**Keep in mind that you do not need to mail this print-out to your local application site.**

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1 **Keep in mind that you do not need to mail this print-out to your local application site.** Thank you for using PEAK to apply for benefits! Uni Cycle, your application has been submitted to Boulder on Oct 09, 2013 at 7:10 PM. Your application tracking number is Be sure to write this number down or print this page for your records. In your application, you have asked for these benefits: Food Assistance Colorado Works / TANF - Cash Assistance for Families with Dependent Children Medical Assistance We need to find out some things to see if you can get assistance. Some information can be verified by your statement at the interview. Other information may need to be verified by giving us "proof". "Proof" is the way you show us what we need to know. In some cases proof must be received before your application for assistance can be completed. Below is a list of items that can be used as proof. If you can't get the proof, let your application site worker know. Your worker may be able to help you. Proof of Identity Your identification, such as picture ID or drivers license. Proof of Assets Proof of resources (assets), such as checking, savings, vehicles, CD's, IRA's, stocks, life insurance, burial policies. Social Security Number Social Security numbers or proof of application for everyone requesting benefits. If you state on the application that you have a Social Security Number, you will need to provide proof. Proof of Citizenship or Alien Status Proof of status in this country such as Visa, Legal Permanent Resident Card, Passport, or Employment Authorization Card for everyone you are applying for. Proof of Income Proof of current wages or income for your household, such as pay stubs, award letter, employer letter, Social Security, child support. Proof of Health Insurance Health insurance card or policy. PEAK Apply For Benefits Page 1

2 Proof of Expenses Proof of expenses such as day care, rent, mortgage, utilities, child support or medical costs. Proof of Disability Determination Please complete a disability determination application if anyone is disabled, blind, or unable to work because of illness of injury or anyone with special needs, such as activities of daily living. This document is not required if you have been currently determined disabled. Disability Determination Release Form Please sign one (1) release for every doctor or hospital you have listed on the disability determination application. Please sign three (3) additional release forms for any new or discovered medical sources. Application Summary Here is a summary of what you told us, as well as important information about your rights and responsibilities. PEAK Apply For Benefits Page 2

3 Help from Others Applying on Your Behalf Other Basic Information Your Name Date of Birth Gender County Uni Cycle 08/16/1980 Male Boulder Preferred Spoken Language English Where You Live Preferred Written Language English Mailing Address 3460 BROADWAY ST BOULDER, Colorado Contact Information Primary Phone Primary Phone Type ext. Cell Secondary Phone Secondary Phone Type Address Expedited Issuance Information Have you received Food Assistance this month? Total amount of income your household will get this month $ Total value of your household's assets $ How much will the people in your home pay for housing and utilities this month? Is anyone in your home a migrant or seasonal farm worker? $ If yes, did his or her job recently end? If yes, will he or she get more than $25 from a new job or other source in the next 10 days? PEAK Apply For Benefits Page 3

4 People In Your Home Person: Uni Cycle Date of Birth Gender Marital Status Language 08/16/1980 Male Divorced English Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? Programs received out of state Received from which state Last date person received benefits Programs Requested Food Assistance Medical Assistance Colorado Works / TANF - Cash Assistance for Families with Dependent Children Backdate Month for Medical Assistance SSN Has this person applied for a Social Security Number? Reason for not applying? US Citizen? Citizenship Status n-citizenship status Does this person have eligible immigration status? n-citizen/document Country of Issuance US Born n-citizen/document Number Alternate Name on n-citizen/document n-citizen/document Expiration Document Type Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? PEAK Apply For Benefits Page 4

5 Migrant Worker? Funeral Preference Preference Does this person plan to file a Federal Income Tax Return? Is this person living with both parents, but the parents do not expect to file a joint return? Where does this person live? Living with more than one other person Ethnicity and Race Other/Unknown Does this person expect to be claimed as tax dependent on someone else's tax return? Does this person expect to be claimed by a non-custodial parent? PEAK Apply For Benefits Page 5

6 Person: Bi Cycle Age: 8 Date of Birth Gender Marital Status Language 05/05/2005 Female English Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? Programs received out of state Received from which state Last date person received benefits Programs Requested Food Assistance Medical Assistance Colorado Works / TANF - Cash Assistance for Families with Dependent Children Backdate Month for Medical Assistance SSN Has this person applied for a Social Security Number? Reason for not applying? US Citizen? Citizenship Status n-citizenship status Does this person have eligible immigration status? n-citizen/document Country of Issuance US Born n-citizen/document Number Alternate Name on n-citizen/document n-citizen/document Expiration Document Type Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Where does this person live? PEAK Apply For Benefits Page 6

