Division of Family and

Children Services Application for Benefits

YOU MUST HAND DELIVER, FAX or MAIL THE COMPLETED APPLICATION TO YOUR LOCAL COUNTY OFFICE.

If you need help reading or completing this document or need help communicating with us, ask us or call
(877) 423-4746. Our services, including interpreters, are free. If you are deaf, hard-of-hearing, deaf-blind or
have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay).

What Services Do We Offer at the Division of Family and Frequently Asked Questions
Children Services (DFCS)? How long does it take to get benefits?
DFCS offers the following services: Food Stamps (SNAP): up to 30 days
TANF: up to 45 days
Medicaid: 10 to 60 days
Food Assistance
You may be able to get Food Stamps (SNAP) within 7 days
Food Stamp (SNAP) benefits can be used to buy food at any if you qualify. See page 6.
store that has the EBT/Quest sign. We will subtract the price of
your food purchase from your Food Stamp (SNAP) account. How much will I get?
Your income, resources, and family size determine benefit
Cash Assistance/Employment Support Services amounts. We will be able to give you specific information
Temporary Assistance for Needy Families (TANF) provides once we determine your eligibility.
cash assistance to families with dependent children, and
pregnant individuals for a limited time. Parents or caretakers, or How will I get my benefits?
pregnant individuals who are included in the grant are required For Food Stamps (SNAP), you will get an Electronic Benefit
to participate in a work program. The Cash Assistance program Transfer (EBT) card to access your benefits. For TANF, you
also provides financial assistance to refugee households who will get an EPPIC Debit Master card to access your benefits.
are not eligible for the TANF program. For Medicaid, you will receive a Medicaid card for each
• Grandparents Raising Grandchildren (GRG) will eligible member.
provide the support necessary so that children can be
cared for in the homes of their grandparents. You may be asked to provide the following
information:
Medical Assistance • Proof of identity for the applicant if applying for Food
Medicaid, for those who are eligible, may help pay medical Stamps (SNAP) and/or TANF. An identification card
bills, doctor’s visits, and Medicare premiums. (ID) or driver’s license (DL) is an acceptable form of
• This includes Pathways Medical Assistance. verification. Proof of Identity is not required for
Pathways Medical Assistance is a program that Medical Assistance applicants.
provides free or reduced cost Medicaid coverage to • Proof of US citizenship/qualified immigrant status for
individuals ages 19 to 64, who have household everyone requesting benefits. If you are applying for
income up to 100% of the Federal Poverty Level Emergency Medical Services (EMA) only, you do not
(FPL), not otherwise eligible for Medicaid and who have to provide your SSN or information about your
meet the eligibility requirements. If you would like to immigration status.
be considered for Pathways, please also complete
Attachment D. • Social Security numbers of everyone requesting
assistance.
Community Outreach Services • Proof of income for example, pay stubs, child support
For more information about other DHS services, please visit our payments, and income award letters. Proof of child
website at http://dfcs.georgia.gov or call (877) 423-4746. support payments is not needed for Medical
Assistance applicants.
• Proof of expenses like childcare receipts, medical
How Do I Apply for Benefits? bills, medical transportation costs, rent/mortgage
costs, and child support payments. This information is
Step 1. Fill out the application. not required for Medical Assistance applicants.

Read the questions carefully and give accurate information. Sign

We will first attempt to verify citizenship/immigration status
and date the application.
and income information through electronic data sources.
Paper verification documents are not required to submit an
Step 2. Turn in the application to your local office. application; however, you may provide the documents with
the application. If we are unable to verify through electronic
You will need to tear off pages 1-2, 17-20 and keep them for data sources and you need help getting this information,
yourself. please tell us.

Form 297 (Rev.7/2023) 1

Division of Family and
Children Services Application for Benefits
Mail, fax, or bring in pages 3-16 of this application to your
local Division of Family & Children Services (DFCS) office. How do we use the applicant’s personal
You can locate your local office at information?
http://dfcs.georgia.gov/locations .
You only have to provide Social Security Numbers (SSN)
If you or the person for whom you are applying is eligible for and citizenship or immigration status for persons who want
benefits, Food Stamp (SNAP) benefits will be provided from the to apply for benefits. This information will be used to check
date we receive the application with your name, address, and the income and eligibility verification system (IEVS). We
signature on it. TANF benefits will be provided from the date will also match your information against other Federal, state,
the application is approved. and local agencies to verify your income and eligibility, to
track wage information and participation in work activities. If
If you are applying for Food Stamps (SNAP), TANF and/or a household member does not want to give us information
Medicaid, you can file an application for benefits with only your about their SSN, citizenship or immigration status, other
household members may still receive benefits. If you are
name, address, and signature. However, it may help us to
applying for emergency medical services only, you do not
process your application quicker if you complete the entire form. have to provide your SSN or information about your
You may use this form to file a joint application for more than immigration status.
one program or for the Food Stamp (SNAP) program only. Your
(SNAP) application will not be denied solely on the basis that Can someone else apply for me?
your application for another program has been denied. We will For Food Stamps (SNAP) and Medicaid, you may ask
make a separate eligibility determination for your Food Stamp someone to apply for you.
(SNAP) application. If you are in an institution and applying for For TANF, anyone can apply but the parent or caretaker or
Food Stamps (SNAP) and SSI at the same time, the filing date pregnant individual must be interviewed.
of your application is the date you are released from the
institution.

Step 3. Talk with us.

You may need to complete an interview with a worker. If so, we
will give you an appointment. This interview can be completed
by phone.

Form 297 (Rev. 7/2023) 2

Division of Family and
Children Services Application for Benefits
(Complete this application and return it to your LOCAL COUNTY DFCS office.)
What Am I Applying For? (Check all that apply)
❑ Food Stamps (Supplemental Nutrition Assistance Program (SNAP))
The Supplemental Nutrition Assistance Program (SNAP), formerly known as Food Stamps, is a federally funded
program that provides monthly benefits to low-income households to help pay for the cost of food. The program
also provides nutrition education to families to meet their food and nutritional needs and provides employment and
training opportunities to help families gain employment that leads to less dependence on SNAP.

❑ Temporary Assistance for Needy Families (TANF)

Temporary Assistance for Needy Families (TANF) provides temporary monthly cash payments, single cash
payments, or other support services, to strengthen eligible families with children or pregnant individuals. If you are
the child’s parent, or the caretaker or a pregnant individual who would like to be included in the grant, we will require
you to participate in a work program.
❒ Grandparents Raising Grandchildren (GRG)
Grandparents Raising Grandchildren (GRG) will provide additional cash payments so that children can be
cared for in the homes of their grandparents. Applicants must apply for TANF to be eligible for GRG.

