
State of Alabama
Department of Human Resources
Food Stamp Application
AGENCY USE ONLY: DATE RECEIVED
FS Case Number ___________________________ BY COUNTY
Name ______________________
Race/Sex _______ IEVS Function ______
Check Digit _____ Process Std. ________
FA Case No. ____________________
Appointment Date _____________ Time _________
You have the right to file an application the same day you contact the Food Stamp Office. To file an application, you need only
complete your name, address, and signature, and turn this form into the county Food Stamp Office where you live. We
will interview you to decide if you are eligible. You will receive benefits from the date we received your signed application if you
are determined eligible.
YOUR NAME (First, Middle, Last) Birth date (Mo., Day, Yr.) Social Security Number
Mailing Address Street Address, if different
City State Zip Code Telephone/Message Number during
the day
Expedited Services
You may get food stamps benefits within 7 calendar days if: your food stamp household has less than $150 in monthly
gross income and liquid resources such as cash, checking or savings accounts are less than or equal to $100 or; your
rent/mortgage and utilities are more than your household’s combined monthly income and liquid resources or;
a member of your household is a migrant or seasonal farm worker.
1. How much money do the members of your household have in cash or a bank account? $__________________
2. What is the total amount of income you expect your household to receive this month? ___________________
3. What is your current monthly rent/mortgage payment? $________Utilities other than phone? $______________
4. Is anyone in your household a migrant or seasonal farm worker? Yes No
If yes, answer these questions: Did all of your household income stop recently? Yes No
Does anyone in your household expect to receive income from a new source this month? Yes No How
much?____________
In accordance with Federal law and U. S. Dept. of Agriculture policy, this institution is prohibited from discriminating
on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of
discrimination, write: USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410
or call (800) 795-3272 (voice) or (202) 401-720-6382 (TTY) USDA is an equal opportunity provider and employer.
Penalty Warnings, Perjury Statement and Signature
When your household receives food stamp benefits, you must follow all the rules. You must provide true and complete
information about everyone in your household and you must provide documents to prove what you say if you are asked to by the
worker. The Social Security numbers for all household members will be used in computer matches with other agencies in
determining eligibility for food stamps. Any member who breaks any of the rules on purpose can be barred from the Food Stamp
Program for one year 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. There are also penalties if any household member is found
guilty of using food stamp benefits to purchase illegal drugs or firearms.
♦ Do not trade or sell food stamp benefits or EBT cards.
♦ Do not use someone else’s food stamp benefits, identification card or EBT card for your household. ♦
Do not give false information or hide information to get or continue to get food stamps.
I certify under penalty of perjury that my answers to all questions about each household member, including
those about citizenship or alien status, are correct and complete.
Household Member Signature or mark (X) Date
Witness if Signed with X
DHR-FSP-2116 1