• Apply for help and to have your eligibility decided without us looking at your race, color, sex, age, disability, religion, national origin
(place of birth), or political belief. If you have a disability that limits you in any way, please tell us so we can make
accommodations to assist you. The Department of Children and Families (DCF) is an equal opportunity provider.
• This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases
religion or political beliefs. The U.S. Department of Agriculture also prohibits discrimination based on race, color, national origin,
sex, 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. Persons with disabilities who require alternative means of communication for program information
(e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the Department of Children and Families 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. Additionally, program information may be made available in languages other than
English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, AD-3027,
found online at http://www.ascr.usda.gov/complaint_filing_cust.html, 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: U.S. Department of Agriculture, Office of the Assistant Secretary for
Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email:
[email protected]. For any other information dealing with Supplemental Nutrition Assistance Program (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:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm. To file a complaint of discrimination regarding a program receiving
Federal financial assistance through the U.S. Department of Health and Human Services (HHS) write: HHS Director, Office for
Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (800) 537-
7697 (TTY). This institution is an equal opportunity provider.
• Apply for help on-line through our web application. Or you can turn in a paper application at a local service center or a community
partner, or you can mail or fax it. You can turn in an incomplete application (either web or paper), as long as it has your name and
address on it, and is signed by you, or another responsible member of your household, or someone acting for you as your authorized
or designated representative.
• Be interviewed and notified of your eligibility within 30 days from when you turned in a signed application (90 days for Medicaid if
your disability is considered in deciding your eligibility).
• Have DCF staff, or someone else, help you fill out forms. Let us know if you need help getting information we need.
• Receive, or have someone receive for you, the benefits for which you are eligible and be notified quickly of any action we take on
your application or any change we make in your benefits.
• Be told about other programs we have that might help you or your family.
• Ask for a hearing before a state hearings officer. You can bring with you or be represented at the hearing by a lawyer, relative,
friend or anyone you choose. If you want a hearing, you must ask for the hearing by writing, calling the Customer Call Center or
coming into the office within 90 days from the mailing date of your notice of case action. If you ask for a hearing by the end of the
last day of the month prior to the effective date of the adverse action, your benefits may continue at the prior level until the hearing
decision. You will be responsible to repay any benefits continued if the hearing decision is not in your favor. If you need information
about how to receive free legal advice, you can call the ACCESS Florida Customer Call Center toll free at 1-866-762-2237 for a
listing of free legal agencies in your area.
• Have the information received by us about you or the people in your household protected as required by federal and state laws.
• Name the adult parent of children or someone acting in the role of parent as the payee (the person who will receive your food
assistance benefits). If there are no children in your assistance group, then the payee must be the person who earns the most money.
(NOTE: You have these same responsibilities if you are applying on behalf of someone else.)
• Give us complete and correct proof of requested information, within the time limits given to you, to determine if you are eligible for help.
• Use your temporary cash assistance benefits to the best benefit of the children in the assistance group. Florida law says that anyone who
uses the money given for the support of a child or children for some other reason can be fined, sent to jail, or both.
• Declare the U.S. citizenship or noncitizen status of your household members, who are applying for help, by signing the application
for assistance. You must provide proof of noncitizen status, from the United States Citizenship and Immigration Services (USCIS),
for all persons who are not U. S. citizens for whom you are requesting help. We may ask USCIS to confirm this information.
Information received from USCIS may affect your eligibility and amount of benefits. Proof of USCIS status is not required for
individuals for whom you are not asking help.
• Apply for benefits from other sources if this application, or information received by us, shows that you might be eligible for those
benefits. (This does not apply to the Food Assistance Program.)
• Assign your rights to child support to the state and cooperate with Child Support Enforcement (CSE) in establishing paternity and
obtaining support from an absent parent of the children who are in your care, unless you can show CSE good cause for not doing
so. (For the Temporary Cash Assistance Program, you must assign your rights to the state. Assigning rights to the state does not
apply to the Food Assistance Program.)
CF-ES 2064, Jul 2016 [65A-1.204, F.A.C.] (continued on next page)