❑ Refugee Cash Assistance

The Refugee Cash Assistance program provides financial assistance to refugee households who are not eligible for
the TANF program. The term refugee includes refugees, Cuban/ Haitian Entrants, victims of human trafficking,
Amerasians, Asylees, Afghanis or Iraqis with Special Immigrant Visa (SIV) or eligible Afghan parolees.

❑ Medicaid
Medicaid offers medical coverage to elderly, blind or disabled adults, pregnant women, children, and families. When
you apply, we will look at all Medicaid programs and decide which ones you may be eligible to receive.

Please fill out the chart below about the applicant.

First Name Middle Initial Last Name Suffix

Street Address Where You Live Apt

City State Zip Code

Are you homeless? Yes _____ or No ______

Mailing Address (If different)

Main Telephone Number Other Contact Number

Electronic Communication: Email Address (optional):

Email: Yes____ or No____ (optional)
Texting: Yes____ or No____ (optional)
What is your Preferred Language? If an interview is required, will you need
interpreter? Yes
an or No____
Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes____ No___ ( If
yes, please describe the Reasonable Modification or Communication Assistance that you are requesting):
Sign Language interpreter____; TTY____; Large Print____; Electronic communication (email)____; Braille______; Video
Relay____; Cued Speech Interpreter____; Oral Interpreter____; Tactile Interpreter___; Telephone call reminder of program
deadlines____; Telephonic signature (if applicable)____; Face-to-face interview (home visit)____; Other:________
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing ___?
If possible, briefly explain when and how long you need this modification or assistance?
___________________________________________________________________________________________________________

Form 297 (Rev. 7/2023) 3

Division of Family and
Children Services Application for Benefits
For All Food Stamp (SNAP), TANF, and Medicaid Applicants:

I declare under penalty of perjury to the best of my knowledge and belief that the person(s) for whom I am applying for benefits is/are U.S.
citizen(s) or are noncitizen(s) lawfully present in the United States. I further certify that all of the information provided on this application is
true and correct to the best of my knowledge. I understand and agree that DHS-DFCS, DCH and authorized Federal Agencies may verify
the information I give on this application. Information may be obtained from past or present employers. I understand that my information
will be used to track wage information and my participation in work activities.

I will report any change in my situation according to Food Stamp (SNAP) and/or TANF program requirements. I will also report if anyone
in my household receives lottery or gambling winnings, gross amount of $4250 or more (before taxes or other amounts are withheld). I
will report these winnings within 10 days from the end of the month in which my household receives the winnings. I understand if any
information is incorrect, my benefits may be reduced or denied, and I may be subject to criminal prosecution or disqualified from DHS-
DFCS programs for knowingly providing incorrect information. I understand that I can be prosecuted if I provide false information or hide
information. I understand that if I fail to tell DHS-DFCS about some of my expenses during my application or renewal process and/or fail to
verify them, DHS-DFCS will not budget that expense in calculating the amount of my Food Stamp (SNAP) benefits.

The Georgia Department of Human Services (“DHS”) collects Personally Identifiable Information (PII), such as names, addresses,
telephone numbers, email addresses, and dates of birth, etc., during your application for benefits. By submitting any personal
information to us, you agree that we may collect, use, and disclose any such personal information in accordance with DHS policies,
procedures, and as permitted or required by law and/or regulations.

Signature Date

Witness Signature if signed by “X” Date

Authorized Representative:

Complete this section only if you want a person or an organization to fill out your application, complete your interview, and/or use your
EBT card to buy food when you cannot go to the store. Please check for each program type who you want to designate as an authorized
representative. Please check which duties you want the person or organization to have. If you are applying for Medicaid, you can choose more
than one person or organization to act on your behalf.

Authorized Representative 1 Program Types: Food Stamps (SNAP) ❑ TANF ❑ Medical Assistance ❑
Authorized Representative 1 Duties: Sign application on applicant’s behalf ❑ Complete and submit renewal form ❑
Receive copies of notices and other communication ❑ Act on behalf of applicant in all other matters ❑
Receive a TANF benefit card (EPPIC) ❑

Person Name 1: __________________________________________

Organization Name 1 (if applicable): __________________________ Phone: _______________________________
Address: ________________________________________________ Apt: ______________________________
City: ____________________________________________________ State: ________ Zip: __________________
Electronic Communication: Email: Yes ___ No ___ (optional) Texting: Yes ___ No ___ (optional)
Email Address (optional) ____________________________________
Preferred Language: _______________________________________ Is an interpreter needed? Yes ___or No ___

Form 297 (Rev. 7/2023) 4

Division of Family and
Children Services Application for Benefits
Authorized Representative 2 Program Types: Food Stamps (SNAP) ❑ TANF ❑ Medical Assistance ❑
Authorized Representative 2 Duties: Sign application on applicant’s behalf ❑ Complete and submit renewal form ❑
Receive copies of notices and other communication ❑ Act on behalf of applicant in all other matters ❑
Receive a TANF benefit card (EPPIC) ❑

Person Name 2: __________________________________________

Organization Name 2 (if applicable): __________________________ Phone: _______________________________
Address: ________________________________________________ Apt: ______________________________
City: ____________________________________________________ State: ________ Zip: __________________
Electronic Communication: Email: Yes ___ No ___ (optional) Texting: Yes ___ No ___ (optional)
Email Address (optional) ____________________________________
Preferred Language: _______________________________________ Is an interpreter needed? Yes ___or No ___

Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance
for Authorized Representatives (if applicable):
Does the Authorized Representative have a disability that will require a Reasonable Modification or
Communication Assistance? Yes___ No___ (If yes, please describe the Reasonable Modification or
Communication Assistance that you are requesting):
Sign Language interpreter____; TTY____; Large Print____; Electronic communication (email)____; Braille_______;
Video Relay____; Cued Speech Interpreter____; Oral Interpreter____; Tactile Interpreter____; Telephone call
reminder of program deadlines____; Telephonic signature (if applicable) ____; Face-to-face interview (home visit) ___;
Other: ______
Does the authorized representative need this Reasonable Modification or Communication Assistance
one-time____or ongoing____? If possible, briefly explain when and how long you need this modification
or assistance? _ _

For Office Use Only: Date Received:

Express Lane Eligibility:

Express Lane Eligibility (ELE) is an automatic process to enroll or renew eligible children under the age of 19 who are
receiving Supplemental Nutrition Assistance Program (SNAP) or Temporary Assistance for Needy Families (TANF) into the
Medical Assistance program. If your children are eligible for SNAP or TANF, the Division of Family and Children Services
(DFCS) will use the household size, residency, and income information from SNAP or TANF, but DFCS will verify
citizenship or immigration status using Medical Assistance rules to make an ELE determination to enroll or renew the
children in Medicaid or PeachCare for Kids®. If your children are eligible for PeachCare for Kids®, they may be subject to a
premium. DFCS will send you a determination notice, let you make any changes and allow you to opt out at any time.

