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1 WORKING WITH STRUGGLING RHODE ISLAND RESIDENTS 50+ TO WIN BACK OPPORTUNITY INFORMATION TO HELP YOU: Increase your income Save money on prescription drugs Pay doctors bills Buy groceries Cover other basic costs YOUR GUIDE TO PUBLIC BENEFITS IN RHODE ISLAND It s hard to be a good provider if you are in crisis yourself. If you are faced with circumstances beyond your control, you need an opportunity to regroup, so you can go back to being a source of help and hope for friends and family. AARP Foundation is here for everyone, 50 years of age or older, who is struggling with problems of hunger, isolation, income, and housing. In addition, we are working side-byside with trusted organizations in your community and nationwide to help you take control, move forward, and feel like a good provider again. Program guidelines, telephone numbers, and Web sites are subject to change. For the most up-to-date information in your state, log on to Benefits QuickLINK at: quicklink. Last updated: 9/2013

2 YOUR GUIDE TO PUBLIC BENEFITS IN RHODE ISLAND PAYING FOR HEALTH CARE AND PRESCRIPTION DRUGS Medicare Benefit: Medicare is health insurance that helps pay for preventive care, doctor visits, hospital stays, and prescription drugs. Who can apply: You must be 65 years of age or older or under age 65 and meet the disability guidelines. How to apply: To apply, call the Social Security Administration at: and tell the operator where you live. You can also go to: www. socialsecurity.gov and click on the Medicare section. For information about Medicare Prescription Drug Coverage, call Medicare at: MEDICARE ( ) or go to: For help in your state, call the Rhode Island Senior Health Insurance Program (SHIP) at: or go to: Medicare Savings Programs Benefit: This benefit helps pay for some of your Medicare costs, which can include the Part A and B premiums, deductibles, and co-payments. The amount of help you get depends on your income and resources. Who can apply: You must have Medicare and have limited income of around $1,313 per month (single) or $1,765 per month (married). How to apply: For more information and to find out how to apply, contact your local Department of Human Services (DHS) at: To find your local office, go to: and click on Contact Us then click on DHS Offices and then choose the program. Medicare Rx Extra Help Benefit: This benefit lowers the cost of your prescription drugs offered through Medicare Prescription Drug Coverage (Part D). The monthly premium, deductible, and co-payments you pay depend on your income and resources. Who can apply: You must have Medicare and have limited income and resources. Your income must be less than $17,235 a year and your resources must be less than $13,300 if you are single. If you are married and living together, your income must be less than $23,265 a year and your resources must be less than $26,580. How to apply: To apply online, go to: www. socialsecurity.gov and click on the Medicare section. If you need help applying, call the Social Security Administration at: For help in your state, call the Rhode Island Senior Health Insurance Program (SHIP) at: or go to: Rhode Island Pharmaceutical Assistance to the Elderly (RIPAE) Benefit: The RIPAE program helps you pay for your prescription drugs. Based on your income, you will pay 40 percent, 70 percent, or 85 percent of the discounted RIPAE price for prescription drugs. You must enroll in a Medicare Prescription Drug Plan (Part D) to get RIPAE. RIPAE will cover prescriptions during the Medicare Prescription Drug Plan's deductible and coverage gap (donut hole) periods. It will also pay for drugs that are not covered by the Medicare Prescription Drug Coverage. Who can apply: To get help from RIPAE, you must be 65 years of age or older or between age 55 and 64 and receiving Social Security Disability checks. In addition, you must have limited income 2

3 YOUR GUIDE TO PUBLIC BENEFITS IN RHODE ISLAND and be enrolled in Medicare. You cannot be on Medicaid. How to apply: For more information or to find out how to apply, call the program at: or contact the Division of Elderly Affairs at: or (TTY). You can also go to: prescription_assist.php. Medicaid Benefit: Medicaid helps make medical coverage more affordable and pays for services such as: hospital care (inpatient and outpatient), health center and clinical services, visits to your healthcare providers (including physician and nurse practitioner), lab tests and x-ray services, nursing home care, and prescription drug coverage (in certain cases). In addition, if you have Medicare, Medicaid may help pay for some of your Medicare costs. Who can apply: You must have limited income and resources and be 65 years of age or older, blind, and/or have a disability. In some cases, you can get Medicaid if you have high medical bills. The income and resource guidelines can vary for the different types of Medicaid programs available. How to apply: For more information and to find out how to apply, contact your local Department of Human Services (DHS) at: To find your local office, go to: and click on Contact Us then click on DHS Offices and then choose the program. HELP WITH YOUR HOME State Property Tax Assistance Benefit: Rhode Island has a property tax relief program that can give you a rebate on some of the property tax or rent you paid. You can receive a rebate of up to $300 and the amount you receive depends on other circumstances, such as your income and how much annual property tax/rent you paid. Who can apply: You can get help from this program if you are a homeowner or a renter. If you are a homeowner, the home must be your primary place of residence and you must pay property taxes on it. If you are a renter, you must be responsible for the lease and payment of the rent. How to apply: For more information and to find out how to get the benefit, call the Rhode Island Division of Taxation at: (option 3) or or go to: Low Income Home Energy Assistance Program (LIHEAP) Benefit: LIHEAP provides your household with a cash grant to help you meet your home heating and cooling costs. The grants are paid either directly to you or to your energy company. Who can apply: You must have limited income to get LIHEAP. In addition, you must pay your own gas and/or electric bill (either directly or included with your rent). How to apply: For additional information or help applying, contact your local Community Action Program (CAP) or call the Office of Energy Resources at: To find your closest CAP office, go to: cap.php. Telephone Assistance/Lifeline Benefit: Lifeline offers monthly discounts on your basic wireless or home telephone service. The discounts can include a lower phone bill or 3

4 YOUR GUIDE TO PUBLIC BENEFITS IN RHODE ISLAND free wireless minutes. Who can apply: You can get help if you have limited income or are enrolled in one of the following programs: Medicaid, Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF), Low Income Home Energy Assistance Program (LIHEAP), Supplemental Nutrition Assistance Program (SNAP), and/or Public Housing or Section 8. How to apply: To get more information, call the Universal Services Administration Company at: or go to: org/ls. HELP BUYING NUTRITIOUS FOOD Supplemental Nutrition Assistance Program (SNAP) Benefit: This program helps you and your family buy food needed for good health. Each month, your state will put money onto a special debit card (called an EBT Card) so that you can buy food from most grocery stores. The amount of money you get on these cards depends on where you live, your household income, and how many people live in your household. CASH INCOME Social Security Benefit: Social Security offers you a cash benefit based on your work history and the amount you paid into Social Security. The cash benefit helps you meet your needs due to loss of income as a result of retirement, disability, or death. You and your dependents or surviving spouse can receive the Social Security benefit. The benefit amount you will get depends on the earning records for the person who worked. Who can apply: To get Social Security retirement benefits, you must have met the work requirements and paid into the Social Security system. You can get the Social Security retirement benefits starting as early as age 62. However, the benefit amount you get will be reduced if you take the benefit before you reach full retirement age. Who can apply: You can get nutrition assistance if your household has limited income. The program rules are more generous if there is at least one person who is elderly (60 years of age or older) or has a disability living in the household. How to apply: For more information and to find out how to apply, contact your local Department of Human Services (DHS) at: To find your local office, go to: and click on Contact Us then click on DHS Offices and then choose the program. To get the Social Security disability benefit, you must have become severely disabled while working. You can get this benefit at any age and must have met the work requirements. The number of quarters you will have needed to work depends on your age. How to apply: You can apply for Social Security online at: and click on Retirement or Disability. You can also apply in person at your local Social Security office. To find your local Social Security office, go to: gov/pgm/reach.htm and click on "Find an Office" or call: Supplemental Security Income (SSI) Benefit: SSI provides a cash benefit to you every month to make sure you have a minimum level of 4

