470-0462 (Rev. 05/24) Page 1 of 16
Iowa Department of Health and Human Services
Food and Financial Support Application
This form is to apply for Supplemental Nutrition Assistance Program (SNAP), Family Investment Program (FIP), or
Refugee Cash Assistance (RCA). If you would prefer to complete an online application, please visit
http://hhs.iowa.gov. Anyone may fill out an application. You may apply for one or both programs on this application.
You only need to complete the sections for the program(s) you want to apply for. Pages 1 and 2, and 13 through 16
are for you to keep for your records.
Part A – Everyone must complete this section to get either SNAP or FIP.
Part B – SNAP: This program helps you buy food for good health.
Part C – FIP or RCA: FIP provides temporary cash assistance to children and families. The Family Investment
Program is also known as Temporary Assistance for Needy Families (TANF). Refugees who do not get FIP may get
Refugee Cash Assistance
You can turn in your application by mail or email or fax or drop it off at any local HHS office.
If mailing application, use this address:
Cedar Rapids Service Area
Imaging Center 4
PO Box 2027
Cedar Rapids IA 52406-2027
If emailing application, use this email address:
[email protected]
If faxing application, use this number:
515-564-4017
The date we receive Page 3 with your name, address, and signature is your application date. This
starts the time we have to work on your application. It is also the date your SNAP may start.
An interview will be set up for you if you need to have one. The interview will likely be held over the phone. There
is information we must verify before we can process your application. You will be given time to provide that
information. If you can’t get proof of the information, you can ask HHS to help you get the information. Before we
can process your application, we may ask for proof of the following:
▪ Your identity, as well as the people who are applying for benefits. Examples of that proof include: a driver’s
license, social security card, or alien documentation card.
▪ That you and the people you are applying for are U.S. citizens or nationals.
▪ The money you have gotten in the last 30 days such as check stubs, self-employment records, child support
payment printouts, or award letters (such as disability benefits, Veterans benefits or financial aid).
▪ Assets you have, such as bank accounts, trust accounts, stocks, or bonds.
▪ Expenses you have, such as shelter, utilities, day care, and child support.
Information About Immigration Status
You can apply for part of your household even if some members do not have lawful immigrant status. For example,
parents who do not have lawful immigrant status may apply for their children who are U.S. citizens or qualified
lawful immigrants. You need to give proof of immigration status or U.S. citizenship for each person in your
household for whom you apply.
Your household’s alien status may be checked with the United States Citizenship and Immigration Services (USCIS).
Any information we get from USCIS may affect your household’s benefits. We will not contact the Citizenship and
Immigration Service about the people you don’t apply for. However, we may use their income and assets to see if
the rest of the household can get help.
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Emergency Service - SNAP
This is who can get SNAP in seven days:
▪ Households with gross monthly income less than $150 and with assets, such as cash or bank accounts, of $100
or less; or
▪ Households with rent, mortgage, and utilities that are more than the household’s gross monthly income and
assets; or
▪ Households with a migrant or seasonal farm worker and with assets of $100 or less whose income is stopping
or starting.
SNAP in 30 days
If you don’t get Emergency Service, you will get SNAP within 30 days if you are eligible, or a letter telling you why
you are not eligible.
FIP or RCA
You will get FIP or RCA within 30 days if you are eligible, or a letter telling you why you are not eligible.
Voter Registration
If you want to register to vote, you can complete a voter registration form at
https://hhs.iowa.gov/sites/default/files/Voter_Registration.pdf. Applying to register or declining to register
to vote will not affect the amount of assistance that you will be provided by this agency.
We use the following terms on the application. This is what they mean:
Alien
A person who is not a U.S. citizen.
Appeal
A request for hearing based on a decision made by the Department.
EAC
Electronic access card (Mastercard debit card) for getting your cash benefits.
EBT card
Electronic benefit transfer card is a plastic swipe card that you use to buy food.