Do you agree to allow DFCS to use your information from SNAP or TANF to make an ELE determination to enroll or renew
your children in Medicaid or PeachCare for Kids®?
☐Yes ☐No

Form 297 (Rev. 7/2023) 5

Division of Family and
Children Services Application for Benefits
Do I Qualify to Get Food Stamps (SNAP) Faster? (This information is required for Food Stamp (SNAP) applicants only)

Answer these questions about the applicant and all household members to see if you can get Food Stamps (SNAP)
within 7 days.

1. Are you or any household member a migrant or seasonal farm worker? ❑ Yes ❑ No

If yes, who

2. Total Gross earned income that will be received for this month: $______________
Employer Name________________________________________
Employment Begin Date___________________ Employment End Date __________________
Rate of Pay ______________________ Hours Worked Weekly___________________
How Often Are You Paid: weekly/bi-weekly/semi-monthly/monthly (circle one)

3. Total Gross unearned income that will be received for this month: $_______________
Type of Unearned Income Amount_______________
How Often Received: weekly/bi-weekly/semi-monthly/monthly (circle one)
Type of Unearned Income Amount_______________
How Often Received: weekly/bi-weekly/semi-monthly/monthly (circle one)

4. Total earned and unearned income for this month: $______________

5. How much money do you and all household members have in cash or in the bank? $______________

6. What is the monthly amount of your rent, mortgage, property taxes, and/or homeowner’s $_______________
Insurance?

7. What is the total amount of your electric, water, gas, and/or other utilities this month? $_______________
(Exclude past due and late fee amounts in the total)

a. What is your household’s primary heating or cooling source? Mark all that apply.
Electric_____ Gas_____ Window or central air conditioner_____ Kerosene oil_____ Wood_____

b. Have you received energy assistance in the last 12 months?

❑ Yes ❑ No If yes, amount received $_______________

Form 297 (Rev. 7/2023) 6

Division of Family and
Children Services Application for Benefits
Tell Us about the Applicant and All Household Members
For Medical Assistance applicants: Please include yourself, your spouse, your children (including stepchildren) under 21 who live
with you, your unmarried partner who needs health coverage, anyone you include on your tax return, even if they do not live with you,
and anyone else under 21 who you take care of and lives with you. You do not have to include your unmarried partner who does not
need health coverage, your unmarried partner’s children, your parents who live with you but file their own tax return (if you are over 21),
or other adult relatives who file their own tax return. If you are applying for Emergency Medical Services (EMA) only, you do not have to
provide your SSN or information about your immigration status.

Please fill out the chart below about the applicant and all household members. The following federal laws and regulations:
The Food and Nutrition Act of 2008, 7 U.S.C. § 2011-2036, 7. C.F.R. § 273.2, 45 C.F.R. § 205.52, 42 C.F.R. § 435.910, and 42
C.F.R. § 435.920, authorize DFCS to request you and your household members social security number(s). Anyone who is living in
your household and is not applying for benefits may be treated as a non-applicant. Non-applicants do not have to give us information
about their social security number, citizenship, or immigration status and are not eligible for benefits. Other household members may still
be able to receive benefits if they are otherwise eligible. If you want us to decide whether any household members are eligible for benefits,
you will still need to tell us about their citizenship or immigration status and give us their social security number (SSN). You will still need
to tell us about their income and resources to determine the eligibility and benefit level of the household. We will not report any non-
applicant household members to the United States Citizenship and Immigration Services (USCIS) Systematic Alien Verification for
Entitlements (SAVE) system if they do not give us their citizenship or immigration status. However, if immigration status information has
been submitted on your application, this information may be subject to verification through the SAVE system and may affect the
household’s eligibility and benefit level. We will match your information with other Federal, state, and local agencies to verify your income
and eligibility. This information may also be given to law enforcement officials to use to catch people who are running from the law. If your
household has a Food Stamp (SNAP) claim, the information on this application, including SSN, may be given to Federal and State
agencies and private claims collection agencies for them to use in collecting the claim. We will not deny benefits to applicant household
members because other household members fail to provide their SSN, citizenship, or immigration status.

NAME Relationship Is this Does this Birth Date Social Security Sex Hispanic Race Are you a U.S
person person Number or Code citizen, U.S.
First Middle Initial Last applying need health Latino? National,
for coverage? qualified
benefits? immigrant or in
a satisfactory
immigration
status?
(Optional (Optional) (Optional) (Applicants
for Non - only)
Applicants)

Format (See
(Y/N) (Y/N) (mm/dd/yy) (M/F) (Y/N) codes (Y/N)
Below)

SELF

Race Codes (Choose all that apply):

AI - American Indian or Alaska Native AS - Asian BL – Black or African American
HP - Native Hawaiian or Other Pacific Islander WH - White
By providing Race/Ethnicity information, you will assist us in administering our programs in a non-discriminatory manner.
Your household is not required to give us this information and it will not affect your eligibility or benefit level.

Form 297 (Rev. 7/2023) 7

Division of Family and
Children Services Application for Benefits
If you or other household applicants are not U.S. Citizens or U.S. Nationals, complete the following chart:
(please add additional pages as needed)
NAME Immigration Alien/Certificate/Document ID Have you lived in Date Are you, or your
document type number the U.S. since Naturalized/Date spouse or parent
First Middle Initial Last 1996? of Entry or a veteran or an
Admission into active-duty
U.S. member of the
(if applicable) U.S. military?

Format
(Y/N) (mm/dd/yy) (Y/N)

Tell Us More about the Applicant and All Household Members

We need more information about the applicant and all household members in order to decide who is eligible for benefits.
Please answer only the questions about the benefits you want to receive on the page below.

1. Has anyone received any benefits in another county or state? (For Food Stamps (SNAP) and TANF only) ❑ Yes ❑ No

If yes:
Who:
Where:
When:

2. Has anyone been convicted of giving false information about where they live and who they are to get multiple FS
benefits in more than one area after 8/22/1996? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

If yes:
Who:
Where:
When:

3. Did anyone in your household voluntarily quit a job or voluntarily reduce his/her work hours below 30 hours per week
within 30 days of the date of application? (For Food Stamps (SNAP) and TANF only) ❑ Yes ❑ No

If yes, who quit?