7 Funeral Preference Preference Does this person plan to file a Federal Income Tax Return? Is this person living with both parents, but the parents do not expect to file a joint return? Living with more than one other person Ethnicity and Race Other/Unknown Does this person expect to be claimed as tax dependent on someone else's tax return? Does this person expect to be claimed by a non-custodial parent? PEAK Apply For Benefits Page 7

8 Person: Tri Cycle Age: 5 Date of Birth Gender Marital Status Language 11/11/2007 Male English Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? Programs received out of state Received from which state Last date person received benefits Programs Requested Food Assistance Medical Assistance Colorado Works / TANF - Cash Assistance for Families with Dependent Children Backdate Month for Medical Assistance SSN Has this person applied for a Social Security Number? Reason for not applying? US Citizen? Citizenship Status n-citizenship status Does this person have eligible immigration status? n-citizen/document Country of Issuance US Born n-citizen/document Number Alternate Name on n-citizen/document n-citizen/document Expiration Document Type Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Where does this person live? PEAK Apply For Benefits Page 8

9 Funeral Preference Preference Does this person plan to file a Federal Income Tax Return? Is this person living with both parents, but the parents do not expect to file a joint return? Living with more than one other person Ethnicity and Race Other/Unknown Does this person expect to be claimed as tax dependent on someone else's tax return? Does this person expect to be claimed by a non-custodial parent? PEAK Apply For Benefits Page 9

10 Relationship Information Person Relationships Do they buy food and eat meals together? Tax Dependents Uni Cycle is the Father of Bi Cycle Uni Cycle is the Father of Tri Cycle Bi Cycle Age: 8 is the Sister of Tri Cycle Absent Parent Information Name of Parent Date of Birth SSN Name of Child Motor Cycle 01/01/1981 Bi Address Place of Employment Questions About the People In Your Home Person: Uni Cycle Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Person: Bi Cycle Age: 8 PEAK Apply For Benefits Page 10

11 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Person: Tri Cycle Age: 5 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Have you or any member of your household been convicted of fraudulently receiving duplicate Food Assistance benefits in any State after September 22, 1996? If yes, when? MM/DD/YYYY Have you or any member of your household been convicted of buying or selling Food Assistance benefits over $500 after September 22, 1996? If yes, when? MM/DD/YYYY Have you or any member of your household been convicted of trading PEAK Apply For Benefits Page 11

12 Food Assistance benefits for guns, ammunitions, or explosives after September 22, 1996? If yes, when? MM/DD/YYYY Liquid Assets Information Person: Uni Cycle Type Value Last 2 digits of account number Bank Name Bank Address Other Owners Available Cash $ Person: Uni Cycle Type Value Last 2 digits of account number Bank Name Bank Address Other Owners Checking/Saving Accounts Person: Uni Cycle $ Tandem Bank Type Value Last 2 digits of account number Bank Name Bank Address Other Owners CDs,Money Market,IRAs $ Fat Tire Investments Vehicle Asset Information Person: Uni Cycle Type Year Make Model Value Amount Owed Car 1995 Volvo Wagon Registered? Primary Use? Other Owners To get to work or training or for job search Real Estate Information You told us that no one in your home has this kind of income, benefit, or bill. PEAK Apply For Benefits Page 12

13 Burial Asset Information You told us that no one in your home has this kind of income, benefit, or bill. Life Insurance Information You told us that no one in your home has this kind of income, benefit, or bill. Other Asset Questions Person Uni Cycle Bi Cycle Age: 8 Tri Cycle Age: 5 Sold or given away assets? Job Income Information Person: Uni Cycle Name of Employer Address of Employer Job Start Date Job end date Last paycheck received Town Bicycles 01/01/2000 How Often Paid Recent Paycheck Gross Pay Gross Amount Hours Monthly 10/01/2013 Salary $ In-Kind Income You told us that no one in your home has this kind of income, benefit, or bill. Self-Employment Information You told us that no one in your home has this kind of income, benefit, or bill. Other Job Income Questions PEAK Apply For Benefits Page 13