Eligible
Meeting all of the program rules to get benefits from HHS.
Household
A group of people who live together.
Migrant Farm
Worker
A person who travels to find work harvesting crops on a seasonal basis.
PROMISE JOBS
A work and training program for the Family Investment Program (FIP).
Quality Control
A HHS unit that might review your case to see if you are getting the correct assistance. If
your case is chosen, the Quality Control unit will contact you.
Refugee
A person who enters the U.S. with a refugee status.
Seasonal Farm
Worker
A person who works on a farm on a seasonal basis within driving distance of their home.
Stocks, bonds,
savings certificates,
annuities, IRAs,
Keogh
These are different types of financial investments and that may be considered
resources/assets for SNAP and FIP.
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Iowa Department of Health and Human Services
Food and Financial Support Application
Check the box next to the program(s) you want to apply for:
SNAP
You do not need to apply for programs you already get. If you can’t fill out the whole application today at
least fill out your name, address, and signature and turn in this page. If you only fill out your name,
address, and signature, then please fill out and turn in the rest of the application as soon as you can
to help us get your application processed. If you need help filling out this form, call your local HHS
office.
Name
Telephone Number
( )
Is morning or afternoon the
best time to call you?
Social Security Number
Birth Date
Street Address
City
State
ZIP Code
Mailing Address (if different)
City
State
ZIP Code
County You Live In:
Email Address:
Do you need an interpreter? If yes, which language?
I authorize HHS to communicate confidential information with me by email at the email address I provided above.
Confidential information includes anything needed for HHS to process my application. By giving HHS my email
address, I understand that it is my responsibility to tell my HHS worker if my email address changes or to stop
communicating with me by email.
I certify, under penalty of perjury, that:
▪ The answers I am about to give are correct and complete to the best of my knowledge.
▪ My answer about citizenship or alien status of each person applying for assistance is correct.
Your Signature or Mark
Today’s Date
Signature of Person, If Any, Who Helped Complete the Form
Today’s Date
Print Name of Person Who Helped Complete Form
Phone Number
Mailing Address of Person Who Helped Complete Form
City
State
ZIP Code
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Social Security Number Information
We can give help only to people who give us their social security number (SSN) or proof of application from the
Social Security office. You don’t have to give us the SSN for people in your household who you do not want help
for, but you can choose to give us their SSN. However, we will use any SSN given to us the same way we use the
SSN of people getting assistance. If you do not give us a SSN for people in your household, we will deny assistance
to those people. There are some exceptions to this. Please ask your worker. We will not give any SSN to the
Citizenship and Immigration Service.
People in Your Home Part A
List all people who live in your home and mark the box yes or no if you are applying for that person. If you choose
no, you only need to list their name, relationship to you, and their birth date.
*Only required if applying for FIP.
We have to ask your ethnicity and race, but you do not have to answer. The reason for the information is to
assure that program benefits are distributed without regard to race, color, or national origin. Your answer won’t
affect how much you get or how soon. If you choose to answer, use the following codes:
**Ethnicity
***Race (Choose all that apply)
H = Hispanic or Latino
N = Not Hispanic or Latino
W = White
B = Black or African American
A = Asian
Apply
for?
Yes/No
Name
(First, MI, Last)
Relationship
to You
Birth
Date
SSN
Citizen
Yes/No
If Not a
Citizen, What
is Your Alien
Status
Birth
State*
Last
Grade
in
School*
Ethnicity
**
Race
***
Self
Grandparents and others applying for children who are not your own:
If you are applying for FIP only for the children, answer the remaining questions only about the children. If you are
applying for SNAP or want FIP for yourself, answer the questions about everyone in your home.
List anyone in your home who is disabled:
List anyone age 18 or over who is in college or trade school:
List anyone getting benefits from another state:
Which state?