Why did he/she quit?

4. Is anyone pregnant? (This question does not apply to Food Stamps (SNAP) applicants) ❑ Yes ❑ No

If yes,
Name of pregnant woman: ______________________
What is the estimated due date? ____________; and how many babies expected? ________

If no, did anyone in the household deliver or was a pregnancy terminated within the last 12 months? ❑ Yes ❑ No

If yes,
Name of pregnant woman: ______________________
What was the delivery/termination date? _________; and how many babies were delivered/expected? _____

*For TANF applicants only please provide the following:

Unborn baby’s father’s name: ____________________ Father’s address: _____________________________________

Form 297 (Rev. 7/2023) 8

Division of Family and
Children Services Application for Benefits
5. For Medicaid applicants, does anyone have any unpaid medical bills for the last 3 months? ❑ Yes ❑ No
If yes, please send the unpaid bills if you have a Medicaid case.

6. Is anyone disqualified from the Food Stamp (SNAP) or TANF Program? (For Food Stamps (SNAP) And TANF only)
❑ Yes ❑ No

If yes:
Who:
Where:

7. Is anyone fleeing to avoid prosecution or jail for a felony? (For Food Stamps (SNAP) and TANF only) ❑ Yes ❑ No
If yes, who: ________________________________________

8. Is anyone violating conditions of probation or parole? (For Food Stamps (SNAP) and TANF only) ❑ Yes ❑ No
If yes, who: ________________________________________

9. Does anyone have a felony conviction because of behavior related to the possession, use or distribution of a
controlled drug substance (i.e., drug felon) after 8/22/1996 (For Food Stamps (SNAP) and TANF only) or a violent
felony (For TANF only)? ❑ Yes ❑ No

If yes:
Who: When: ________________________________

a. Are you in compliance with the terms of probation related to any sentence received as a result of a drug felony
conviction? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

b. Are you in compliance with the terms of parole related to any sentence received as a result of a drug felony
conviction? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

c. Have you successfully completed all the terms of probation or parole related to any drug related conviction? (For
Food Stamps (SNAP) only) ❑ Yes ❑ No

10. Have you or any household member been convicted of trading Food Stamp (SNAP) benefits for drugs after 8/22/1996?
(For Food Stamps (SNAP) only) ❑ Yes ❑ No

If yes:
Who: When: ________________________________

11. Have you or any household member been convicted of buying or selling Food Stamp (SNAP) benefits
over $500 after 8/22/1996? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

If yes:
Who:
When:

12. Have you or any household member been convicted of trading Food Stamp (SNAP) benefits for guns,
ammunition, or explosives after 8/22/1996? (For Food Stamps (SNAP) Only) ❑ Yes ❑ No

If yes:
Who:
When:

Form 297 (Rev. 7/2023) 9

Division of Family and
Children Services Application for Benefits
13. Have you or any member of your household been convicted as an adult of aggravated sexual abuse,
murder, sexual exploitation, and other abuse of children, a Federal or State offense involving sexual
assault, or an offense under State law determined by the Attorney General to be substantially similar
to such an offense, after 2/7/2014? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

If yes:
Who: __________________________________________________ When: __________________________________________

a. Are you in compliance with the terms of probation related to any sentence received as a result
of a felony conviction? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

b. Are you in compliance with the terms of parole related to any sentence received as a result of a
felony conviction? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

c . Have you successfully completed all the terms of probation or parole related to any felony related
conviction? (For Food Stamps (SNAP) only) ❑ Yes ❑ No

14. Have you or any household member received lottery or gambling winnings? ❑ Yes ❑ No

If yes:
Who: When: ___________________ Amount Received: _______________

15. Has anyone used TANF funds or the EPPIC Card at the following establishments, liquor stores, casinos, poker
rooms, adult entertainment business, bail bonds, night clubs, salons/taverns, bingo halls, racetracks,
gun/ammunition stores, cruise ships, psychic readers, smoking shops, tattoo/piercing shops, and spa/massage
salons? (For TANF only) ❑ Yes ❑ No

If yes:
Who: ________________________________________ When:____________________________________________

16. Is anyone who is applying for benefits, currently receiving alimony? ❑ Yes ❑ No

If yes:
Who:
Monthly Amount Received: ___________________
Date alimony agreement finalized or last modified:

Tell Us about the Applicant and All Household Members Income

Do you or anyone who lives in your household receive any type of income such as: wages, tips, bonuses, self-employment, Social
Security/Railroad Retirement, other disability, pensions, unemployment, or any other income? For Food Stamps (SNAP) and TANF, please
also list income such as: VA income, child support, money from other people or workers compensation. If yes, complete the chart below.
How Often
Employer Monthly received
Household Member Name Amount Pay Per Hours per DATE (S)
Type of Income Name/Source of (monthly,
with Income (Before Hour Week PAID
Income biweekly,
Deductions) weekly)

Is anyone currently on strike? ❑ Yes ❑ No

If self-employed, please list your monthly business expenses amount: $_________________________________

Form 297 (Rev. 7/2023) 10

Division of Family and
Children Services Application for Benefits
Tell Us about the Applicant and All Household Members Resources - For TANF applicants, list all resources
for all household members and Medicaid applicants who are Aged (65 or older), Blind or Disabled
(permanent impairment that prevents you from working)

Do you or anyone you are applying for own any resources? ❑ Yes ❑ No
If yes, please complete the information below (Check all resources (assets) owned by you, your spouse, your dependents or jointly owned
with someone else. Attach additional pages if necessary).

Checking Accounts ❑ Yes ❑ No Funeral Plans/Prepaid Burial Item ❑ Yes ❑ No

Savings Accounts ❑ Yes ❑ No Burial Plots or Contracts ❑ Yes ❑ No
Government Bonds ❑ Yes ❑ No Stocks and Bonds ❑ Yes ❑ No
Trust Funds ❑ Yes ❑ No Other (IRA, CD, etc.) ❑ Yes ❑ No
Real Property/Homeplace Property? ❑ Yes ❑ No

Have you or your spouse given away any assets for less than its value? ❑ Yes ❑ No
If you answered yes to any of these questions, please describe below.
Household Member Name Account/Policy Name of Bank, Insurance
Type of Resource Number Value
with Resource Company, etc.