14 Person Uni Cycle Bi Cycle Age: 8 Tri Cycle Age: 5 Left or Lost a Job Other Income Questions Person Uni Cycle Bi Cycle Age: 8 Tri Cycle Age: 5 Grants, Loans or Scholarships Room and Meals Other Income Information You told us that no one in your home has this kind of income, benefit, or bill. Medical Costs Person Type of Medical Cost Actual Monthly Amount Paid Date Paid Tri Cycle Age: 5 Prescriptions $ /30/2013 Housing Bills Questions Have you paid for any temporary shelter costs (not rent or mortgage) this month? If, what was the amount paid? Does your household get housing or rent assistance? If your household gets Public Housing Assistance, do you get a separate bill for utilities? PEAK Apply For Benefits Page 14

15 Room and Meals Expense (Boarders) Person Uni Cycle Bi Cycle Age: 8 Tri Cycle Age: 5 Paying for room and meals? Housing Bills Information Type of Housing Bill Monthly Cost Rent $ Rent $ Utility Bills Questions Are all utilities included in the rent? Utility Bills Information Type of Utility Bill Monthly Cost Company, Provider, or Landlord Name on Bill Garbage/trash $ Other Bills Questions Person Child or Adult Care Bills Medical Bills Uni Cycle Bi Cycle Age: 8 Tri Cycle Age: 5 PEAK Apply For Benefits Page 15

16 Child or Adult Care Bills Other Information Questions Person Medicare Part A, Part B, or Part D Health Insurance Coverage Health Insurance Previous SSI Benefits SSI Letter? Uni Cycle Bi Cycle Age: 8 Tri Cycle Age: 5 Medicare Information You told us that no one in your home has this kind of income, benefit, or bill. Health Insurance Information You told us that no one in your home has this kind of income, benefit, or bill. School Enrollment Information Person: Uni Cycle Going to school? Plan to go to school in next 2 months? Graduation Status Time Spent in School Graduated Type Of School School Name Date of Graduation Caring for a child under 6 years old? Caring for a child 6 to 12 years old and daycare not available? Caring for a child 6 to 12 years old and enrolled in daycare? In a federal or state funded work-study program? PEAK Apply For Benefits Page 16

17 Your Interview In some cases, people who are applying for benefits have an in-person interview with an application site worker. You will be contacted by your local application site with the time and date of your interview, if applicable. Preferred method of contact: Phone Interpreter Language? Electronic Signature By signing this form, I certify that I have reviewed this application; I understand and agree to the Rights, Responsibilities and Penalties and under penalty of perjury, I certify the information I have given is true including the information concerning citizenship and alien status. I have received information on how to apply, what information is available, and what I may need to give the county to help me with getting benefits. By checking this box and typing my name below, I am electronically signing my application. Uni Cycle Oct 09, 2013 at 7:10 PM PEAK Apply For Benefits Page 17

18 What I Should Know PLEASE KEEP THIS FOR YOUR INFORMATION. By completing and signing the State of Colorado Application for Public Assistance and other documents required to determine whether I'm eligible for public assistance benefits AND by accepting benefits that I am eligible to receive, I understand the following information and agree to the following requirements: I must tell the truth; it is a crime to lie on this application. I may have to give papers that show what I've told you is true. I must tell you of any changes in money I get. I must tell you of any changes to the information I gave you on my application. If I think you made a mistake, I can ask for an appeal or fair hearing. In accordance with Federal law and U.S. Department of Agriculture (USDA) and U.S. Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs. To file a complaint of discrimination, contact USDA or HHS Write USDA Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C or call (800) (voice) or (202) (TTY). Write HHS Director, Office of Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C or call (202) (voice) or (202) (TTY). USDA and HHS are equal opportunity providers and employers. The department will verify citizenship and immigration status for everyone applying for benefits. The department will tell you if your benefits change. The department will take back any benefits you should not have received. I understand that in order to receive Food Assistance, certain members of the household need to register for work. This means that certain members of the household must: Report to the Employment First (work program) when the Food Assistance office schedule you for an appointment. Comply with the instructions the Employment First (work program) gives you, including reporting for all scheduled appointments and following through on the written agreements you sign. Provide information to the Food Assistance office or the Employment First (work program) about any jobs you get while you are on Food Assistance. Tell the Food Assistance office or Employment First (work program) if you are not able to work you will be asked to provide verification; work any Workfare Hours you are assigned; go to job interviews arranged for you. If you do not do what you are assigned to do, you may be disqualified from receiving Food Assistance benefits. If you are an adult between the ages of 18 and 49, with no children under the age of 18 in your Food Assistance household, you will only be able to get Food Assistance benefits for three months during the next three years unless: You work in a job 80 hours each month and report that information to Employment First (work program); or you work your assigned hours in your county s Employment First (work program), including workfare; or The Employment First (work program), or you are determined to be physically or PEAK Apply For Benefits Page 18

