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Application for Supplemental Nutrition Assistance Program (SNAP)

To apply: You have the right to apply for SNAP benefits at any time.

Benefits are provided from the date Family Support Division (FSD) receives your application which must contain your name, address and signature. Please complete sections 2 through 6 to help FSD process your application faster.

If an interview is required, it can be completed by phone. Family Support Division will attempt to call you, if you provided a phone number on the application, the next business day after your application is registered to complete an interview. If you did not provide a phone number, or if you are unable to complete your interview at the time we call, please call 855 823 4908 to complete your interview or visit an FSD office to complete this as soon as possible. We may ask you for proof of some of the information you give to FSD.

Date of application: If approved, your SNAP benefits are provided from the date FSD receives your application. This is your filing date. If you are in an institution and apply for SNAP benefits and Supplemental Security Income (SSI) at the same time, your filing date is the date of release from the institution.

Authorized Representative: You can choose more than one person or facility to complete your application and/or manage your benefits on your behalf. They will act as your authorized representative. If you want an authorized representative, complete the Authorized Representative Form (IM-6AR) at https://dssmanuals.mo.gov/wp-content/uploads/2020/09/im-6ar-app.pdf or call FSD.

Multi-Language Interpreter Services

Section 2 – Key questions for faster service

If eligible, you will receive your benefits within 7 days of filing your application if you answer “yes” to any of the questions below. Otherwise, you will receive your benefits within 30 days of filing your application.

Does your household expect to receive less than $150 in income this month and have $100 or less available in cash and/or in a bank account?

Yes

Does your household have rent/mortgage and/or utility costs that are more than your total income, available cash, and bank accounts for this month?

Yes

Does your household include a migrant or seasonal farm worker whose income has stopped and whose available cash and bank accounts do not exceed $100?

Yes

Help FSD verify your identity for faster service. FSD will try to verify your identity electronically. Please (1) include a copy of your identification with your application, or (2) bring someone such as a friend, family member, landlord, or employer to any FSD office, or (3) list a contact below in order to help us verify your identity. FSD will call this person if needed.

Name of person to verify your identity:

Phone Number:

Specify the telephone number for the contact point.

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Section 3 – Household members

Write your information on line 1. Enter the information of all the people who live in your household, including your spouse, any children under age 22 who are in your household at least half (50%) of the time, and anyone who eats the majority of their meals in your household. Include all household members regardless of their citizenship or immigration status.

Citizenship or immigration status does not automatically disqualify an applicant from receiving SNAP benefits. Racial and ethnic information is collected to ensure that program benefits are distributed without regard to race, color, or national origin. Providing this information is optional and does not affect your eligibility or the amount of SNAP benefits you receive.

Providing the Social Security Number (SSN) and immigration status of each household member is voluntary. However, you will not receive SNAP benefits for individuals who do not provide a SSN and/or immigration status. Immigration status of applicant household members may be subject to verification by U.S. Citizenship and Immigration Services (USCIS). Information provided by USCIS may affect your eligibility and benefit level.

Self (Start With You)

Legal First Name

Legal Last Name

Sex

Not Required for  SNAP eligibility  determination

Date of birth

SSN

Hispanic or Latino?

Race

Buy And Cook?

Mark “Yes” if you buy and cook with the household member and “No” if you do not.

Additional Household Members

Legal First Name

Legal Last Name

Sex

Not Required for  SNAP eligibility  determination

Relationship

Date of birth

SSN

Hispanic or Latino?

Race

Buy And Cook?

Mark “Yes” if you buy and cook with the household member and “No” if you do not.

Click + to add additional household members, if needed.

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

If you do not have enough space for all household members, attach an additional list with their information.

1. List anyone who is a boarder in your household:

2. List anyone who is a foster child or foster adult in your household:

3. List anyone who is not a U.S. citizen in your household:

4. Do you need a new Missouri EBT card?

Yes

5. Is English your preferred language?

Yes

If no, what is the language most spoken in your home?

