Page 4: Signature & Authorized Rep

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Signature

Whether you apply online, by telephone, or use a paper form, all applications require a signture. When you sign, you are agreeing that:

  • to the best of your knowlege, everyone you are applying for is a U.S. citizen or are lawfully in the U.S.
  • to the best of your knowledge, all the information you provided is true and correct
  • You agree government agencies may verify the information you provided.
  • Information may be obtained from current and past employers
  • Information provided will be used to track wages and your participation in work activies
  • You will report:
    • any changes according to program requirements
    • lottery or gambling winnings anyone in your household receives greater than $4250.00 before taxes or garnishment
    • You will report the winnings before the last 10 days of the month (Example: If they month ends on 31st, you will report by the 21st of the month you won.)
  • You understand
    • If any information is incorrect, benefits may be reduced or denied
    • if you know you provided incorrection information or hide information, you may be criminally prosecuted or disqualified from DFCS programs
    • If you do not tell DFCS about some of your expenses or fail to provide verfication, DFCS will not use that expense to calculate your Food Stamp benefits.
    • DFCS collects Personally Identifiable Information (PII) such as your name, birthdates, addresses, etc. You agree that DFCS may collect, use, and disclose that information according to policy. laws, and regulations. (They cannot give that information to just anyone. You are guaranteed privacy.) The information is used to interact with other government agencies such as Child Support Enforcement, Social Security, etc.

Authorized Representative

This section is not required. Complete only if you want someone to be able to fill out your applications, complete interviews, or use your EBT card when you cannot do these things.

You may designate anyone you like as an authorized representative. But remember, you are trusting this person or organization with your personal information. It should always be someone you trust and can depend on.

Select which programs you want the authorized representative to help you with.

Select what you want the representative to do for you. You can choose for them to:

  • Sign applications on your behalf
  • Complete benefit renewals for you
  • Receive copies of notices and any other communication
  • Act on your behalf for any other DFCS matters
  • Receive a TANF benefit card

To officially make a person your authorized representative, provide that person’s:

  • Name
  • Organization (only if they are serving on your behalf through an organization)
  • Phone number(s)
  • Mailing Address
  • Email address (only if they select yes to email communication)
  • Whether they want to receive texts or not
  • Preferred language and if an interpreter is needed


Published by brokebitchingeorgia