19 mentally unable to work, or the Food Assistance office tells you that you are exempt. As long as you do one of these activities each month, you will be able to receive Food Assistance benefits if you are otherwise eligible. The Department of Health Care Policy and Financing (HCPF) is the state agency responsible for Medical Assistance Programs in Colorado. The Department of Human Services is the state agency responsible for the other public assistance programs. The County Departments of Human/Social Services and Medical Assistance Sites are the agencies that receive and process applications for all public assistance programs. In this statement, the term "department" is used to refer to all agencies. I must give the department all needed proof and documents before qualifying for benefits. If there is an absent parent(s) from my home and I am applying for Medicaid, I must seek medical support from the absent parent(s). I may contact Child Support Enforcement for assistance. I am responsible for paying fees and co-payments for myself and my family if they are required for Medical Assistance benefits. If enrolled in Medicaid and other insurance is paying for medical care, Medicaid will pay last. The information I give on the application and in the application interview is confidential. But, the department can use or share the information with other program(s) that any of my family members are getting or are applying. The information can only be used for purposes of treatment, payment, determining eligibility, and other program and administrative operations, or other purposes permitted by law for my family members or me. It is a crime to lie on the application or to take benefits that I know that my family and I are not eligible to receive and I may be subject to criminal prosecution for knowingly providing false information. Giving false information may be punished by a fine of up to $250,000 or a jail term of up to 20 years, or both. A person found to have intentionally given false information cannot get food assistance and/or Colorado Works/TANF for 12 months for the first offense, 24 months for the second offense, and permanently for the third offense. A court can also stop a person from getting food assistance for another eighteen months. This crime is subject to prosecution under other federal laws. Receiving duplicate benefits of food assistance by lying about identity or residence will be a 10-year disqualification. The department will notify me in writing of how and when to tell the department of any changes. If I do not tell the truth on my application or if information is left off of the application, or if I do not report changes to the department, as required, I may lose my assistance, and I may have to pay the department for the assistance received when I was not eligible, including Medical Assistance received and medical premium payments. Income tax refunds the persons on my application and I might get, may be taken to pay back money to the department. The law says the department must check the immigration status and citizenship for anyone who is applying. They will not check immigration status of family members who are not applying for benefits. I may be requested to verify proof of non-citizen registration documentation received from the United States Citizen and Immigration Service (USCIS) for every non-citizen member in my house who is applying for benefits. The department will verify information with USCIS and any information received from USCIS may affect my eligibility and benefits. Federal law (Public Law 97-98) requires me to give the department the Social Security number and/or alien registration number of all persons who are applying for public assistance. I must also provide the Social Security number and/or alien registration number for all sponsors. PEAK Apply For Benefits Page 19