List anyone who is on strike or gets regular meals instead of paying rent:
List anyone who is in the military, a veteran, or a spouse of a veteran:
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List anyone in your home who is pregnant:
Criminal Actions and Disqualifications Part A
Is anyone fleeing to avoid prosecution, custody, or jail for a felony crime?
Yes
No
Is anyone violating a condition of probation or parole?
Yes
No
Is anyone in or expecting to go to jail or prison?
Yes
No
Has anyone been disqualified from SNAP in any state for fraud or a program violation?
Yes
No
Income Part A
You must tell us about all money the people in your household get. If you leave a space blank, we will take
that to mean no one in your household gets money of this kind. Please use an additional sheet of paper, if
needed. You may be required to show proof of your income for the last 30 days.
List all jobs the people in your household have.
Who Works?
Employer Name?
How Much is
this Person
Paid Per
Hour?
How Many Hours
Does this Person
Expect to Work
Each Week?
How Often is this
Person Paid?
Does this Person
Get Tips?
$__________
Regular Hours:
_______________
Overtime Hours:
_______________
Weekly
Every 2 Weeks
Twice a Month
Monthly
Other (explain)
_____________
Yes,
Weekly Amount
$___________
No
$__________
Regular Hours:
_______________
Overtime Hours:
_______________
Weekly
Every 2 Weeks
Twice a Month
Monthly
Other (explain)
_____________
Yes,
Weekly Amount
$___________
No
$__________
Regular Hours:
_______________
Overtime Hours:
_______________
Weekly
Every 2 Weeks
Twice a Month
Monthly
Other (explain)
_____________
Yes,
Weekly Amount
$___________
No
$__________
Regular Hours:
_______________
Overtime Hours:
_______________
Weekly
Every 2 Weeks
Twice a Month
Monthly
Other (explain)
_____________
Yes,
Weekly Amount
$___________
No
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Does anyone get bonuses or commissions? Yes No
If yes, who?
Will the amount of money you get from jobs stay about the same? Yes No
If no, explain:
Has anyone been hired for a job but not received a paycheck yet? Yes No
If yes, who? New employer name?
Rate of pay __________________________ Hours worked per week _____________________
Has anyone reduced their work hours or ended a job in the last 30 days? Yes No
If yes, who? Employer name?
What Other Money Do People in Your Household Get?
Who Gets the Money?
How Much
Per Month?
Self-Employment or Odd Jobs (send the most recent federal tax forms.
If tax return has not been filed, send records that show income and
expenses)
Unemployment Benefits or Worker’s Compensation
Social Security or SSI
Veterans Benefits, Pensions, or Retirement
Child Support or Alimony
Money from Friends or Relatives
Other: (Including irregular or one time payments)
Explain:
Will the amount of other money people in your household get stay about the same? Yes No
If no, explain:
Expenses Part A
If you have day care expenses for a child or a disabled adult who lives with you, tell us how much you are
responsible to pay below. We need proof of how much you are responsible to pay to see if you can get a
deduction. Proof can be receipts or statement of expenses from the provider.
Who gets care: Amount you pay $ per month
If anyone pays court-ordered child support, tell us how much you pay below. We need proof of how much you
pay to see if you can get a deduction.
Who pays: Amount you pay $ per month
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Resources (Assets) Part A
Does anyone have a car, truck, boat, camper, motorcycle, or other vehicle? Yes No
If yes, list make, model, year: _______________________________________________________
List the total money anyone has in:
Checking/savings or other
bank/credit union accounts $ Who?
Cash $ Who?
Stocks, bonds, savings certificates,
annuities, IRAs, Keogh, or other assets $ Who?
