a form. Forms for appeals are available on the Internet at www.dmas.virginia.gov, at your
local department of social services, or by calling (804) 371-8488. Send your request for Medicaid or FAMIS appeals to Client Appeal
Division, Department of Medical Assistance Services, 600 East Broad Street, Richmond, Virginia 23219. Appeal requests may also be
faxed to: (804) 786-5778
YOUR SNAP RIGHTS AND RESPONSIBILITIES
Federal laws, such as the Food and Nutrition Act, require that the Virginia Department of Social Services ask for Social Security
Numbers. Social Security Numbers and other information you give on this application may be matched against federal, state, and local
records or private claims collection agencies.
The amount of benefits you may receive is based on the number of people you include on the application. Only persons who are
eligible for benefits will receive them. You may choose not to apply for benefits for certain people in your household but, it may be
necessary to provide financial information about these persons to determine if others are eligible for benefits however. Households
must report if the number of work hours goes under 20 hours per week for members who are between the ages of 18-50 if there are no
children in the home.
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.

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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
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.
APPLICATION PROCESSING
The process of determining eligibility for assistance must be explained to you. You may be asked to verify certain information, if it
cannot be obtained electronically.
The local department 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 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 have a right to see the information in your record.
REPORTING CHANGES
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.
Reporting Requirements - Simplified Reporting Households
Certified five months or longer, households must report:
All the income for your household, before taxes, goes over 130% of the Federal poverty level. See the Change Report or the Notice
of Action for the amount or visit www.dss.virginia.gov.
The number of work hours in a week goes under 20 for anyone who is 18-49 if there are no children in your SNAP household.

Reporting Requirements - Change Reporting Households

Certified four months or less, households must report:
There is a change in the number of people in your household;
Your address changes, including shelter expenses that change resulting from the move;
The obligation to pay child support changes or the amount paid to someone outside the household changes;
Your liquid resources, such as bank accounts, cash, bonds, etc. are $2,250 or $3,250* or more;
The number of work hours goes under 20 per week for persons who are between the ages of 18-50 if there are no children in the
home; or
There are changes in income;
There are unearned income changes of more than $50 for income sources such as Social Security, SSI, pensions, etc.;
There are unearned income changes of more than $100 for money received from working;
You start or stop a job; or

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 Your job switches from full-time to part-time or part-time to full-time

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.
Consent to Exchange Information
THE DATA BEING SHARED
Your User Profile will only be created if you agree to share it and you are eligible for assistance. Your User Profile will contain first
name, last name, middle initial, suffix (Jr., Sr., etc.), current home address, date of birth, Social Security Number and Medicaid
identification number (if applicable), email address, home phone, driver's license ID and cell phone number. However, you can share
your User Profile without sharing your Social Security number; this will not affect your eligibility. Your Medicaid identification number
will only be shared with VDSS and your local department of social services. Because the User Profile is based on your application for
assistance, the agencies named below also will know that you are receiving assistance.
AGENCIES INCLUDED AND ALLOWED USE
Below are the agencies that will get your information. The reasons they have requested your User Profile and what they will be allowed
to do with your User Profile are listed.
Sharing your User Profile will allow them to update the information in their computers, saving taxpayer dollars. It may save you a visit
to one of these agencies because your information has been changed electronically.
The Department of Motor Vehicles (DMV) would like a copy of your User Profile when it changes. DMV can change your address for
cars you own or driver's license/identification card information they have for you. They will send you a card automatically through the
mail to complete this update.
The Virginia Information Technologies Agency (VITA) operates an electronic system known as Enterprise Data Management (EDM).
EDM contains data that you have already provided to DMV for your driver's license or identification card. If you give permission to
share your User Profile, EDM will match the DMV data and your User Profile, and share this information with your local department of
social services and DMV. If the data does not match, DMV or your local department of social services may contact you to confirm the
information. Email address, home phone number, cell phone number and Medicaid identification number may be reviewed by a local
department of social services worker inside EDM to identify possible duplicate User Profiles.
IF YOU CHOOSE NOT TO SHARE YOUR USER PROFILE
Your information will remain only with the Department of Social Services. Choosing not to share your User Profile will not affect your
eligibility for assistance.
SOCIAL SECURITY NUMBER
Including your Social Security Number (SSN) in your User Profile is your choice. The SSN is used to match your User Profile with
DMV data in EDM easily. Your SSN is kept confidential.
DEPENDENTS
This request is for your own User Profile and for the User Profile of any person who is your legal dependent, including your children
under age 18, any person for whom you serve as legal guardian, or any other person for whom you have the authority to agree to
share information.
TO STOP SHARING OF YOUR USER PROFILE
You can stop sharing your User Profile at any time by returning to this website and changing your decision to share. You can also
change your decision to share your User Profile by visiting your local department of social services.
HOW LONG CONSENT TO SHARE LASTS
Your permission to share your User Profile will remain active for one (1) year from the date you approve, unless you change your
decision to share sooner. Your agreement for any minor child who turns 18 will be stopped on the date of the child's 18th birthday.
That individual then will be asked to agree to share his information.
You will be asked to share your information every time you make a change to the information that is used in your User Profile.
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 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.
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I understand the Department of Social Services or the Department of Medical Assistance 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 Medicaid 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 Medicaid or 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 Medicaid or FAMIS.
I understand that for individuals enrolled in managed care, a premium is paid each month to the MCO for the person's coverage. If the
child or pregnant woman is eligible for Medicaid or FAMIS because I did not report truthful information or failed to report required
changes in my family size or income, I may have to repay the monthly premiums even if no medical services were received during
those months.
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 if Medicaid is paying for long-term care costs, 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 Medicaid to pay long-term care costs.
If I am applying for Medicaid, 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 Medicaid.
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.
I will report any changes in my situation within the time frames specified to my local department of social services or to the Cover
Virginia Unit for Health Care coverage.
My signature authorizes the release to the local department of social services and to the Cover Virginia Unit all information necessary
to determine my eligibility for services. I authorize the release of any employment, medical, 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.

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