5 YOUR GUIDE TO PUBLIC BENEFITS IN RHODE ISLAND income so that you can pay for basic needs such as: food, clothing, and shelter. Who can apply: You may get help from this program if you are 65 years of age or older, blind, or have a disability. In addition, you must have limited income and resources. Some resources such as your home, car, and certain portions of life insurance and burial accounts may not be counted when determining whether you meet the program guidelines. How to apply: You must make an appointment at your local Social Security office to apply. You can find your local Social Security office by calling: or go to: links_ssi.htm. OTHER INFORMATION Eldercare Locator The Eldercare Locator connects you to local sources of information for senior services. You can get help by calling: (hours of operation are Monday Friday, 9 am 8 pm ET) or visiting: Senior Information Help Line The Rhode Island Division of Elderly Affairs can connect you to agencies in your state that provide programs and resources for older adults. Call the Division of Elderly Affairs at: or (TTY) or go to: You can also contact THE POINT, Rhode Island s Aging and Disability Resource Center, at: or (TTY) or go to: ri.gov. Legal Help If you need a lawyer but have limited resources, contact the Area Agency on Aging (AAA) in your area for help. You can also call Rhode Island Legal Services at: (Providence) or (Newport) or go to: Benefits QuickLINK If you want to get more information about what benefits you may be able to get help with and how to apply, go to Benefits QuickLINK at: org/quicklink. 5

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7 R h o d e I s l a n d C o m m u n i t y F o o d B a n k R e g i o n a l D i r e c t o r y Appendix E Services to Seniors & Adults with Disabilities THE POINT 50 Valley St. Providence, RI The POINT Rhode Island s Aging and Disability Resource Center (ADRC). It is a one-stop center for options counseling, and information and referral for programs and services that support seniors, adults with disabilities, families, and caregivers. THE POINT staff has the ability to communicate with persons for whom English is not their primary language. The Rhode Island Department of Human Services, Division of Elderly Affairs funds THE POINT and the regional POINTS with funding from the Centers for Medicare and Medicaid Services (CMS). SHIP Senior Health Insurance Program RI Dept. of Elderly Affairs (TTY) SHIP is part of a national partnership to help consumers make informed health care choices. SHIP volunteers provide one-to-one counseling to seniors, adults with disabilities, families, and caregivers. The program is designed to help seniors and adults with disabilities understand health care cost and coverage. SHIP counselors can discuss Medicare, Medicare Part D, supplemental insurance, Medicare Advantage plans, and other health insurance options. In the next year, there will be changes in Medicare due to the full implementation of the Affordable Care Act and to Medicaid as a result of the implementation of the Integrated Care Initiative for persons enrolled in both Medicare and Medicaid. SHIP counselors will be able to assist beneficiaries in making the most appropriate choice for their health care needs. The Ocean State Senior Nutrition Program This program provides nutritionally balanced, hot lunches, five days a week at more than 65 meal sites, for persons who are 60, and eligible adults with disabilities. Donations are accepted, but no one is refused a meal if he/she is unable to contribute. Transportation to the nearest meal site is available. The best references for all services to Seniors and Adults with disabilities are: Rhode Island State Offices: Division of Elderly Affairs - or call Annual Pocket Manual The Rhode Island Guide to Services for Seniors and Adults with Disabilities or call *This guide includes a complete listing of Senior Centers in RI United Way or The Point, or dial Also see: rifoodbank.org >> Member Agencies >> Agency & Community Resources >> Community-Based Resources & Programs P a g e 57

8 R h o d e I s l a n d C o m m u n i t y F o o d B a n k R e g i o n a l D i r e c t o r y Town Senior Center SHIP Agency POINT Regional Office Barrington Barrington SC, 281 County Rd , Bristol Benjamin Church SC, 1020 Hope St , Barrington SC, East Bay CAP, 610 Waterman, E Prov., East Bay CAP, 610 Waterman, E Prov., Nutrition Program East Bay (Ocean State) Nutrition Prog., Barrington SC, East Bay (Ocean State) Nutrition Prog., Benjamin Church SC Burrillville Tri-Town CAP, Johnston, Senior Services, Inc., Pascoag-Bradford Central Falls Ralph J. Holden Ctr., 361 Cowden St , Ralph J Hoden Community Ctr, East Bay CAP, 610 Waterman, E Prov., Blackstone Health NP, Forand Manor; Progreso Latino; Wilfred Manor Charlestown Charlestown SC, 100 Park La , So. County CAP, So. Kingstown, Westbay Program, Charlestown SC Coventry Coventry SC, 50 Wood St , Coventry SC, Westbay CAP, Warwick, Blackstone Health NP, Coventry SC Cranston Cranston SC, 1070 Cranston St , Cumberland Cumberland SC, 1464 Diamond Hill Rd , East Greenwich East Greenwich Senior Services, 125 Main St , East Providence East Providence SC, 610 Waterman Ave , Exeter Foster 181 Howard Hill Rd., 02825, Glocester 1210 Putnam Pike, 02814, Hopkinton Main St. Crandall House, Ashaway, 02804, Cranston Senior Services, East Providence SC, Tri-Town CAP, Johnston, Tri-Town CAP, Johnston, Westbay CAP, Warwick, East Bay CAP, 610 Waterman, E Prov., So. County CAP, So. Kingstown, Tri-Town CAP, Johnston, Tri-Town CAP, Johnston, So. County CAP, So. Kingstown, Blackstone Health NP, Cranston SC; Temple David Senior Services, Inc., Chminey Hill Apts.; Cumberland Manor; Cumberland SC Westbay Program, St. Luke's Church East Bay (Ocean State) Nutrition Prog., E. Providence SC, ; Goldsmith Manor, ; Harbor View Manor (Riverside), Senior Services, Inc., Glocester SC Crandall House - Limited Service, P a g e 58

