410-2 THE APPLICATION FORM
410-2 A. WHAT IS AN ACCEPTABLE APPLICATION FORM?
The Application for Services form (GEN 50C) is the initial application form that is used to apply for any public assistance program, except the Heating Assistance Program (HAP). To apply for Heating Assistance, a Heating Assistance Program application (HAP 1) must be completed.
The Eligibility Review Form (GEN 72) is the recertification application form that is used to determine continued eligibility for Adult Public Assistance, SNAP , Medicaid, and Temporary Assistance. It may also be accepted for Senior Benefits starting with the April 2020 form revision.
A Native Family Assistance Program (NFAP ) application form is an acceptable application and recertification form.
The Med 4 specialized application form is also available and its use is encouraged when appropriate. The Med 4 is used to apply for nursing home, home and community-based services, disabled children living at home (TEFRA ) coverage, children applying for or receiving SSI , and APA .
410-2 B. WHEN IS AN APPLICATION REQUIRED?
410-2 C. WHEN IS AN APPLICATION NOT REQUIRED?
410-2 D. WHAT IS AN IDENTIFIABLE APPLICATION?
An identifiable application is an acceptable application form containing the applicant’s name, address, and signature (or witnessed mark) of the individual seeking assistance or of the individual's authorized representative. Each DPA office must accept and date the identifiable application when it is presented.
See MS 410 for application signature requirements.
An individual who contacts a DPA office and who shows interest in the program or a desire to apply shall be advised of his or her right to submit an identifiable application on the date of the contact in order to establish the benefit start date. The individual may file an identifiable application on an acceptable application form, as described at manual section 410-2A.
410-2 E. WHO CAN SIGN THE APPLICATION FORM?
The signer must certify, under penalty of perjury, the truth of the information contained in the application.
The proper individual to sign an APA application is the applying adult. If both members of a married couple wish to apply, they may do so on a single application form if both spouses sign the form. If the applying adult is incompetent or incapacitated, or wishes to appoint an authorized representative, a responsible individual acting on the individual's behalf may apply for him or her.
See MS 410 for application signature requirements.
Note:
If both members of a married couple wish to apply, both spouses must sign the application.
410-2 F. WHO CAN BE AN AUTHORIZED REPRESENTATIVE?
A responsible adult, 18 years or older, may be designated by the applicant in writing as authorized representative. If the applicant is illiterate, his/her mark must be witnessed by two individuals who must each sign their names and date the document. No special form is required.
Authorized representatives may sign the application and act on behalf of a household. A household member should prepare or review the application, if possible, even though the authorized representative will be filing the application and/or participating in the interview.
410-2 G. COMPLETING THE APPLICATION FORM
In addition to making an identifiable application and having it signed by an eligible individual, the applicant must answer all of the questions on the application form.
If the individual requests help in completing the application form, the caseworker will offer assistance.
If the application form is not completed, the caseworker will allow the household an opportunity to complete the form. In this case, written notification will be sent to the household listing the items that need to be completed. See manual section 410-5C, Pending the Application.
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