List anyone who:
Owns land, buildings or houses other
than the house you live in:
Owns resources with someone who
does not live in your household:
Has a conservatorship or trust:
Has sold, traded or given away any
resources in the past three months: ____________________________
Help With Your SNAP – Authorized Representative Part B
If you feel like you need help from someone else to be at your HHS interviews, complete your HHS documents,
answer HHS questions, and buy food for you with your EBT benefits, you can tell us who that is. The person who
represents you to HHS is called your Authorized Representative. It’s very important to pick an Authorized
Representative who you trust and can rely on. Any information given to HHS from your Authorized Representative
is the same as if that information came from you. If they give wrong information and you get too many benefits, you
will have to pay those benefits back. If they use your EBT benefits, you can’t get those benefits replaced. You don’t
have to have an Authorized Representative. It’s optional and is your decision.
I understand what having an Authorized Representative means and I would like to have one. I understand HHS will
be able to share my information with the person I list below.
Name: Telephone number:
Address:
Email address:________________________________________ Relationship to you: ___________________
SNAP Part B
Write down the names of the people in your household who are not applying for SNAP:
Write the names of the people who live with you, but don’t eat with you:
Does anyone who lives with you already have an Iowa EBT card?
If yes, write their name here:
List anyone in your home who aged out of foster care: ____________________________________________
List anyone in your household who is experiencing homelessness: ____________________________________
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Is anyone a migrant or seasonal farm worker?
Yes
No
Have you or any member of your household been convicted, after September 22, 1996, of:
Buying or selling SNAP benefits over $500?
Yes
No
Fraudulently receiving duplicate SNAP benefits in any state?
Yes
No
Trading SNAP benefits for drugs, guns, ammunition or explosives?
Yes
No
SNAP Expenses Part B
To get the most SNAP you can, please tell us about your bills. You must provide proof of your expenses. Proof for
renters can be a lease agreement or written statement from the landlord or housing authority. Proof for
homeowners can be mortgage, property tax, and insurance statements.
Shelter
Do you get rent assistance? Yes No
If yes, enter the exact amount you are responsible to pay. Do not estimate. $ _________per month
Tell us the exact amount you are responsible to pay. Do not estimate.
Rent $_________ per month
Lot rent $_________ per month
Mortgage* $_________ per month
If you pay taxes or insurance separate from your mortgage, list the exact amounts you are responsible to
pay. Do not estimate.
Property Taxes: $ every 1 3 6 12 months
Homeowner’s Insurance: $ every 1 3 6 12 months
Check the boxes next to the utility bills you have to pay:
Lights/Electricity
Water and Sewage
Gas
Garbage and Trash
Telephone
Garage Rent
Extra charges from your landlord
Pet fees
Other, explain
Check the boxes if:
Any of the utility bills you have to pay are for heating or air conditioning.
You got energy assistance in the past year.
Your utilities are included in your rent.
Anyone helps you pay rent, utilities, or other expenses. Example: roommate, parent, friend, etc.
If yes, who helped and which expenses did they pay? _____________________________
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Medical Expenses
If you have medical expenses not paid by insurance for anyone who is disabled or over age 59, tell us. These
could be doctor or hospital bills, medicine, transportation, health insurance premiums, home health costs, health-
related supplies, medical equipment, or other medical expenses. Send proof if your expenses have changed.
Who pays: Amount you pay $ per month
Help Paying Expenses
If you get help with your expenses tell us:
Which Expense Was Paid
Who Paid
Amount Paid
Family Investment Program (FIP) or Refugee Cash Assistance Part C
If you do not get FIP or Refugee Cash Assistance and want to apply, answer the questions in this section.
List the people in your home who are not applying for FIP: _________________________________________
List anyone who already has an Iowa Electronic Access Card (EAC):
Does anyone expect to get a one-time payment such as an inheritance or insurance
settlement or did anyone get one in the past 30 days?
Yes
No
Does anyone have life or death benefit insurance?
Yes
No
List anyone in your household who has received TANF or other cash assistance benefits outside of Iowa since
January 1, 1997:
Where were the benefits received and for what months?
Child Support
Complete this section for each parent who does not live in the home with the children.