9 R h o d e I s l a n d C o m m u n i t y F o o d B a n k R e g i o n a l D i r e c t o r y Town Senior Center SHIP Agency POINT Regional Office Nutrition Program Jamestown Jamestown SC, 6 West St , Johnston Johnston SC, 1291 Hartford Ave , Lincoln Little Compton Lincoln SC, 150 Jenckes Hill Rd, 02865, Middletown Middletown SC, 650 Green End Ave , Narragansett Narragansett SC, 53 Mumford Rd , New Shoreham Newport Edward King House, 35 King St , // Martin Luther King Ctr., 20 West BRd.way 02840, // Park Holm SC, 1 Eisenhower Rd., 02840, No. Kingstown North Kingstown SC, 44 Beach St , No. Providence Salvatore Mancini Ctr., 2 Atlantic Boulevard 02911, No. Smithfield Pawtucket Leon Mathieu SC, 420 Main St , Johnston SC, Lincoln SC, No. Kingstown SC, Salvatore Mancini Ctr., Leon Mathieu SC, Child & Family Service Newport Cnty, Middletown, Tri-Town CAP, Johnston, Tri-Town CAP, Johnston, Child & Family Service Newport Cnty, Middletown, Child & Family Service Newport Cnty, Middletown, So. County CAP, So. Kingstown, So. County CAP, So. Kingstown, Child & Family Service Newport Cnty, Middletown, So. County CAP, So. Kingstown, Tri-Town CAP, Johnston, Tri-Town CAP, Johnston, East Bay CAP, 610 Waterman, E Prov., Westbay Program, Jamestown SC Blackstone Health NP, Johnston SC Senior Services, Inc., Lincoln SC East Bay (Ocean State) Nutrition Prog., Middletown SC, East Bay (Ocean State) Nutrition Prog., Donovan Manor, Blackstone Health NP, Beechwood House Blackstone Health NP, Steve Piccillo Ctr.; Salvatore Mancini Ctr Senior Services, Inc., The Meadows Blackstone Health NP, Leon Mathies SC P a g e 59

10 R h o d e I s l a n d C o m m u n i t y F o o d B a n k R e g i o n a l D i r e c t o r y Town Senior Center SHIP Agency POINT Regional Office Nutrition Program Portsmouth Portsmouth SC, 110 Bristol Ferry Rd , Portsmouth SC, Child & Family Service Newport Cnty, Middletown, East Bay (Ocean State) Nutrition Prog., Portsmouth SC, Providence Richmond Capital City Senior Programs, 85 Chalkstone Ave , // DaVinci Community Ctr., 470 Charles St , // Federal Hill Community Ctr., 9 Courtland St , // Fox Point SC, 90 Ives St , // Hamilton House, 276 Angell St , // Hartford Park SC, 20 Syracuse St , // Jewish Community Ctr., 401 Elmgrove Ave , // Lillian Feinstein Ctr., 1085 Chalkstone Ave., 02908, // Nickerson House SC, 133 Delaine St , // Silver Lake Ctr., 529 Plainfield St , (Voice/TTY) // St. Martin deporres SC, 160 Cranston St , // Washington Park Ctr., 42 Jillson St , // West End Community Ctr., 109 Bucklin St , Richmond Adult Center, 1168 Main St , Scituate ScituateSC, 1315 Chopmist Hill Rd , DaVinci Ctr., ; Hamilton House, ; Lillian Feinstein Ctr., ; St. Martin deporres Ctr ; Westminster SC, United Way ( ); St. Martin deporres ( ) So. County CAP, So. Kingstown, Tri-Town CAP, Johnston, Meals on Wheels, Carrol Towers, Ctr. for Southeast Asians, Federal Hill House, Fox Point SC, St. Elizabeth's Place, St. Martin deporres // Blackstone Health NP, DaVinci Ctr.; Elmwood Community Ctr.; Lillian Feinstein SC; Jewish Community Ctr. Blackstone Health NP, Scituate Sc P a g e 60

11 R h o d e I s l a n d C o m m u n i t y F o o d B a n k R e g i o n a l D i r e c t o r y Town Senior Center SHIP Agency POINT Regional Office Smithfield Smithfield SC, 1 William J. Hawkins Trail 02828, So. Kingstown The Center, 25 St. Dominic Rd , Smithfield SC, So. Kingstown SC, Tri-Town CAP, Johnston, So. County CAP, So. Kingstown, Nutrition Program Senior Services, Inc., Smithfield SC Westbay Program, Larry Tetreault Ctr. Tiverton Tiverton SC, 207 Canonicus Rd , Tiverton SC, Child & Family Service Newport Cnty, Middletown, East Bay (Ocean State) Nutrition Prog., Tiverton SC, Warren Warren SC, 20 Libby Lane 02885, East Bay CAP, 610 Waterman, E Prov., East Bay (Ocean State) Nutrition Prog., Warren SC, Warwick JONAH Community Center, 830 Oakland Beach Ave , // Pilgrim SC, 27 Pilgrim Parkway 02888, Pilgrim SC, Westbay CAP, Warwick, Westbay Program, Pilgrim SC; Shalom Housing; Sparrow I Housing; Sparrow III Housing, Harding Brook Housing West Greenwich Westbay CAP, Warwick, West Warwick West Warwick SC, 145 Washington St , Westbay CAP, Warwick, Westbay Program, West Warwick SC Westerly Westerly SC, 39 State St , Westerly SC, So. County CAP, So. Kingstown, Westbay Program, Westerly SC; Parview Manor Woonsocket Woonsocket SC, 84 Social St , Woonsocket RSVP, Tri-Town CAP, Johnston, Senior Services, Inc., Woonsocket SC, Parkview Manor, Kennedy Manor, Crepeau Court Rhode Island Community Food Bank 200 Niantic Ave Providence, RI For information or corrections, contact: Mev Miller Community Resource Manager Edition Current Version May P a g e 61

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13 OSCIL 1944 Warwick Avenue Warwick, RI Access to Information OSCIL has a website, oscil.org, a Facebook page and publishes a quarterly newsletter, Signs of Independence, to enable consumers with disabilities, service providers, and the community at large to keep informed of statewide community resources and disability issues. Specialized Services Ocean State Center for Independent Living Services at the Center include individual and community advocacy, information and referral, peer support, housing assistance, independent living skills training, assessment services, Deaf Services, Gift of Hearing program, Nursing Home Transition program, Young Adult Transition program, community outreach, disability awareness, and assistance in the attainment of assistive devices and home modifications as related to goals for increased independence Warwick Ave Warwick, RI x (Toll Free) (VP) Website: oscil.org