Do you or your spouse own a vehicle? ❑ Yes ❑ No

If yes, please describe below.
Household Member Who
Vehicle Make Model Year Amount Owed
Owns Vehicle

Do you or your spouse have a life insurance policy? ❑ Yes ❑ No

If yes, please complete the following information.
Policy Owner Insurance Company Policy Number Face Value Cash Value

Tell Us about the Applicant and All Household Members Expenses (Optional for Medicaid applicants)
Do you pay for the care of a dependent child or a disabled adult household member? ❑ Yes ❑ No
If yes, complete the chart below.

Person who requires Person who pays Provider’s Amount paid to

Reason for care How often paid
care for care Name/Number Provider

Do you pay transportation expenses for a dependent child or disabled adult household member? ❑ Yes ❑ No
Are these expenses included in the dependent care expenses? ❑ Yes ❑ No
If no, please answer this question: Total miles driven weekly:
Form 297 (Rev. 7/2023) 11
Division of Family and
Children Services Application for Benefits
Does anyone in the household pay child support to someone living outside of the home? ❑ Yes ❑ No
If yes, complete the chart below.
Household Member Obligated to Name of Child for Whom Obligated Amount Actual Amount To Whom is Child
Pay Support is paid to Pay Paid Support Paid?

Tell Us More about the Applicant and All Household Members Expenses (Optional for Medicaid applicants)
Does anyone 60 years of age or older or disabled have medical expenses? ❑ Yes ❑ No
If yes, complete the chart below.
Type of Expense
(doctor visits, hospital
Will Insurance
Household Member Who Has visit, prescriptions, Amount Still Owed?
Date Paid Pay?
Expense Medicare or health Owed Yes/No
Yes/No
Insurance premiums,
glasses)

Does anyone 60 years of age or older or disabled have medical expenses for transportation? ❑ Yes ❑ No
If yes, complete chart below.
Purpose of the trip Total miles driven: Cost of taxi, bus, parking or
(doctor or hospital visit; pharmacy pick-up) lodging:

Do you or any household member have shelter and utility expenses? ❑ Yes ❑ No
If yes, complete the chart below.
Expense Amount How Often? Who paid?
Rent/Mortgage

Property Taxes

Property Insurance

Electricity

Gas

Garbage

Telephone

Other

Form 297 (Rev. 7/2023) 12

Division of Family and
Children Services Application for Benefits
Do you share monthly household expenses with anyone in the home? ❑ Yes ❑ No
If yes, who?
Comments/Documentation
Paid to whom Amount paid $ per
Landlord’s Name
Landlord’s address:

Does someone else pay any of these household bills for you? ❑ Yes ❑ No If yes, complete the chart below:
Who pays the bill? What bills are paid?

What amount is paid? To whom does this person pay the bills?

Please complete the following information if applying for Medicaid.

Tax Filer Information

1. Does anyone in the household plan to file a federal income tax return NEXT YEAR? ❑ Yes ❑ No
If yes, who? (List each person who plans to file.)

2. Will any of the tax filers listed file jointly with a spouse? ❑ Yes ❑ No If yes, please list spouse’s name:
________________________________________________________________________________

3. Will any of the tax filers claim any dependents on their tax return? ❑ Yes ❑ No If yes, please list name(s) of dependents:
_________________________________________________________________________________

4. Will anyone be claimed as a dependent on someone else’s tax return? ❑ Yes ❑ No If yes, please list the name of the tax filer
and the dependent:
(Filer) ______________________________________________________
(Dependent) ______________________________________________________________________
How is the tax dependent related to the tax filer? __________________________________________

Deductions: Check all that apply and give the amount and how often you pay it.
❑ Alimony paid $_______ How often? _______ ❑ Student loan interest $_______ How often? _______
❑ Health Insurance Premiums, 401K, and Other Pre-Tax Deductions $_________________ How often? _______
❑ Other deductions $_______ How often? _______ Type: _____________________________

Other health coverage

1. Does anyone have other health insurance that covers anyone in your household? ❑ Yes ❑ No
If you answered yes to question 4 above, please complete the following information and Attachment A:

Type of Coverage
Health Insurance Company
Name of Policy (Hospital, Medicare Effective
Name, Address and Telephone Name of Persons Covered Policy Number
holder Supplement, Drugs, Date
Number
Major Medical)

2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job,
such as a parent or spouse.
❑ Yes ❑ No If yes, you need to complete Attachment A.
Is this a state employee benefit plan? ❑ Yes ❑ No

Form 297 (Rev. 7/2023) 13

Division of Family and
Children Services Application for Benefits
3. Have you or anyone listed on this application lost any health coverage in the last 2 months?

a. ❑ Yes If yes, why was it lost? ________________________________________________________________________

b. ❑ No

4. Was anyone in Foster Care at age 18 applying for Medicaid? ❑ Yes ❑ No

5. Is anyone in your household American or Alaska Native? ❑ Yes ❑ No
If yes, complete Attachment B.

If anyone is aged (65 or older), blind or disabled (permanent impairment that prevents you from working),
please answer questions. (Optional)
1. Is anyone applying for health coverage blind or disabled?
❑ Yes ❑ No If yes, please list name: __________________________________________________
2. Are you or your spouse currently covered by Medicare?
❑ Yes ❑ No If yes, please list name: __________________________________________________
3. Are you applying for Medicaid to cover unpaid medical bills from the three months prior to a Supplemental Security
Income (SSI) application?
❑ Yes ❑ No If yes, date of SSI application:
4. Are you applying for someone who is now deceased and has unpaid medical bills within the last three (3) months?
❑ Yes ❑ No
5. Are you applying for Medicaid to help pay for the care of a person who is in a nursing home?
❑ Yes ❑ No
6. Are you applying for Medicaid for a person over the age of 18 whose SSI check has stopped?
❑ Yes ❑ No
7. Are you applying for Medicaid to help pay for community-based waiver services such as Community Care Services, NOW/COMP,
Hospice Care, Independent Care Waiver, or the Deeming Waiver (Katie Beckett)?
❑ Yes ❑ No

Form 297 (Rev. 7/2023) 14

Division of Family and
Children Services Application for Benefits
Food Stamp (SNAP) Program Penalties
You may lose your benefits or be subject to criminal prosecution for knowingly providing false information.

• Do not give false information or hide information to get benefits that your household should not get.
• Do not use Food Stamps (SNAP) or EBT cards that are not yours and do not let someone else use yours.
• Do not use Food Stamp (SNAP) benefits to buy nonfood items such as alcohol or cigarettes or to pay on credit cards.
• Do not trade or sell Food Stamps (SNAP) or EBT cards for illegal items; such as firearms, ammunition, or controlled
substance (illegal drugs).