Name and Address of Parent
Not
Living in the Home
Date of Birth
of This Parent
Social Security
Number of This
Parent
Name of This
Parent’s Children
County Where
Court Order is
Filed, if Any
Name and address of employer of parent not in the home:
If ever married to this parent, list the date and place of marriage:
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PAGE RESERVED
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Iowa Department of Health and Human Services
Addendum to Application and Review Forms for Release of Information
OPTIONAL Release of Information
Help Us Help You!
You do not have to sign this, but it will help us get information we need to help you,
without having to get your signature on specific requests.
You should know that:
• We may need more information to decide if you can get assistance.
• If more information is needed from you, you will get a letter telling you what we need and the date
you must get it to us.
• You are responsible to get the information or to ask us for help to get it.
• If you do not give us the information or ask for help by the due date, your application may be denied
or your assistance may stop.
• We may be able to use the release below to get the information we need. But you still have to
provide information we request or ask us for help.
• We may attach a copy of this release to a form that asks other people or organizations (like your
employer) for specific information needed about you or others in your household.
Print and sign your name below to give us permission to get needed information.
RELEASE OF INFORMATION
I hereby authorize any person or organization to give the Iowa Department of Health and
Human Services requested information about me or other members of my household.
A copy of this release is as valid as the original.
This release does not apply to protected health information.
This release is good for 12 months from the date signed.
________________________________ ________________________________
Your Name (please print clearly) Other Adult Name (please print clearly)
________________________________ ________________________________
Signature or Mark Signature or Mark
________________________________
Date
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PAGE RESERVED
470-0462 (Rev. 05/24) Page 13 of 16
You Have the Right to Appeal An appeal is a request for a hearing regarding a decision made by the
Department. You can appeal in person, by telephone, or in writing for SNAP and FIP. To appeal in writing, you
must do one of the following:
▪ Complete an appeal electronically at https://hhs.iowa.gov/programs/appeals, or
▪ Write a letter telling us why you think a decision is wrong, or
▪ Fill out an Appeal and Request for Hearing form. You can get this form at your county HHS office.
Send or take your appeal to the Department of Health and Human Services, Appeals Section, 321 E. 12
th
St., Des
Moines, IA 50319-1002. If you need help filing an appeal, ask your county HHS office. You can represent yourself.
Or, you can have a friend, relative, lawyer, or someone else act on your behalf. You may contact your county HHS
office about legal services. You may have to pay for these legal services. If you do, your payment will be based on
your income. You may also call Iowa Legal Aid at (800) 532-1275. If you live in Polk County, call (515) 243-1193.
You Will Not Be Discriminated Against It is the policy of the Iowa Department of Health and Human
Services (HHS) to provide equal treatment in employment and provision of services to applicants, employees and
clients without regard to race, color, national origin, sex, sexual orientation, gender identity, religion, age, disability,
political belief or veteran status.
If you feel HHS has discriminated against or harassed you, please send a letter detailing your complaint to: Iowa
Department of Health and Human Services, Bureau of Human Resources, 321 E. 12
th
St., Des Moines, IA 50319-
1002 or via email [email protected]
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 (833) 620-1071, 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:
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. email:
[email protected]
This institution is an equal opportunity provider.
Do Not Mail Applications to the Above Address
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SNAP, FIP, and RCA
We Check What You Tell Us
The information you give us may be checked by federal, state, and local officials to make sure it is
true. Things we might check are any listed person’s: social security number, job and pay, bank
account amount, amounts received from other sources like Social Security or unemployment, and
alien status. If any information you give us is not correct, we may deny your application.
We may check records from other states to see if any person in your household can get benefits in
Iowa. This may be because a person was disqualified from a program in another state.
We check and use computer systems like the state Income and Eligibility Verification System. If
something you told us is different from what the computer system tells us, we will check to find out
what is correct. We might check your information by contacting your employer, your bank, or other
people. Such information may affect your household’s eligibility and level of benefits.