14 WHAT IS OSCIL? OSCIL is a non-residential, consumer-driven, community-based, cross-disability, nonprofit organization. OSCIL was established in 1988 to provide a range of independent living services to enhance, through self direction, the quality of life for persons with disability and to promote integration into the community. OSCIL is governed by an active Board of Directors comprised largely of persons having disabilities, who play a major role in setting policy and programming. GENERAL ELIGIBILITY REQUIREMENTS The presence of a disability Motivation to actively participate in an independent living program Indication that the consumer will benefit from participation in services For information on OSCIL s services, programs and eligibility requirements, please contact our office. ADVOCACY SERVICES OSCIL provides both individual and systems advocacy services. Consumers are provided information and support to become self advocates. INFORMATION & REFERRAL An active Information and Referral program provides consumers and their families, service providers, and the general public with information on a wide array of community resources and disability services. Information can be obtained via telephone, , fax or in person. OSCIL s Signs of Independence newsletter provides information on disability issues to consumers and service providers. PEER SUPPORT OSCIL offers opportunities for persons with disabilities to share similar interests and concerns and gain greater awareness and control over their lives. INDEPENDENT LIVING SKILLS TRAINING OSCIL staff work with self-directed consumers to set goals that will enable the consumers to be self-sufficient and independent in their home and community. Basic life skills training may include budgeting, meal preparation, arranging transportation, and/or self-advocacy. Life skills training is goal-directed and does not involve long-term case management or therapeutic intervention. HOUSING OSCIL provides assistance to locate affordable and/or accessible housing, complete the application process, and assists consumers to connect to community resources. OSCIL also helps consumers to acquire assistive devices to support independence in the home. ASSISTIVE TECHNOLOGY INFORMATION A partner in the Assistive Technology Partnership (ATAP), OSCIL provides elders and individuals with disabilities with information about how low tech equipment and assistive devices may enhance their independence. ASSESSMENT SERVICES We are able to assist other agencies in finding the best solutions for increased independence for their consumers by offering comprehensive assessment services in the areas of independent living, assistive technology and home modifications. These services are provided on a fee for service basis. DEAF SERVICES Highlights for this program include advocacy services, citizenship training, driver education to prepare for the written exam, and education on the use of the video phone, CapTel phone and Relay Service. HOME ACCESSIBILITY & ADAPTIVE EQUIPMENT OSCIL helps consumers with home modifications and the acquisition of adaptive equipment as part of their independent living goal to remove barriers to independence. Individuals must meet income and eligibility requirements. COMMUNITY LIVING OPTION - NURSING HOME TRANSITION PROGRAM Individuals with significant disability who are living in nursing homes can request assistance from OSCIL to move from the nursing home to a less restrictive environment. OSCIL s experienced staff will assist the consumer with community connections for a safe transition. YOUNG ADULT TRANSITION PROGRAM Assists young adults (ages 18-24) who are self directed to transition to community independence. OSCIL provides basic independent living skills training, peer support, and information on disability and community resources. DISABILITY RESOURCE CENTER OSCIL is a designated location for The Point, RI s Aging & Disability Resource Center (ADRC), offering information on disability resources as well as being a satellite walk-in site offering one-to one services for persons seeking disability related information.

15 SNAP INCOME GUIDELINES People in household Gross monthly Income FOR SENIORS & DISABLED Many seniors over the age of 59 have not applied for SNAP. Could you be one of them? SNAP is the Supplemental Nutrition Assistance Program Each Additional $1,916 $2,586 $3,256 $3,926 $670 ** If your income is above this, you may still be eligible. We can help you figure it out. ** Important Facts: The value of your car, house, life insurance, or savings does not impact your eligibility for SNAP. Receiving benefits doesn t take away from others in need. In fact, SNAP benefits help everyone; you, your grocer, and the local economy. You are not alone. A Food Bank Outreach worker can provide application assistance to you. Worried about getting to DHS for the determination interview? DHS interviews can be done by phone so you don t have to leave your house. The SNAP application for seniors is only 3 pages long. SNAP recipients are also eligible for many other benefits such as energy assistance and lower phone rates. Recurring monthly out-of-pocket medical expenses that exceed $35 a month may be deducted. Once you are found eligible, you only have to recertify every two years, if all members of your household are on a fixed income. Contact: RI Community Food Bank Community Resource Coordinators Robin Covington, Mev Miller, Prepared by RI Community Food Bank for use by our Member Agencies & their guests. All information has been confirmed using reliable sources. Last Updated November 2013

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17 RHODE ISLAND DEPARTMENT OF HUMAN SERVICES APPLICATION FOR SNAP SERVICE FOR ELDERLY HOUSEHOLDS For Office use only: Screener s Name: Date Screened: Intake: Do you speak English? Yes No If no, what is the primary language spoken? Can you read and write in English? Yes No If you do not speak English, does any adult member of the household speak English? Yes No Your Last Name: Your Date of Birth: / / Month Day Year Your First Name: Your Social Security Number Your Middle Initial: Maiden / Other Names: Your Address (where you live): Apartment/Floor: City: State: Zip: Your Mailing Address (if different) Apartment/Floor: City: State: Zip: Your Telephone Number (home): Other: Do you need help filling out this application? Yes No If you wish to authorize someone other than yourself to apply on your behalf, please indicate below: Name: Date of Birth Telephone Number: MM DD YYYY Street/Route Apt./Floor City State Zip If you have a disability of condition that makes it hard for you to understand or answer questions on this application, we can help. For example, we can read the form with you and write your answers for you. We can make other accommodations, depending on what assistance you need. Please let us know. YOU MAY GET SNAP BENEFITS WITHIN SEVEN DAYS IF OTHERWISE ELIGIBLE: 1. If your household s gross monthly income is less than $150 and your households resources, such as cash, checking or savings accounts are $100 or less; 2. If your rent/mortgage and utilities are more than your household s combined gross monthly income and liquid resources; or, 3. If you are a migrant or seasonal farm worker household. If you qualifiy for this service, we are required to provide SNAP benefits within seven (7) days from the time you give us this form during normal work hours and it is date stamped. I CERTIFY THAT THE INFORMATION CONTAINED ON THIS PAGE IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND THAT THERE ARE PENALTIES FOR NOT TELLING THE TRUTH ABOUT MY FAMILY AND MYSELF. Please sign below and continue to following pages. Signature of Applicant SNAP APP-1 Rev Date