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Section 4 – Household declarations

Answer “yes” or “no” to each of the questions in this section. Please provide the name of the household member for whom the answer is “yes”. A “yes” response to any of the questions in this section may result in a disqualification for SNAP benefits for the person in which the “yes” answer applies.

1. Have you or any member of your household been convicted of buying or selling SNAP benefits of $500 or more after 9-22-96?

Yes

First Name:

Last Name:

2. Are you or any member of your household hiding or running from the law to avoid prosecution, custody, or jail for a crime (or attempted crime) that is a felony?

Yes

First Name:

Last Name:

3. Are you or any member of your household violating a condition of probation or parole?

Yes

First Name:

Last Name:

4. Have you or anyone in your household made false statements about your identity or address to receive SNAP benefits in 2 or more households at the same time?

Yes

First Name:

Last Name:

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Section 5 – Household information

Answer these questions for yourself and all of the people who live with you (as listed in Section 3). If yes, please provide the first and last name of the household member.

1. Has anyone received SNAP benefits in a state other than Missouri within the past 30 days?

Yes

First Name:

Last Name:

State:

Specify the state that is included as a part of the postal address. For example, CA.

2. Is anyone disabled?

Yes

First Name:

Last Name:

3. Is anyone age 18 or older and enrolled in school?

Yes

First Name:

Last Name:

School:

First Name:

Last Name:

School:

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Resources

Resources are bank accounts and other types of money you own by yourself or with other people.

Does anyone have or is anyone’s name on any checking or savings accounts, debit cards, CDs, IRAs or another type of retirement accounts, trusts, stocks, bonds, or digital cash accounts? 

Yes

If yes, please list the information for the account(s) below:

Account Type:

Balance/Cash Value:

Bank Name:

Who Owns First Name:

Who Owns Last Name:

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Income

Income is money that’s paid to you, such as earnings from a job or payments from Social Security or child support.

1. Does anyone earn income or money from working?

Yes

If yes, list who gets it, their employer, and monthly gross income before taxes or deductions:

Who earns income from working?

First Name

Last Name

Employer

Amount

How Often Received?

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

2. Does anyone receive income or money from the following sources? If yes, check the source and list who gets it and the monthly amount:

Yes

If yes, check the source and list who gets it and the monthly amount:

Social Security Income (Retirement, Disability or Survivor's)

First Name

Last Name

Monthly amount

Supplemental Security Income (SSI)

First Name

Last Name

Monthly amount

Veteran's Administration (VA) benefits

First Name

Last Name

Monthly amount

Child Support

First Name

Last Name

Monthly amount

Unemployment benefits

First Name

Last Name

Monthly amount

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Gifts or donations

First Name

Last Name

Monthly amount

Student loans, grants, scholarships

First Name

Last Name

Monthly amount

Other sources – list here:

Other Source

First Name

Last Name

Monthly amount

3. Has anyone's income stopped or been reduced in the last 30 Days?

Yes

First Name

Last Name

Date of last check

Amount of last check

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Phone:

Amount Paid Per Month:

Who Pays?

First Name:

Last Name:

Trash:

Amount Paid Per Month:

Who Pays?

First Name:

Last Name:

Water:

Amount Paid Per Month:

Who Pays?

First Name:

Last Name:

Sewer:

Amount Paid Per Month:

Who Pays?

First Name:

Last Name:

2. Does anyone pay court-ordered child support and/or alimony?

Yes

If yes, list the total monthly amount:

Who Pays?

First Name:

Last Name:

3. Does anyone who is either disabled or age 60 and older have medical expenses such as insurance or Medicare premiums, doctor visits, in-home care, transportation for medical care, or eyeglasses?

Yes

If yes, list the total monthly amount:

Who Pays?

First Name:

Last Name:

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Section 6 – Notices (Please read and sign)

USDA NON-DISCRIMINATION STATEMENT: In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating on the basis of 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.

Program information may be made available in languages other than English. Persons with disabilities who require alternative means of communication to obtain 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 have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339.