Things You Need to Know
▪ HHS may give your answers to law enforcement officials to catch persons fleeing to avoid the law.
▪ The Quality Control unit or Investigations unit may review your case. They may contact other people or
organizations to get proof of your information. By signing this application, you give permission to release
confidential information to the Quality Control unit or Investigations unit. You must cooperate with Quality
Control and Investigations to keep your FIP benefits. You must cooperate with Quality Control to keep your
SNAP benefits.
▪ We will use the information you give us to determine what assistance you are eligible to receive.
▪ You will have to pay back any benefits you got or that was paid to a third party on your behalf for which you
were not eligible.
▪ Section 1128B of the Social Security Act provides federal penalties for fraudulent acts and false reporting in
connection with these programs.
▪ Anyone who gets, tries to get, or helps any other person get assistance to which they are not entitled, is guilty
of violating the laws of the state of Iowa. This includes, but is not limited to, Iowa Code Chapters 239B, 243,
249, and 249A.
▪ Your expenses may be used to figure the amount of assistance you get. You may have expenses included in
your benefit calculation by reporting and giving proof of your expenses. If you do not report or give proof of
your expenses, you choose not to claim the expense. You can report and give proof later, and the expense can
be used for future months.
You also have the right to:
▪ Have someone help you complete the application.
▪ Have all of your questions answered.
▪ Get information about programs you applied for and any other HHS programs you may be able to get.
▪ Be sent a notice if you are eligible and when your benefits change or stop.
▪ Have information about you and your family kept private.
To report a change
▪ Call: 1-877-347-5678 Monday – Friday 7:00 a.m. to 6:00 p.m., excluding state holidays
▪ Email: [email protected]
SNAP Only
Follow these Rules of the SNAP Program:
▪ Don’t hide or give wrong information on purpose to get SNAP benefits.
▪ Don’t use SNAP benefits to buy non-food items like alcohol or tobacco.
▪ Don’t trade, sell, or give away SNAP benefits.
▪ Don’t use someone else’s SNAP benefits for yourself.
470-0462 (Rev. 05/24) Page 15 of 16
▪ Don’t purchase a product with SNAP benefits that has a container requiring a return deposit with the intent of
obtaining cash by intentionally discarding the product and intentionally returning the container for the deposit
amount.
▪ Don’t buy food on credit and attempt to pay for it with SNAP.
▪ Don’t buy a product with SNAP benefits so you can get cash or something other than eligible food by reselling
that product.
▪ Don’t fail to report if your household goes over its income limit.
If you get SNAP, your worker will tell you what your household’s income limit is. If your household’s income
goes over your limit, or if anyone in your household receives lottery or gambling winnings of $4,250 or more in
any month, you must tell us by the 10th day of the next month. If you don’t tell us on time, you might have to
pay back the benefits.
Penalties of the SNAP Program. Anyone who breaks the above rules:
▪ May not get SNAP benefits for one year for the first time, two years for the second time, and
forever for the third time;
▪ May be fined up to $250,000 or jailed up to 20 years or both; and may also be subject to
prosecution under other applicable Federal and State laws.
▪ May be kept off SNAP for an additional 18 months, if court ordered.
▪ If a court finds you guilty of trading SNAP benefits for firearms, ammunition, or explosives, you
will lose benefits forever.
▪ If a court finds you guilty of buying, selling, or trading more than $500 in SNAP benefits, you will
lose benefits forever.
▪ If a court finds you guilty of trading SNAP benefits for controlled substances, you will lose
benefits for two years the first time and forever the second time.
▪ You will not get SNAP for 10 years if you are found guilty of getting or trying to get SNAP in
more than one household at a time. This penalty happens if you give wrong information about
who you are or where you live.
Giving wrong information on purpose may result in us taking legal action against you, either criminal or
civil. It might also mean we reduce your benefits or take money back from you.