18 List EVERY ONE in your home on THIS SIDE of the line D.O.B. (mm/dd/yyyy) Relationship to you Self List information on THIS SIDE of the line only if the person is requesting SNAP benefits U.S. Citizen?* (If NO< you will be required to provide Alien S.S.N. documentation**) YES NO YES NO YES NO YES NO Last Name First Name, MI Sex M F M F M F M F *Alien status information may be subject to verification through USCIS and such information may affect the household s eligibility and level of benefits **Alien documentation includes: Alien number; origin country, Alien Status; Entry date: Status date; Sponsor information. MY shelter arrangement is (Check one): 01 Elderly/disabled housing 02 Drug/alcohol rehab center 03 Disabled/blind group home 04 Battered Women s shelter 05 Shelter 06 Own home/trailer 07 Rent home/apt/trailer 08 Living in another s home/apt 09 No permanent address 10 Halfway house 11 Non-traditional; lobby, street, car 12 Residential care and assisted living 13 Long-Term Care Facility 99 Other (specify): Did you move to Rhode Island within the last three (3) months? Yes No If YES, Date: If yes, what was your reason for moving here? (Check One) L Looking for Employment W To get Cash, SNAP benefits, and/or Medical D Domestic violence R Close to Relative O Other (please specify) Where did you move from: Do you receive any assistance now? Yes No Have you previously applied for, or received any type of assistance payments, benefits or SNAP in R.I. or in another state? Yes No If Yes, under what name? Where? When? Type? Are you or is anyone in your household fleeing to avoid prosecution, custody, or confinement after conviction, under the law of the place from which you are fleeing, for a crime or attempt to commit a crime that is a felony under the law of the place from which you are fleeing or which, in the case of New Jersey, is a high misdemeanor under the state of New Jersey or violating a condition of probation or parole imposed under a Federal or State law? Yes No If yes, name of household member(s) Date State Have you or anyone in your household ever been found by the Department through its Administrative Hearing process of having made, or been convicted in a Federal or State court of having made a fraudulent statement or representation with respect to one s identity or place of residence in order to receive multiple benefits simultaneously under assistance from a TANF case program, Food Stamp (SNAP) program or Medicaid Assistance Program? Yes No If yes, name of household member(s) Date State SNAP APP-1 Rev

19 Has anyone in the household received any income from any source so far this month? Yes No If YES, how much gross income? TYPE OF INCOME RSDI (SOCIAL SECURITY) SSI PENSION VA BENEFITS WORKER S COMP WAGES OTHER (SPECIFY) OTHER (SPECIFY) $ GROSS AMOUNT FREQUENCY (Weekly, monthly, etc.) NAME OF RECIPIENT Did your household s only income recently stop? Yes No If Yes, when? Why? Does anyone in your household expect to receive other income later this month? Yes No If Yes, how much? When? How many people live in your home and eat with you? (include yourself) How much is your monthly rent or mortgage? Monthly Utilities: Heat: Air Conditioning: Other Utilities: Do you pay for any medical expenses such as prescriptions, over the counter medications, diabetic supplies, eyeglasses, dental expenses, hearing aid, etc.? $ per month? I certify under penalty of perjury that I have read (or have had read to me) and I understand the Notice of Rights, Responsibilities and Penalties and that my answers are correct, including information about citizenship and alien status, and complete to the best of my knowledge and belief. I know that under the state of Rhode Island General Laws, Section , a maximum fine of $1,000, or imprisonment of up to five 95) years, or both, may be imposed for a person who obtains or attempts to obtain, or aids or abets any person to obtain, public assistance to which s/he is not entitled or who willfully fails to report income, resources, or personal circumstances or increases therein which exceed the amount previously reported. Do you prefer a TELEPHONE or an IN-OFFICE interview? DATE APPLICANT S SIGNATURE SIGNATURE OF APPLICANT S SPOUSE or OTHER ADULT APPLICANT LIVING IN THE HOUSEHOLD SNAP APP-1 Rev

20 FOR OFFICE USE ONLY CASE RECORD CLEARANCE FOR PARTICIPATION PERS SEARCH PREVIOUS CASE RECORD STATUS RECORD LOCATION REQUEST DATE RIW/CASH Yes No SNAP Yes No MA Yes No RITE CARE Yes No GPA Yes No CCAP Yes No DISPOSITION: SNAP Intake Appt Date Expedited SNAP Intake Appt Date Comments: Signature of Screener Date SNAP APP-1 Rev

21 IMPORTANT: This Notice is for your information only You do not need to sign or return this page of the application to DHS RIGHTS AND RESPONSIBILITIES of Applicants/Recipients of SNAP RIGHTS You have a RIGHT to appeal and receive a Hearing before a Hearing Officer of the Department if you are dissatisfied with any Department decision, or if the Department delays in making a decision. If you request a hearing, your appeal will be heard promptly. You may be represented by a lawyer or any other person you select to appear on your behalf. Hearing forms, on which you may file your complaint, are available in every local and State Department office. If are not satisfied with any Department decision regarding your application, you have a right to request a hearing. You must request a hearing within 90 days from the date that you receive a written notice for SNAP benefits. You have a RIGHT to non-discriminatory treatment. In accordance with Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d et seq.), Section 504 of the Rehabilitation Act of 1973, as amended (29 U.S.C. 794); Americans with Disabilities Act of 1990 (42 U.S.C et seq.), and Title IX of the Education Amendments of 1972 (20 U.S.C et seq.); the Food and Nutrition Act of 2008 (formerly the Food Stamp Act); the Age Discrimination Act of 1975; the U.S. Department of Health and Human Services implementing regulations (45 C.F.R. Parts 80 and 84) and the U.S. Department of Education implementing regulations (34 C.F.R. Parts 104 and 106); and the U.S. Department of Agriculture, Food and Nutrition Services (7 C.F.R ); the Rhode Island Department of Human Services (DHS), does not discriminate on the basis of race, color, national origin, disability, religion, political beliefs, age, religion or gender in acceptance for or provision of services, employment or treatment, in its education and other program activities. Under other provisions of applicable law, DHS does not discriminate on the basis of sexual orientation. For further information about these laws, regulations and DHS discrimination complaint procedures for resolution of complaints of discrimination, contact DHS at 57 Howard Avenue, Cranston, Rhode Island 02920, telephone number (for deaf/hearing impaired or 711). The Community Relations Liaison Officer is the coordinator for implementation of Title VI; the Office of Rehabilitation Services (ORS) Administrator or his/her designee is the coordinator for implementation of the Title IX, Section 504, and ADA. The Director of DHS or his/her designee has the overall responsibility for DHS civil rights compliance. The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the basis of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation or because all of a part of an individual's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department (Not all prohibited bases will apply to all programs and/or employment activities). If you wish to file a complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at or at any USDA office, or call (866) to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to use by mail at the U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , by fax (202) or at Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) ; or (800) (Spanish). SNAP APP-1 Rev