To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program Discrimination Complaint Form which can be obtained online at: https://www.usda.gov/sites/default/files/documents/ad-3027.pdf, from any USDA office, by calling (866) 632-9992, or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed AD-3027 form or letter must be submitted to:

MAIL: 

Food and Nutrition Service,

USDA 1320 Braddock Place,

Room 334 Alexandria, VA 22314; or

FAX:

(833) 256-1665 or (202) 690-7442; or

EMAIL: 

FNSCIVILRIGHTSCOMPLAINTS@usda.gov

This institution is an equal opportunity provider.

Note: Please do not send any application materials to the address above. The address above is for civil rights complaints only.

DSS NON-DISCRIMINATION STATEMENT: The Missouri Department of Social Services (DSS) is committed to the principles of equal employment opportunity and equal access to services. DSS applicants for, or recipients of, services from DSS are treated equitably regardless of race, color, national origin, ancestry, sex (including pregnancy and gender identity), sexual orientation, age, disability, religion, or veteran status. Appropriate interpretive services will be provided as required for the visually or hearing impaired and for persons with language barriers. Anyone who requires an auxillary aid or service for effective communication, or a modification of policies or procedures to participate in a program, service, or activity of the Department of Social Services should notify DSS as soon as possible. To request an accommodation: visit your local DSS office, contact DSS by phone, TDD/TTY: (800) 735-2966; Relay Missouri 711; or contact the DSS ADA Coordinator by phone at (800) 776-8014 or via email at HRC.OCR@dss.mo.gov. DSS will provide reasonable accommodations as required by law.

FSD FAIR HEARING RIGHTS:

You have the right to a hearing if you have applied for or are receiving SNAP benefits, and the following happens:

FSD decides that you are not eligible and you think you are.
FSD provides you with SNAP benefits and then reduces or stops the benefits and you think the reasons are wrong.
You disagree with the information used to determine the benefit amount or disagree with the benefit amount.
FSD refuses to take your application.
FSD does not act promptly on your request for help and you think that they have had enough time to do so.

If your application has been refused or rejected or any action on your case has already been taken, you may request a hearing within 90 days of the refusal or action. If the proposed action will change or stop your benefits and you request a hearing within ten days from the date of the notice, you may continue to receive the same benefits until the hearing decision. You or your representative may request a hearing by phone, in-person, or in writing. Your case can be presented by a household member, or a representative such as legal counsel, relative, friend or other spokesperson.

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

YOU MAY BE DISQUALIFIED FROM RECEIVING SNAP BENEFITS IF YOU:

Sell your SNAP benefits for cash or consideration other than eligible food, either directly, indirectly, in complicity or collusion with others, or acting alone.
Lie or hide information to get SNAP benefits that your household should not get.
Use SNAP benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit accounts.
Purchase 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 purchase products with SNAP benefits in exchange for cash. For example, do not purchase food to make products for resale.
Pay for food purchased on credit with SNAP benefits.
Use or have in your possession EBT cards that are not yours.
Trade or sell EBT cards or provide food purchased with SNAP benefits to non-household members.

NOTIFICATION AND ACKNOWLEDGEMENT OF FRAUD PROVISIONS

It is against the law to lie to receive SNAP or to sell or trade your SNAP benefits. Excessive Electronic Benefit Transfer (EBT) card replacement requests may result in a referral for fraud investigation. 7 USC 2015(b)(1) any person who has been found by any state or federal court or administrative agency to have intentionally made a false or misleading statement, or misrepresented, concealed or withheld facts or committed any act that constitutes a violation of this act, the regulations issued thereunder, or any state statute, for the purpose of using, presenting, transferring, acquiring, receiving, or possessing SNAP benefits shall, immediately upon the rendering of such determination, become ineligible for further participation in the program for a period of 1 year upon the first occasion of any such determination, 2 years for the second occasion and permanently upon the third occasion.