Any household member who breaks any of the Food Stamp (SNAP) rules on purpose can be barred from the Food Stamp
(SNAP) Program for one year to permanently, fined up to $250,000, imprisoned up to 20 years or both. She/he may also
be subject to prosecution under other applicable Federal and State laws. She/he may also be barred from the Food Stamp
(SNAP) Program for an additional 18 months if court ordered.

Any household member who intentionally breaks the rules may not get Food Stamps (SNAP) for one year for the first
offense, two years for the second offense, and permanently for the third offense.

If a court of law finds you or any household member guilty of using or receiving Food Stamp (SNAP) benefits in a
transaction involving the sale of a controlled substance, you or that household member will not be eligible for benefits for
two years for the first offense, and permanently for the second offense.

If a court of law finds you or any household member guilty of having used or received benefits in a transaction involving
the sale of firearms, ammunition, or explosives, you or that household member will be permanently ineligible to
participate in the Food Stamp (SNAP) Program upon the first offense of this violation.

If a court of law finds you or any household member guilty of having trafficked benefits for an aggregate amount of $500
or more, you or that household member will be permanently ineligible to participate in the Food Stamp (SNAP) Program
upon the first offense of this violation.

If you or any household member is found to have given a fraudulent statement or representation with respect to identity
(who they are) or place of residence (where they live) in order to receive multiple Food Stamp (SNAP) benefits, you or that
household member will be ineligible to participate in the Food Stamp (SNAP) Program for a period of 10 years.

TANF Program Penalties

In the TANF Program, an IPV (Intentional Program Violation) is an intentional action by an individual to establish or maintain an
assistance unit’s (AU’s) eligibility, or to increase or prevent a decrease in the AU’s benefits, by providing false or misleading
information or withholding information.

• Any household member who hides information and does not report changes on time or does not tell the truth will lose TANF
benefits for six months for the first violation, twelve months for the second violation and permanently for the third violation. The
misuse of the cash assistance funds or TANF DEBIT card to withdraw cash or perform transactions at casinos, liquor stores,
adult-oriented entertainment facilities “strip clubs”, poker rooms, bail bonds, night clubs/salons/taverns, bingo halls, race tracks,
gaming establishments, gun/ammunition stores, cruise ships, psychic readers, smoking shops, tattoo/piercing shops, and
spa/massage salons is strictly prohibited and will result in a loss of TANF benefits for six months for the first violation, twelve
months for the second violation and permanently for the third violation.

• If a court of law finds you or any household member hiding information or you do not report changes on time or do not tell the
truth and are convicted, you may not get TANF for 6 months for the first violation, 12 months for the second violation and
permanently for the third violation.

• If a court of law finds you or any household member guilty of giving false information about where you live so you can receive
benefits in more than one state, you will be barred for 10 years.

• If a court convicted you of a drug-related charge, controlled substance, or a serious violent felony on or after 1/1/1997, you
or that household member will not be eligible and/or permanently disqualified.

For All Medicaid Applicants:

To report suspected Medicaid fraud on recipients or providers, call the Georgia Department of Community Health-Office of
Inspector General at (local) (404) 463-7590 or (toll free) (800) 533-0686; by email at [email protected]; by mail at
Department of Community Health, OIG PI Section, 2 Martin Luther King Jr. Drive SE, 19 th Floor, East Tower, Atlanta GA 30334;
or visit https://dch.georgia.gov/report-medicaidpeachcare-kids-fraud.

Form 297 (Rev. 7/2023) 15

Division of Family and
Children Services Application for Benefits
For All Food Stamp (SNAP), TANF, and Medicaid Applicants:

I declare under penalty of perjury to the best of my knowledge and belief that the person(s) for whom I am applying for benefits is/are U.S.
citizen(s) or are noncitizen(s) lawfully present in the United States. I further certify that all of the information provided on this application is
true and correct to the best of my knowledge. I understand and agree that DHS-DFCS, DCH and authorized Federal Agencies may verify
the information I give on this application. Information may be obtained from past or present employers. I understand that my information
will be used to track wage information and my participation in work activities.

I will report any change in my situation according to Food Stamp (SNAP) and/or TANF program requirements. I will also report if anyone in
my household receives lottery or gambling winnings, gross amount of $4250 or more (before taxes or other amounts are withheld). I will
report these winnings within 10 days from the end of the month in which my household receives the winnings. I understand if any
information is incorrect, my benefits may be reduced or denied, and I may be subject to criminal prosecution or disqualified from DHS-
DFCS programs for knowingly providing incorrect information. I understand that I can be prosecuted if I provide false information or hide
information. I understand that if I fail to tell DHS-DFCS about some of my expenses during my application or renewal process and/or fail
to verify them, DHS-DFCS will not budget that expense in calculating the amount of my SNAP benefits.

The Georgia Department of Human Services (“DHS”) collects Personally Identifiable Information (PII), such as names, addresses,
telephone numbers, email addresses, and dates of birth, etc., during your application for benefits. By submitting any personal
information to us, you agree that we may collect, use, and disclose any such personal information in accordance with DHS policies,
procedures, and as permitted or required by law and/or regulations.

_______________________________________________________ ___________________________________
Applicant’s Signature Date

_______________________________________________________ ___________________________________
Authorized Representative’s Signature Date

VOTER REGISTRATION INFORMATION

If you are not registered to vote where you live now, would you like to apply to register to vote here today?

______ Yes

______ No

______ I do not want to answer the Voter Registration question.

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is
yours. You may fill out the application form in private.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding
whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may
file a complaint with the Secretary of State at 2 Martin Luther King Jr. Drive, Ste. 802, West Tower, Atlanta, GA 30334 or by calling (404)
656-2871.

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS
TIME.

A copy of the Georgia Voter Registration application is included with DFCS applications, renewals, and change of address
forms. You can also request a Voter Registration application from your caseworker. If you complete a Voter Registration
application, submit it to the Georgia Secretary of State’s Office following the instructions provided on the Voter Registration
application.

Form 297 (Rev. 7/2023) 16

Division of Family and
Children Services Application for Benefits
(Keep these documents for your information)
What Do the Words Used in this Application Mean?
This chart explains the words we have used in this application.

Applicant An individual who applies to receive public assistance or benefits.

Assistance Unit (AU) An assistance unit includes eligible individuals who live together, including a pregnant individual and an unborn
child, and receive public assistance/benefits.

Caretaker A parent, pregnant individual, relative or legal guardian who applies for and receives TANF with children in his
or her care, including an unborn child.
The action taken to remove an individual from a Food Stamp (SNAP) or TANF case because they did not
Disqualified tell the truth and received benefits that they should not have received.