22 For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact that USDA SNAP Hotline Number at (800) , which is also in Spanish or call the State Information/Hotline Numbers found online at USDA is an equal opportunity provider and employer. You have a RIGHT to confidentiality. The Department uses information about you and other members of your household only for purposes directly related to the administration of the programs and in compliance of the Health Insurance Portability and Accountability Act (HIPAA) Standards for Privacy of Individually Identifiable Health Information. The Department does not release information about you or other members of your household without your consent except as provided in Rhode Island General Laws and , and regulations set forth in the DHS and SNAP Policy Manuals. Any person found guilty of violating the provisions of Rhode Island General Laws shall be deemed guilty of a misdemeanor. Violators are subject to a maximum fine of two hundred dollars ($200), or imprisonment of up to six (6) months, or both. RESPONSIBILITIES You have a RESPONSIBILITY to supply the Department with accurate information and provide proof about your income, resources and living arrangements. You have a RESPONSIBILITY to tell us immediately (within ten (10) days) of any changes in your income, resources, family composition, or any other changes that affects your household. For SNAP, if you are a simplified reporter, you must report when your income exceeds 130% of the Federal Poverty Level. You have a RESPONSIBILITY to provide Social Security numbers for yourself and your household, or to apply, if you are required to, for them as a condition of eligibility. Your Social Security number, As well as the social security number (SSN) of each household member, is authorized under the Food Stamp Act of 1977, as amended, 7 U.S.C 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 all SSNs, may be referred to Federal and State agencies, as well as private claims collection agencies, for claims collection action. Providing the requested information, including the SSN of each household member, is voluntary. However, failure to provide an SSN will result in the denial of SNAP benefits to each individual failing to provide an SSN. Any SSNs provided will be used and disclosed in the same manner as SSNs of eligible household members You have a RESPONSIBILITY to report and provide proof of your expenses; you will get the maximum amount of SNAP allowed. Failure to report or provide proof of your expenses will be regarded as your statement that you do not want to receive a deduction for the unreported or unproven expense. You have a RESPONSIBILITY to cooperate fully with State and Federal personnel conducting quality control reviews. SNAP APP-1 Rev

23 DECLARATION OF APPLICANT/RECIPIENT SNAP PENALTY WARNINGS I understand that: 1. Any member of my household who intentionally breaks a SNAP rule can be barred from the SNAP Program: *For a period of one (1) year for the first violation, with the exceptions in numbers 2. and 3. below; *For a period of two (2) years after the second violation, with the exception in number 3. below; and, *Permanently for the third occasion of any intentional program violation. 2. Individuals found by a Federal, State, or local court to have used or received SNAP benefits in a transaction involving the sale of firearms, ammunitions or explosives shall be permanently ineligible for the SNAP program upon the first occasion of such violation. 3. Individuals convicted of trafficking SNAP benefits of five hundred dollars ($500) or more shall be permanently disqualified from the SNAP program. 4. Individuals found by the Department of having made, or convicted in a Federal or State court of having made, a fraudulent statement or representation with respect to their benefits simultaneously under the SNAP program would be disqualified for a ten (10) year period. DO NOT give false information or hide information to get or continue to get SNAP benefits. DO NOT trade or sell EBT cards. DO NOT use SNAP benefits to buy ineligible items, such as alcoholic drinks and tobacco. DO NOT use someone else s EBT card for your household. DHS can use or share information on this application for the administration of DHS programs, as well as the administration of other federally funded assistance programs in accordance with state and federal law, contract and regulation. DHS can release non-identifying information for research purposes. Any release of identifying information shall be done in accordance with state and federal law. I understand the questions on this application and the penalty for hiding or giving false information or breaking any of the rules listed in this Penalty Warning. PLEASE SIGN APPLICATION, Page 3 SNAP APP-1 Rev

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27 DEPARTAMENTO DE SERVICIOS HUMANOS DE RHODE ISLAND SOLICITUD PARA OBTENER EL SERVICIO DEL PROGRAMA DE ASISTENCIA NUTRICIONAL SUPLEMENTARIA (SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM, SNAP) PARA MIEMBROS ANCIANOS DE LA FAMILIA Spanish Version For Office use only: Screener s Name: Date Screened: Intake: Habla inglés? Sí No Si la respuesta es no, cuál es su idioma principal? Puede leer y escribir en inglés? Sí No Si no habla inglés, hay algún miembro adulto de la familia que hable inglés? Sí No Apellido: Fecha de nacimiento: / / Nombre: N. º de seguro social mes día año Inicial del segundo nombre: Dirección (dónde vive): Nombre de soltera/otros nombres: Departamento/piso: Ciudad: Estado: Código postal: Dirección postal (si es diferente): Departamento/piso: Ciudad: Estado: Código postal: Número de teléfono (particular): Otro: Necesita ayuda para completar esta solicitud? Sí No Si desea autorizar a otra persona para que presente una solicitud en su nombre, indíquelo a continuación: Nombre: Fecha de nacimiento: Número de teléfono : MM DD AAAA Calle/ruta Dpto./piso Ciudad Estado Código postal Si tiene una discapacidad o enfermedad que le dificulta entender o responder las preguntas de esta solicitud, podemos ofrecerle ayuda. Por ejemplo, podemos leer el formulario con usted y escribir las respuestas por usted. Podemos hacer otros arreglos, según qué tipo de ayuda necesite. Háganoslo saber. PUEDE OBTENER LOS BENEFICIOS DEL SNAP DENTRO DE SIETE DÍAS SI REÚNE TODOS LOS SIGUIENTES REQUISITOS DE ELEGIBILIDAD: 1. Si el ingreso bruto mensual de su hogar no supera los $150 y los recursos de los miembros de su familia como, por ejemplo, dinero en efectivo, cuentas corrientes o de ahorro es de $100 o menor a dicha suma, 2. Si la renta o la hipoteca y los servicios públicos superan la suma del ingreso bruto mensual y de los recursos líquidos de su hogar, o 3. Si es trabajador agrícola inmigrante o temporal. Si reúne los requisitos para obtener este servicio, tenemos la obligación de brindarle los beneficios del SNAP dentro de los siete (7) días a partir del momento en que presenta este formulario durante el horario de trabajo habitual y la fecha de sellado. CERTIFICO QUE LA INFORMACIÓN QUE CONTIENE ESTA PÁGINA ES CORRECTA SEGÚN MI LEAL SABER Y ENTENDER, Y QUE EXISTEN SANCIONES POR NO DECIR LA VERDAD SOBRE MÍ Y SOBRE MI FAMILIA. Firme a continuación y continúe con las siguientes páginas. Firma del solicitante Fecha SNAP APP-1 Rev

