601-2          THE APPLICATION FORM

601-2 A.     WHAT IS AN ACCEPTABLE APPLICATION FORM?

The Gen 50B, Application for Services form, is the initial application form that is used to apply for any public assistance program, except the Heating Assistance Program.  To apply for Heating Assistance, a Heating Assistance Program application must be completed.

The Gen 72, Eligibility Review Form, is the review application form that is used to determine continued eligibility for Adult Public Assistance, Food Stamps, Medicaid, and Temporary Assistance.

• If received in the month following the end of the certification period, the Gen 72 form can be used as an initial application form.
   

• If received after the month following the end of the certification period, a Gen 50B application form is required.  The Gen 72 form will be accepted to protect the benefit start date, however, it cannot be used as the initial application form.

The Native Family Assistance Program (NFAP Native Family Assistance Program) application form is an acceptable application form for Adult Public Assistance, Food Stamps, Medicaid, and Temporary Assistance.

601-2 B.     WHEN IS AN APPLICATION REQUIRED?

1. Upon the individual's first application for a program, even if the individual is already a recipient of another DPA Division of Public Assistance assistance program.
    

2. Upon application from a denied, withdrawn, or closed status, unless the denial or closure was the result of an administrative error.

Note:  

When a case is closed following the household's failure to provide the verification waived under expedited service rules, a new application is required if the household wants to receive food stamps again.

3. Any time the caseworker believes the individual’s circumstances have changed sufficiently to justify conducting a special redetermination of eligibility, including when an office conducts a special review project for all or part of its caseload.

601-2 C.     WHEN IS AN APPLICATION NOT REQUIRED?

1. To reopen a closed case as a result of an individual's timely request for a fair hearing, or to open or reopen a case as the result of a fair hearing decision.
    

2. To reopen a case that had been closed incorrectly.
    

3. To resume benefits after benefits have been suspended.
    

4. To redetermine eligibility after the initial application is denied for failing to provide verification and the household provides the verification within 60 days from the application filing date.  For recertification applications, a new application is not needed if the household provides the verification within 30 days following the end of the certification period.  See MS 604-2D(2).
    

5. To redetermine eligibility after the initial application is denied for failing to attend an interview and the household contacts the office to reschedule the interview within 60 days from the application filing date.  For recertification applications, a new application is not needed if the household contacts the office to reschedule the interview within 30 days following the end of the certification period.  See MS 604-2D(1).
    

6. When there is a change in “payee”, “in care of” addressee, or mailing address.
    

7. When individuals are added to an open case.

8. When the household is ineligible for the first month but eligible for the second month.  See MS 601-5A.

601-2 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 Division of Public Assistance office must accept and date the identifiable application when it is presented.  

An individual who contacts a DPA Division of Public Assistance 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 MS 601-2A.

601-2 E.     WHO CAN SIGN THE APPLICATION FORM?

• An adult household member
   

• An authorized representative
   

• An individual who has legal authority to act on the applicant’s behalf (i.e., Office of Public Advocacy, legal guardian)
   

• An individual with appropriate power of attorney

The signer must certify, under penalty of perjury, the truth of the information contained in the application.

601-2 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 attending the interview.

The household may designate an emergency authorized representative (no age limit) if the need arises.  The emergency authorized representative can obtain benefits on those occasions when, due to an emergency, neither a household member nor the authorized representative is able to do so.  A separate written designation is needed each time an emergency authorized representative is requested to act for the household.

The household is liable for any overpayment resulting from erroneous information provided by an authorized representative.

If an authorized representative has knowingly provided false information, or misused the household's food stamp benefits, the caseworker can disqualify the individual from acting as an authorized representative in the Food Stamp Program for one year.  For special requirements concerning authorized representatives for residents of certain institutions see MS 605-1D.

601-2 G.     WHO CANNOT BE AN AUTHORIZED REPRESENTATIVE?

Retailers authorized to accept food stamp benefits, fee agents, or DPA Division of Public Assistance employees involved in the certification or issuance process may not be authorized representatives without the written approval of the Director or Chief of Policy & Program Development.

Individuals disqualified from the Food Stamp Program for fraud may not be authorized representatives during the period of disqualification, unless the disqualified individual is the only adult living with the household and no one else is available to act as an authorized representative.

601-2 H.     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 MS 601-5C, Pending the Application.