Electronic Benefit Transfer The system used in Georgia to pay benefits to individuals who are eligible for Food Stamps (SNAP). Individuals
(EBT) receiving assistance are issued an EBT debit card, which is used to access their Food Stamp (SNAP) accounts.

Electronic Communications You have the option to choose how you would like to receive notifications about your information. If you
choose to receive email or text notifications, you will receive a message notifying you that you have a notice
in My Notices located in GA Gateway Customer Portal.

For Email Communication, you must provide us with your email address and accept the terms and conditions
for paperless notices located in GA Gateway Customer Portal after you create an account. Please visit the
GA Gateway Customer Portal Website at www.gateway.ga.gov to update your notification settings.

For Texting Communication, you must provide us with your phone number. Standard message and data rates
may apply. This may vary by carriers, please check with your provider.

EPPICard debit MasterCard The State of Georgia has implemented a convenient “electronic” payment option for the TANF recipients called
the EPPICard debit MasterCard. Under this payment option, money is deposited in the recipient’s account on
the first calendar day of the month. If the first falls on a weekend or holiday, benefits are made available on the
last business day of the prior month. The recipient has immediate access to his or her funds because the funds
are electronically loaded to the debit MasterCard.

A parent, pregnant individual, relative or legal guardian who applies for and receives TANF in his or her
Grantee Relative
name on behalf of the children, including an unborn child.

Gross Income A person’s total income before taking taxes or other deductions into account.

Homeless Individual An individual who lacks a fixed and regular nighttime residence or an individual whose primary nighttime
residence is:
• a supervised shelter designed to provide temporary accommodations (such as a welfare hotel or
congregate shelter);
• a halfway house or similar institution that provides temporary residence for individuals intended to be
institutionalized;
• a temporary accommodation for not more than 90 days in the residence of another individual; or
• a place not designed for, or ordinarily used, as a regular sleeping accommodation for human beings
(a hallway, a bus station, a lobby, or similar places).

Household Members Individuals who live in your home. For Food Stamps (SNAP), individuals who live together and purchase
and prepare their meals together.

Payments such as wages, salaries, commissions, bonuses, worker’s compensation, disability, pension,
Income
retirement benefits, interest, child support or any other form of money received.

Form 297 (Rev. 7/2023) 17

Division of Family and
Children Services Application for Benefits
Middle Class Tax Relief Act of This Act prohibits the use of cash assistance funds or TANF Debit Cards to withdraw cash or perform
2012 transactions at casinos, liquor stores, adult-oriented entertainment facilities, poker rooms, bail bonds, night
clubs/salons/taverns, bingo halls, racetracks, gaming establishments, gun/ammunition stores, cruise ships,
psychic readers, smoking shops, tattoo/piercing shops, and spa/massage salons. The use of cash assistance
funds or the TANF Debit Card at these businesses will constitute an intentional program violation (fraud) on the
part of the recipient.

Individuals who are seasonal farm workers and who move from one home base to another to work or look for
Migrant Farm Workers
farm work.

An individual who does NOT apply for or receive public assistance/benefits. Non-applicants are not required to
Non-applicant
provide a social security number, citizenship, or immigration status.

Qualified A qualified alien/immigrant is a person who is legally residing in the U.S. who falls within one of the following
Alien/Immigrant categories:
• a person lawfully admitted for permanent residence (LPR) under the Immigration and Nationality Act
(INA);
• Amerasian immigrant under section 584 of the Foreign Operations, Export Financing and Related
Program Appropriations Act of 1988.
• A person who is granted asylum under section 208 of the INA;
• Refugees, admitted under section 207 of the INA;
• A person paroled as a refugee or asylee under section 212 (d)(5) of the INA;
• A person whose deportation is being withheld under section 243(h) of the INA as in effect prior to
April 1, 1997, or section 241(b)(3) of the INA, as amended;
• A person who is granted conditional entry under section 203(a)(7) of the INA as in effect prior to April
1, 1980;
• Cuban or Haitian immigrants as defined in section 501(e) of the Refugee Education Assistance Act
of 1980;
• Victims of human trafficking under section 107(b)(1) of the Trafficking Victims Protection Act of 2000;
• Battered immigrants who meet the conditions set forth in section 431 (c) of the Personal
Responsibility and Work Opportunity Reconciliation Act of 1996, as amended;
• Afghan or Iraqi immigrants granted special immigrant status under section 101(a)(27) of the INA
(subject to specified conditions);
• American Indians born in Canada living in the U.S. under section 289 of the INA or non-citizens of
federally recognized Indian tribe under Section 4(e) of the Indian Self-Determination and Education
Assistance Act and;
• Hmong or Highland Laotian tribal members that rendered assistance to U.S. personnel by taking part
in military or rescue operation during Vietnam Era (8/05/1964 – 5/07/1975).

For Medical Assistance applicants only, Compact of Free Association (COFA) are citizens of the Federated
States of Micronesia, the Republic of the Marshall Islands and the Republic of Palau. COFA migrants do not
have to meet the 5-year bar.

Resources Cash, property, or assets such as bank accounts, vehicles, stocks, bonds, and life insurance.

Seasonal Farm Individuals who work at certain times of the year planting, picking, or packing produce. They are hired on a
Workers temporary basis when a job requires more workers than the farm employs on a regular basis.
Trafficking SNAP benefits means: (1) Buying, selling, stealing, or otherwise exchanging SNAP benefits issued
Trafficking in the Food and accessed via EBT cards, card numbers and PIN numbers or by manual voucher and signature, for CASH
Stamp (SNAP) or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or
Program acting alone; (2) The exchange of firearms, ammunition, explosives, or controlled substances; (3) Purchasing
a product with SNAP benefits that has a container requiring a return deposit with the intent of obtaining cash
by discarding the product and returning the container for the deposit amount, intentionally discarding the
product, and intentionally returning the container for the deposit amount; (4) Purchasing a product with
SNAP benefits with the intent of obtaining cash or consideration other than eligible food by reselling the
product, and subsequently intentionally reselling the product purchased with SNAP benefits in exchange for
cash or consideration other than eligible food; (5) Intentionally purchasing products originally purchased with
SNAP benefits in exchange for cash or consideration other than eligible food; (6) Attempting to buy, sell,
steal, or otherwise affect an exchange of SNAP benefits issued and accessed via Electronic Benefit Transfer
(EBT) cards, card numbers and personal identification numbers (PINs), or by manual voucher and signatures,
for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with
others, or acting alone.

Form 297 (Rev. 7/2023) 18

 Notice of ADA/Section 504 Rights

Help for People with Disabilities

The Georgia Department of Human Services and the Georgia Department of Community Health (“the Departments”) are
required by federal law* to provide persons with disabilities an equal opportunity to participate in and qualify for the
Departments’ programs, services, or activities. This includes programs such as SNAP, TANF and Medical Assistance.