28 Mencione a TODOS los miembros de su hogar en ESTA COLUMNA Apellido Nombre, inicial del segundo nombre Sexo Fecha de nacimiento (mm/dd/aaaa) Relación con usted Mencione información en ESTA COLUMNA únicamente si la persona solicita los beneficios del SNAP. N. º de seguro social Es ciudadano de los Estados Unidos? (SI LA RESPUESTA ES NO, deberá presentar la documentación para extranjeros correspondiente**) M F Usted SÍ NO M F SÍ NO M F SÍ NO M F SÍ NO *La condición de extranjero de los miembros solicitantes de la familia puede estar sujeta a verificación por parte de los Servicios de Ciudadanía e Inmigración de los Estados Unidos (United States Citizen and Immigration Services, USCIS) a través de la presentación de información de la solicitud a USCIS y la información presentada recibida por USCIS puede afectar la elegibilidad y nivel de beneficios de la familia. **La documentación para extranjeros incluye: número de extranjero, país de origen, condición de extranjero, fecha de ingreso: fecha de la condición, información del patrocinador. MI vivienda es (marque una opción): 01 Vivienda para personas ancianas o discapacitadas 02 Centro de rehabilitación de drogas/alcohol 03 Hogar para grupos de personas discapacitadas/ciegas 04 Albergue para mujeres maltratadas 06 Hogar propio/casa rodante 07 Casa/dpto./casa rodante alquilado 08 Vivo en la casa/el dpto. de otra persona. 09 Sin dirección permanente 10 Casa de rehabilitación 11 No tradicional: vestíbulo, calle, auto 12 Geriátrico y residencia asistida 13 Centro de cuidados a largo plazo 99 Otro (especifique): 05 Refugio Se mudó a Rhode Island dentro de los últimos tres (3) meses? Sí No Si la respuesta es SÍ, indique la fecha: Si la respuesta es sí, indique el motivo por el cual se mudó aquí: (marque una opción) L Busca empleo W Desea obtener dinero en efectivo, los beneficios del SNAP y/o servicios médicos D Violencia doméstica R Cercanía a un pariente O Otro (especifique)) De dónde proviene? Recibe algún tipo de ayuda ahora? Sí No Presentó anteriormente una solicitud o recibió algún tipo de pagos de asistencia, beneficios o SNAP en Rhode Island o en algún otro estado? Sí No Si la respuesta es sí, bajo qué nombre? Dónde? Cuándo? Tipo? Hay alguien en el hogar que se esté escapando de la ley para evitar procesos legales, que esté en custodia o que vaya a prisión por un delito grave según las leyes del lugar de donde se esté escapando, esté acusado de intento de cometer un delito o haya cometido un delito según las leyes del lugar de donde se esté escapando o, en el caso de Nueva Jersey, sea un delito grave según el estado de Nueva Jersey o por violación de la libertad condicional o de un período de prueba impuesto según una ley federal o estatal? Sí No Si la respuesta es sí, mencione el nombre de los miembros del hogar Fecha Estado Hay alguien en el hogar que haya sido declarado por el Departamento a través del proceso de Audiencia administrativa de haber cometido o haya sido condenado en un tribunal federal o del estado de haber realizado una declaración fraudulenta con respecto a su identidad o lugar de residencia para recibir varios beneficios simultáneamente según la ayuda de algún programa de la Asistencia Temporaria para Familias Necesitadas (Temporary Assistance for Needy Families, TANF), del programa Cupones para Alimentos (SNAP) o del Programa de Asistencia de Medicaid? Sí No Si la respuesta es sí, mencione el nombre de los miembros del hogar Fecha Estado SNAP APP-1 Rev

29 Hay alguien en el hogar que haya recibido ingresos de alguna fuente hasta ahora este mes? Sí No SI LA RESPUESTA ES SÍ, cuál es el monto del ingreso bruto? TIPO DE INGRESO RSDI (Seguro por Jubilación, Supervivencia y Discapacidad) (SEGURO SOCIAL) Seguridad de Ingreso Suplementario (Supplemental Security Income, SSI) JUBILACIÓN BENEFICIOS PARA VETERANOS (Veteran Benefits, VA) INDEMNIZACIÓN LABORAL $ DEL MONTO BRUTO FRECUENCIA (por semana, por mes, etc.) NOMBRE DE LA PERSONA QUE RECIBE EL INGRESO SALARIO OTRO (ESPECIFIQUE) OTRO (ESPECIFIQUE) Hace poco que dejaron de percibir el único ingreso del hogar? Sí No Si la repuesta es sí, cuándo? Por qué? Hay alguien en el hogar que espera recibir otro ingreso más adelante este mes? Sí No Si la repuesta es sí, cuál es la suma? cuándo? Cuántas personas viven en su hogar y comen con usted? (incluido usted) Cuál es la suma mensual de la renta o de la hipoteca? Servicios públicos mensuales: Calefacción: Aire acondicionado: Otros servicios públicos: Posee algún gasto médico como, por ejemplo, recetas, medicamentos de venta libre, suministros para la diabetes, gafas, gastos odontológicos, audífono, etc.? $ por mes Certifico bajo pena de perjurio, que he leído (o he hecho que me lean) y entiendo la Notificación de Derechos, Responsabilidades y Sanciones y que mis respuestas son correctas y completas, incluida la información sobre la ciudadanía y el estado de extranjero, y que la he completado según mi leal saber y entender. Sé que, según las Leyes Generales de Rhode Island, Sección , se puede imponer una multa máxima de $1,000 o encarcelamiento por hasta 95 años o ambos castigos a una persona que obtenga, intente obtener o ayude o induzca a cualquier persona a obtener asistencia pública para la que no tiene derecho, o que intencionalmente no informe ingresos, recursos o circunstancias personales o aumentos de estos que superen la suma informada anteriormente. Prefiere una entrevista TELEFÓNICA o una entrevista EN LA OFICINA? FECHA FIRMA DEL SOLICITANTE FIRMA DEL CÓNYUGE DEL SOLICITANTE U OTRO ADULTO SOLICITANTE QUE VIVA EN EL HOGAR SNAP APP-1 Rev

30 PARA USO EXCLUSIVO DE LA OFICINA AUTORIZACIÓN PARA UTILIZAR EL EXPEDIENTE POR BÚSQUEDA EXPEDIENTE ANTERIOR ESTADO UBICACIÓN DEL EXPEDIENTE RIW/DINERO Sí No EN EFECTIVO SNAP Sí No Asistencia Sí No Médica (MA) RITE CARE Sí No Asistencia Sí No Pública General (GPA) CCAP Sí No FECHA DE SOLICITUD DISPOSICIÓN: Fecha de admisión del solicitante de SNAP Fecha de envío de la admisión del solicitante de SNAP Comentarios: Firma de la persona que selecciona Fecha SNAP APP-1 Rev