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

Applicants cannot violate the Food and Nutrition Act of 2008 which includes the following:
Any member who breaks any of the rules on purpose can be ineligible from the SNAP Program for one year, up to permanently, fined up to $250,000, imprisoned up to 20 years or both. S/he may also be subject to prosecution under other applicable Federal and State laws. S/he may also be barred from SNAP for an additional 18 months if ordered by a court.
Any member of your household who intentionally breaks the rules may be ineligible to receive 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 any household member guilty of using or receiving benefits in a transaction involving the sale of a controlled substance, you will not be eligible for benefits for two years for the first offense, and permanently for the second time.
If a court of law finds you guilty of having used or received benefits in a transaction involving the sale of firearms, ammunition or explosives, you will be permanently ineligible to participate in the Program upon the first occasion of such violation.
If you are found to have made a fraudulent statement or representation with respect to the identity or place of residence in order to receive multiple SNAP benefits simultaneously, you will be ineligible to participate in the Program for a period of 10 years.
If a court of law finds you guilty of having trafficked benefits for an aggregate amount of $500 or more, you will be permanently ineligible to participate in the Program upon the first occasion of such violation. The information you provide on the application will be subject to verification by Federal, State or local officials to determine if the information is factual; that if any information is incorrect, SNAP benefits may be denied and you may be subject to criminal prosecution for knowingly providing incorrect information.

Information available through the Income Eligibility and Verification System (IEVS) will be requested, used and may be verified through collateral contacts when discrepancies are found by the State, and that such information may affect the household’s eligibility and level of benefits.

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

The collection of information on the application, including the SSN of each household member, is authorized under the Food and Nutrition Act of 2008 (formerly the SNAP Act), as amended, 7 USC 2011-2036. The information will be used to determine whether your household is eligible or continues to be eligible to participate in the SNAP. We will verify this information through computer matching programs. This information will also be used to monitor compliance with program regulations and for program management. This information may be disclosed to other Federal and State agencies for official examination, and to law enforcement officials for the purpose of apprehending persons fleeing to avoid the law. If a SNAP claim arises against your household, the information on this application, including SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action.

Pursuant to section 570.030 RSMO the stealing of public assistance benefits is a class “D” felony if the value of benefits is $750.00 or more, but less than $25,000.00. Punishment includes imprisonment for up to seven years and a fine not to exceed $5,000.00. Stealing of $25,000.00 or more is a class “C” felony. If the value of the benefits is less than $750.00, the crime is a class “A” misdemeanor. Punishments and fines may increase for repeat offenders.

Pursuant to Section 578.377 (570.400 effective 1/1/17), RSMo, unlawful receipt of public assistance benefits or EBT cards, you understand that it is against the law to obtain or attempt to obtain SNAP benefits to which you are not entitled, or obtain, or attempt to obtain SNAP benefits in the amount greater than those to which you are entitled. YOU UNDERSTAND THAT ANY FALSE CLAIM, STATEMENT, OR CONCEALMENT OF ANY MATERIAL FACT WHATSOEVER, IN WHOLE OR PART, ON THIS FORM OR DURING THE INTERVIEW, MAY SUBJECT YOU TO CRIMINAL AND/OR CIVIL PROSECUTION. You will be asked to complete an interview with the Family Support Division to complete this application process. You will be required to provide proof of some of the information you provide on this application and/or in the interview. Your

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

WORK REGISTRATION

I understand and agree that to receive SNAP, certain members of the household need to register for work. This means that certain members of the household must: A) Register for work at time of application and recertification.

B) Not quit a job of 30 or more hours/week without good cause. C) Not reduce work hours under 30 hours per week without good cause. D) Not refuse to accept a bona fide offer of suitable employment without good cause. Anyone who does not follow the work requirements may be disqualified from receiving SNAP. This form also acts as a work registration notice. You, along with other nonexempt household members, will be considered work registered and must comply with the requirements associated with work registration once this form is signed.

WORK AND/OR TRAINING REQUIREMENT (ABAWD)

Individuals identified as Able Bodied Adults Without Dependents (ABAWDs) are not eligible to participate in the SNAP Program as a member of any household if the individual received SNAP benefits for three countable months during a three year period. Countable months are months during which an individual receives SNAP benefits for the full benefit month while not fulfilling the work requirement by working and/or attending training 20 hours per week, averaged monthly for a total of at least 80 hours.