Things You Need to Know
▪ If you have a SNAP overpayment, HHS will give your answers to federal and state agencies as well as private
claims collection agencies, to collect the overpayment.
▪ The SNAP office may contact other people or organizations to get proof of your information.
▪ The application filing date is different if your household is in an institution and applying for SNAP and
Supplemental Security Income at the same time. In this case, the filing date is the date of release from the
institution.
▪ For information regarding services provided for Healthy Marriages contact your local office.
▪ You may not be denied SNAP benefits just because you were denied benefits from other programs. SNAP
applications will not be delayed due to requirements of other programs you may apply for.
▪ By having signed this application, you agree that all members of your household will register for work and
follow all of the work and training rules.
▪ To see what employment and training opportunities are available, please visit:
• SNAP Employment & Training (E&T) Program either by phone (515) 281-3131 or online at:
https://hhs.iowa.gov/food-assistance/related-programs/employment-and-training
• Your local IowaWorks Center. You may find your local work center at
https://www.iowaworkforcedevelopment.gov/contact
• United Way – 211
▪ The collection of information on the application, including the social security number of each household
member, is authorized under the Food and Nutrition Act of 2008 (formerly the Food Stamp Act of 1977), as
amended, 7 U.S.C. 2011-2036. The information will be used to determine whether your household is eligible or
continues to be eligible to participate in the SNAP program. We will verify this information through computer
470-0462 (Rev. 05/24) Page 16 of 16
matching programs. This information will also be used to monitor compliance with program regulations and for
program management.
▪ A household consisting of only Supplemental Security Income (SSI) applicants or recipients is entitled to apply
for SNAP recertification at a Social Security Administration office.
FIP or Refugee Cash Assistance (RCA) Only
Within 10 days of the date the change happens, you must tell HHS about changes, such as:
▪ Income, when it starts or stops, including getting an inheritance or a one-time payment of past due child
support
▪ Resources or assets
▪ Someone moving in or out of your home
▪ Mailing or living address
▪ Receipt of a SSN
▪ Change of school attendance of a child
If you receive FIP or Refugee Cash Assistance benefits, your SNAP may go down or stop.
Unless exempt, all members of your household must cooperate with the Family Investment Agreement (FIA) you
signed with PROMISE JOBS. Talk with your worker if you feel you have a reason not to cooperate. If you choose
not to participate in your FIA with PROMISE JOBS, your FIP benefits will stop.
You must cooperate with the Child Support Recovery Unit. While you get FIP, you give up your rights to child
support for the months you are on FIP. The state of Iowa will keep your child support to pay back the money you
get from FIP.
Using Your FIP/RCA Electronic Access Card (EAC) or Your Debit Card to Access FIP/RCA
Funds from Your Personal Bank Account
You cannot access your cash benefits with your EAC or personal debit card at a:
▪ Liquor store or any place that mainly sells liquor,
▪ Casino or other gambling or gaming establishment, or
▪ Business which provides adult-oriented entertainment in which performers disrobe or perform in an unclothed
state (such as a strip club).
This includes these types of businesses located in Iowa, on tribal land, or in any other state. If HHS determines that
you have accessed your cash benefits with your EAC or personal debit card at one of the above places you:
▪ Will have committed fraud,
▪ Have to repay the amount of cash accessed at the location, as well as any access fees, and
▪ Your family will not get cash benefits for three months with the first misuse and six months for each additional
misuse.
By having signed this application, you agree that no member of your household will use the EAC or your personal
debit card to access FIP/RCA funds at prohibited locations.
Additional responsibilities:
You must:
▪ Apply for and accept any benefits that you may be able to get.
▪ Give us information and provide proof when we ask for it.
▪ Fill out review forms when you are asked to.
Penalty for Getting FIP in More Than One State
You will not get FIP for 10 years if you are found guilty of getting or trying to get FIP in more than one state at a
time. This penalty happens if you give wrong information about where you live.