The Departments provide reasonable modifications when the modifications are necessary to avoid discrimination based on
disability. For example, we may change policies, practices, or procedures to provide equal access. To ensure equally
effective communication, we provide persons with disabilities or their companions with disabilities communication assistance,
such as sign language interpreters. Our help is free. The Departments are not required to make any modification that would
result in a fundamental alteration in the nature of a service, program, or activity or in undue financial and administrative
burdens.

How to Request a Reasonable Modification or Communication Assistance

Please contact your caseworker if you have a disability and need a reasonable modification, communication assistance, or
extra help. For instance, call if you need an aid or service for effective communication, like a sign language interpreter. You
may contact your caseworker or call DFCS at (877) 423-4746 or the DCH Katie Beckett (KB) Team at 678-248-7449 to make
your request. You may also make your request using the DFCS ADA Reasonable Modification Request Form, which is
available at your local DFCS office or online at https://dfcs.georgia.gov/adasection-504-and-civil-rights, or you may obtain the
DCH ADA Reasonable Modification Request Form at the KB office, online at https://medicaid.georgia.gov/programs/all-
programs/tefrakatie-beckett, or you may email your modification request to [email protected].

How to File a Complaint

You have the right to make a complaint if the Departments have discriminated against you because of your disability. For
example, you may file a discrimination complaint if you have asked for a reasonable modification or sign language interpreter
that has been denied or not acted on within a reasonable time. You can make a complaint orally or in writing by contacting
your case worker, your local DFCS office, or the DFCS Civil Rights, ADA/Section 504 Coordinator at 47 Trinity Avenue SW,
Atlanta, GA 30334, (877) 423-4746. For DCH, contact the KB Team ADA/Section 504 Coordinator at 2211 Beaver Ruin
Road, Suite 150, Norcross, GA 30071 or P.O. Box 172, Norcross, GA 30091, (678) 248-7449. The DCH email is:
[email protected].

You can ask your case worker for a copy of the DFCS civil rights complaint form. The complaint form is also available at
https://dfcs.georgia.gov/adasection-504-and-civil-rights. If you need help making a discrimination complaint, you may contact
the DFCS staff listed above. Individuals who are deaf or hard of hearing or who may have speech disabilities may call 711
for an operator to connect with us. The email for DCH Civil Rights complaints is: [email protected]. The link for the
DCH Civil Rights process and complaint form is located at: https://dch.georgia.gov/adasection-504-and-civil-rights.

You may also file a discrimination complaint with the appropriate federal agency. Contact information for the U.S.
Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) is within the
“Nondiscrimination Statement” included within.

*Section 504 of the Rehabilitation Act of 1973; Americans with Disabilities Act of 1990; and the Americans with Disabilities
Act Amendments Act of 2008 ensure persons with disabilities are free from unlawful discrimination.

Under the Department of Community Health (DCH) policy, the Medical Assistance programs cannot deny you eligibility
or benefits based on your race, age, sex, disability, national origin, or religion.

Form 297 (Rev. 7/2023) 19

 Do Not Send Applications to the USDA or HHS

Nondiscrimination Statement
In accordance with federal civil rights laws and U.S. Department of Agriculture (USDA) civil rights regulations and policies,
the USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are
prohibited from discriminating based on race, color, national origin, sex (including gender identity and sexual orientation),
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. Programs that receive federal financial assistance from the U.S. Department of
Health and Human Services (HHS), such as Temporary Assistance for Needy Families (TANF), and programs HHS
directly operates are also prohibited from discrimination under federal civil rights laws and HHS regulations.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print,
audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits.
Individuals who are deaf, hard of hearing or who 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.
CIVIL RIGHTS COMPLAINTS INVOLVING USDA PROGRAMS
USDA provides federal financial assistance for many food security and hunger reduction programs such as the
Supplemental Nutrition Assistance Program (SNAP), the Food Distribution Program on Indian Reservations (FDPIR) and
others. To file a program complaint of discrimination, complete the Program Discrimination Complaint Form, (AD-3027)
found online at https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, 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: Food and Nutrition Service, USDA
1320 Braddock Place, Room 334, Alexandria, VA 22314; or
2. fax: (833) 256-1665 or (202) 690-7442; or
3. phone: (833) 620-1071; or
4. email: [email protected].

For any other information regarding 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: SNAP hotline.

CIVIL RIGHTS COMPLAINTS INVOLVING HHS PROGRAMS

HHS provides federal financial assistance for many programs to enhance health and well-being, including TANF, Head
Start, the Low Income Home Energy Assistance Program (LIHEAP), and others. If you believe that you have been
discriminated against because of your race, color, national origin, disability, age, sex (including pregnancy, sexual
orientation, and gender identity), or religion in programs or activities that HHS directly operates or to which HHS provides
federal financial assistance, you may file a complaint with the Office for Civil Rights (OCR) for yourself or for someone
else.
To file a complaint of discrimination for yourself or someone else regarding a program receiving federal financial
assistance through HHS, complete the form online through OCR’s Complaint Portal at https://ocrportal.hhs.gov/ocr/. You
may also contact OCR via mail at: Centralized Case Management Operations, U.S. Department of Health and Human
Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201; fax: (202) 619-3818; or
email: [email protected]. For faster processing, we encourage you to use the OCR online portal to file complaints rather
than filing via mail. Persons who need assistance with filing a civil rights complaint can email OCR
at [email protected] or call OCR toll-free at 1-800-368-1019, TDD 1-800-537-7697. For persons who are deaf, hard of
hearing, or have speech difficulties, please dial 7-1-1 to access telecommunications relay services. We also provide
alternative formats (such as Braille and large print), auxiliary aids and language assistance services free of charge for
filing a complaint.
This institution is an equal opportunity provider.
Under the Department of Human Services (DHS), you may also file other discrimination complaints by contacting your
local DFCS office, or the DFCS Civil Rights, ADA/Section 504 Coordinator at Georgia Department of Human Services,
Office of General Counsel, 47 Trinity Avenue SW, Atlanta, GA 30334, (877) 423-4746. For complaints alleging
discrimination based on limited English proficiency, contact the DHS Limited English Proficiency and Sensory Impairment
Program at Georgia Department of Human Services, Office of General Counsel, 47 Trinity Avenue SW, Atlanta, GA
30334, (877) 423-4746.
Do Not Send Applications to the USDA or HHS

Form 297 (Rev. 7/2023) 20