20 I do not have to be a U.S. citizen to apply for assistance. Both U.S. citizens and qualified non-citizens may be eligible for Medical Assistance. Please do not let the fear about immigration status stop you from seeking benefits for your family. Receiving Medical Assistance will not stop you from gaining lawful permanent residence or U.S. citizenship. If I am a resident of an institution and jointly applying for SSI and food assistance prior to leaving the institution, the filing date of the application is my date of release from the institution. Processing time will begin from the date the application is received in the food assistance office. Privacy Act Information: The department is authorized to collect information on the application, including Social Security numbers and will confirm information that may affect initial or ongoing eligibility and payments for all persons listed on my application. I am allowing the department to use Social Security numbers and other information from my application to request and receive information or records to confirm the information in my application. Food assistance will be denied to individuals that do not provide a Social Security number, and Social Security numbers will be used and disclosed in the same manner for both eligible and ineligible members. The EBT (or Quest) card is used to pay me most of my public assistance benefits. I cannot trade or sell EBT cards or use, or have in my possession, EBT cards that are not mine and I cannot let someone else use my EBT card. If I think the department made a mistake, I can ask for a Fair Hearing. The department will tell me in writing how to make an appeal. I may request an appeal for any action on any program except for the CHP+ program. If I think the CHP+ program made a mistake, I can ask for an appeal. CHP+ tells me about how to make an appeal in writing. Colorado Works is Colorado s TANF (Temporary Assistance for Needy Families) program. It is not an entitlement program and benefits are not guaranteed. Each county has the authority to determine eligibility requirements and benefit levels. To remain eligible, I may be required to complete an assessment and develop a plan. Unless exempted, I will be required to participate in work readiness activities. As an applicant for Colorado Works, I am required to assign all rights to child support that may be received on my behalf or for those in my household that I am applying for. This assignment starts when I am determined eligible and will continue until my Colorado Works benefits end. If I do not do this or refuse to cooperate with Child Support Enforcement at the time I apply or while receiving cash assistance through Colorado Works, without good cause, I will not receive assistance or a basic cash assistance grant for my family. To receive food assistance all members of the house that are required to register for work must follow all requirements (comply with) Employment First. Anyone who does not follow the work requirements may be disqualified from receiving food assistance. If I am an adult between the ages of 18 and 49, with no children under the age of 18 in my food assistance house, I will only be able to get food assistance benefits for three months during the next three years unless: I work in a job 80 hours each month and report that information to Employment First; or I work my assigned hours at my Employment First office, including Workfare or the Employment First work program; or I am determined to be physically or mentally unable to work; or the food assistance office tells me that I am exempt. As long as I do one of these activities each month, I will be able to receive food assistance benefits if I am otherwise eligible. PEAK Apply For Benefits Page 20

21 I must cooperate fully with state and federal staff if my case is reviewed. My information on this application may be reviewed and verified by the department, or its representatives. My house will not be eligible for food assistance if I refuse to cooperate with any review of my case, including a quality control review. I cannot use food assistance benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit accounts. A person found guilty of using food assistance to illegally purchase controlled substances shall be disqualified for two years for a first offense and permanently for a second offense. Individuals found by a Federal, State, or local court to have used or received benefits in a transaction involving the sale of firearms, ammunition, or explosives shall be permanently ineligible to receive food assistance upon the first occasion of such violation. An individual convicted by a Federal, State, or local court of having trafficked benefits for an aggregate amount of $500 or more shall be permanently ineligible to receive food assistance upon the first occasion of such violation. I will immediately notify the State of any medical claim or lawsuit I have. I will cooperate with the State in collecting the medical bills the State has paid. The State may collect from any insurance company or court settlement for medical bills that the State has paid. If I am on Medical Assistance and receive money for the same medical bills that the State has paid, I will give the money to the State. I assign to the State all rights to payment for medical expenses and treatment. I also assign my right to appeal a denial of benefits by another party responsible for payment for the benefits to the State. The Medical Assistance Estate Recovery Program authorizes the department to recover all medical assistance benefits paid on behalf of Medicaid clients, including capitation payments, from the estates of deceased Medicaid clients who were permanently institutionalized or were over the age of 55 when benefits were provided. The Federal and State laws governing estate recovery also provide for certain exemptions to the medical assistance Estate Recovery Program. For further information or questions please contact the department and request "The Medical Assistance Estate Recovery Program" brochure. If I do not report and provide proof of rent, mortgage, housing fees, property insurance, property taxes, court ordered child support payments, child or adult care, and medical expenses paid by elderly or disabled members, I am stating that I do not want that specific deduction used to determine my food assistance benefit amount. Domestic violence information and services are available to me. If I ever feel I am in immediate danger I will call 911. If I would like to receive information regarding safety and services in Colorado, I will call the Colorado Coalition Against Domestic Violence at or toll free at I may also find the location of services near me by going to colorado.gov/cdhs/dvp. The National Domestic Violence Hotline at SAFE (7233) or TTY or ndvh.org can also provide information. If I am a survivor of domestic violence, sexual assault, or stalking the Address Confidentiality Program (ACP) can provide me with a legal substitute address to use instead of my real address for use with state and local government agencies. I can find out more about ACP at acp.colorado.gov. If I need or receive either of these services I will tell my department worker. PEAK Apply For Benefits Page 21

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