An ABAWD is 18-54 years old; has no children under age 18 in the SNAP household; is not disabled; is not pregnant; is not a full-time student; not caring for an ill or incapacitated household member; not receiving unemployment (in any state); is not a veteran; is not homeless; did not age out of foster care; and is not attending a drug or alcohol treatment program. The time limit (three months) applies to ABAWDs only and ABAWDs may regain eligibility by meeting the work/training requirement for at least 80 hours in the last 30 days.

You may submit this application at any time as long as you have completed your name, address and signature.

To do so please proceed to the “Sign and Submit” section and finalize your submission.

READ THIS PAGE CAREFULLY BEFORE SIGNING

When you sign, you are certifying you understand the statements on this application. You are certifying, under penalty of perjury, you understand the information that you provide on this form and during the interview must be true and accurate, including information concerning citizenship and immigration status. You understand that any expenses you do not report, and verify when requested, will not be used to determine your SNAP benefits.

You are authorizing the Director of Family Support Division or his/her appointee to verify your circumstances and statements via Federal, State or local officials to determine if the information you provided is factual.

Pursuant to Section 578.385 (570.408 effective 1/1/17), RSMo, under the penalty of perjury, you certify that you have given true, accurate, and complete statements to the best of your knowledge, for each household member for whom you are applying including the information concerning citizenship and alien status.

By signing this application on paper or electronically, you are giving us permission to deliver, or cause to be delivered, automated phone calls and text messages regarding your case at the primary phone number you provided on page 1. You do not have to consent to this as a condition of eligibility. If you do not want to be contacted in this manner, you can opt out of getting these calls or messages.

Check here:

opt out of cells

opt out of texts

opt out of calls and texts

Electronic Signature

Fill in the following to complete your application:

Terms and Conditions

I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete, to the best of my knowledge, for each household member for whom I am applying, including the information concerning citizenship and alien status. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

▼ SIGN HERE:

Your Signature:

Form Signature Date

Signature of witness (needed if you cannot sign your name):

Witness Signature Date

Please attach supporting documents:

Need help?

Visit https://dss.mo.gov to start a chat, check the status of your benefits, or report changes
Call 855-FSD-INFO (855-373-4636) to speak with a team member
Relay Missouri 711
TTY users can call 800-735-2966

If you are blind or visually impaired and would like information about rehabilitation services for the blind, please call 800-592-6004.

Establishing paternity is not required for SNAP benefits. However, if you want assistance in establishing paternity, please contact the FSD Paternity Hotline at 855-454-8037.

If you are a Veteran in the state of Missouri and are interested in learning more about benefits and resources available to you and your dependents, visit: https://mvc.dps.mo.gov/MoVeteransInformation/Survey/DSS

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Thank You

Dear {formsubmittinguser},

Thank you for completing your application for the Supplemental Nutrition Assistance Program (SNAP). Your information has been sent to the Family Support Division (FSD). If you would like to print or save a copy of your application for your files, click the Print button below. If you decide to print or save, keep in mind that your application has your private and personal information in it.

FSD has 30 days to make a final decision on your SNAP application. During this time, FSD will attempt to contact you to complete the interview and/or possibly request you provide additional information based on your household's circumstances. You may call 855-823-4908 to complete your interview at any time during our regular business hours.

The information below may be needed prior to processing your application:

Proof of your Identity (for example: a driver's license for any state, another form of government-issued identification card, a paystub, or a voter registration card), or
Income verification for the past 30 days (for example: paycheck stubs, letter for employer, federal income tax return, award letter, etc).

You will be informed if you need to turn in any additional information once you have completed your interview.

If you have questions or want to check on the status of your application, you may call the FSD Information Center at 855-FSD-INFO (855-373-4636). If you would like to call to complete your interview you may call 855-823-4908.

Your application id is {formuniqueid}.

Sincerely,

Family Support Division

Form ID