31 IMPORTANTE: Este aviso es únicamente informativo. No debe firmar ni devolver esta página de la solicitud para recibir los beneficios del Departamento de Servicios Humanos (Department of Human Services) DERECHOS Y RESPONSABILIDADES de los solicitantes o beneficiarios del SNAP DERECHOS Usted tiene el DERECHO de apelar y de que se le conceda una Audiencia ante un Funcionario del Departamento a cargo de la Audiencia si no está satisfecho con la decisión del Departamento o si este se demora en tomar una decisión. Si solicita una audiencia, se dará lugar a su apelación con prontitud. Puede representarlo un abogado o cualquier otra persona que usted elija para que se presente en su nombre. Los formularios para solicitar audiencias, en los que puede presentar su queja, están disponibles en todas las oficinas del Departamento de Estado y localidades. Si no está satisfecho con alguna decisión que haya tomado el Departamento respecto de su solicitud, tiene el derecho de solicitar una audiencia. Debe solicitarla en un plazo de 90 días a partir de la fecha en la que reciba una notificación por escrito acerca de sus beneficios del SNAP. Usted tiene el DERECHO de recibir un trato no discriminatorio. De acuerdo con el Título VI de la Ley de Derechos Civiles de 1964 (42 U.S.C. 2000d et seq.), Sección 504 de la Ley de Rehabilitación de 1973, y sus enmiendas (29 U.S.C. 794), la Ley para Estadounidenses con Discapacidades de 1990 (42 U.S.C et seq.), el Título IX de las Enmiendas a la Ley de Educación de 1972 (20 U.S.C et seq.), la Ley de Alimentación y Nutrición de 2008 (anteriormente conocida como Ley de Cupones para Alimentos) y la Ley de Discriminación por Edad de 1975, las reglamentaciones reguladoras del Departamento de Salud y Servicios Humanos de los Estados Unidos (45 C.F.R. Partes 80 y 84), las reglamentaciones reguladoras del Departamento de Educación de los Estados Unidos (34 C.F.R. Partes 104 y 106) y el Departamento de Agricultura de los Estados Unidos y los Servicios de Alimentos y Nutrición (7 C.F.R ), el Departamento de Servicios Humanos (Department of Human Services, DHS) de Rhode Island no discrimina por raza, color, nacionalidad, discapacidad, creencias políticas, edad, religión o sexo para aceptar o para ofrecer servicios, empleo o tratamiento en sus programas y actividades educativos y de otro tipo. Según otras disposiciones de leyes vigentes, el DHS no discrimina por orientación sexual. Para obtener información adicional acerca de estas leyes, reglamentaciones y procedimientos de quejas por discriminación de DHS para la resolución de quejas sobre discriminación, comuníquese con el DHS en 57 Howard Avenue, Cranston, Rhode Island 02920, número de Teléfono (los individuos que sean sordos o tengan dificultades auditivas pueden llamar al o 711). El Funcionario de Enlace de Relaciones Comunitarias es el coordinador de la implementación del Título VI; el Administrador de la Oficina de Servicios de Rehabilitación (Office of Rehabilitation Services, ORS) o la persona que este designe es el coordinador de la implementación del Título IX, Sección 504 y la Ley sobre Estadounidenses con Discapacidades, ADA. El Director del DHS o la persona que este designe tiene la responsabilidad general del cumplimiento de los derechos civiles por parte del DHS. El Departamento de Agricultura de los Estados Unidos prohíbe la discriminación hacia sus clientes, empleados y solicitantes de trabajo por cuestiones de raza, color, nacionalidad, edad, discapacidad, sexo, identidad de género, religión, represalia y, cuando corresponda, creencias políticas, estado civil, estado familiar o paternal, orientación sexual, debido a que el total o parte de los ingresos de un individuo proceden de un programa de asistencia pública, o bien debido a que su información genética se encuentra protegida en su empleo o en algún programa o actividad dirigida o financiada por el Departamento (no toda la información prohibida se aplicará a todos los programas o actividades relacionadas con el empleo). Si desea presentar una queja por discriminación, complete el Formulario de quejas por discriminación del Programa USDA, que podrá encontrar en línea en o bien llame a cualquier oficina del USDA o al (866) para solicitar el formulario. También podrá escribir una carta que contenga toda la información que se solicita en el formulario. Envíe la carta o el formulario de queja completo por correo al Departamento de Agricultura de los Estados Unidos, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , envíe un fax al (202) o envíe un correo electrónico a Los individuos que sean sordos, tenga dificultades auditivas o tengan problemas en SNAP APP-1 Rev

32 el habla se podrán comunicar con el USDA al Servicio Federal de Transmisiones al (800) , o bien al (800) (español). Para obtener información adicional sobre el Programa de Asistencia Nutricional Suplementaria (SNAP), las personas deben comunicarse con el número de la línea directa del SNAP del USDA al (800) , en la que también se brinda asistencia en español o llamar a los números de línea directa/información estatal que podrá encontrar El USDA es un proveedor y empleador que ofrece igualdad de oportunidades. Usted tiene DERECHO a la confidencialidad. El Departamento utiliza información acerca de usted y de otros miembros de su familia solamente a los fines directamente relacionados con la administración de los programas y en cumplimiento con las normas de la Ley de Transferibilidad y Responsabilidad del Seguro de Salud (Health Insurance Portability and Accountability Act, HIPAA) en lo que respecta a Información médica que lo identifica individualmente. El Departamento no divulga información sobre usted u otros miembros de su familia sin su consentimiento, excepto según las Leyes Generales de Rhode Island y y las reglamentaciones publicadas en los Manuales de Política del DHS y del SNAP. Toda persona que sea declarada culpable de infringir las disposiciones de las Leyes Generales de Rhode Island se considerará culpable de un delito menor. Los infractores están sujetos a una multa máxima de doscientos dólares ($200) o hasta seis (6) meses de encarcelamiento, o ambos castigos. RESPONSABILIDADES Usted tiene la RESPONSABILIDAD de otorgar al Departamento información precisa y de ofrecer pruebas de sus ingresos, recursos y tipo de vivienda. Usted tiene la RESPONSABILIDAD de informarnos inmediatamente, en un plazo de diez (10) días, sobre cualquier cambio en sus ingresos, recursos, composición de familia o cualquier otro cambio que afecte su familia. Para SNAP, si usted es un informante simple, debe informar cuando sus ingresos superen el 130 % del Nivel Federal de Pobreza (Federal Poverty Level, FPL). Usted tiene la RESPONSABILIDAD de otorgar los números de seguridad social de usted y de su familia o solicitarlos, si así se le exige, como condición de elegibilidad. La compilación del número de seguro social, así como del Número de Seguro Social (Social Security Number, SSN) de cada miembro de la familia, está autorizada por la Ley de Cupones para Alimentos de 1977, con sus enmiendas 7 U.S.C Se utilizará esta información para determinar si su familiar reúne las condiciones o si todavía las reúne para participar en el SNAP. El Departamento corroborará esta información a través de programas de coincidencias por computadora. También se utilizará esta información para controlar el cumplimiento con las reglamentaciones del programa y para la administración de este. Podrá divulgarse esta información a otras oficinas estatales y federales para que la examinen a nivel oficial y a funcionarios del cumplimiento de las leyes, con el objetivo de detener a las personas que están prófugas para evadir la ley. Si surge un reclamo de SNAP en contra de su familia, podrá entregarse la información de esta solicitud, incluidos todos los SSN, a oficinas estatales y federales, además de oficinas privadas de cobro de reclamos, para proceder con el cobro de los reclamos. La entrega de la información solicitada, incluidos los SSN de cada miembro de la familia, es voluntaria. Sin embargo, si no se otorga un SSN, se le negarán los beneficios de SNAP a cada persona que no haya entregado un SSN. Todo SSN otorgado se utilizará y publicará de la misma manera que los SSN de los miembros de la familia que reúnan las condiciones para los beneficios del plan. Usted tiene la RESPONSABILIDAD de informar y ofrecer comprobantes de sus gastos para recibir la mayor cantidad de beneficios de SNAP permitidos. Si no lo hace, se considerará que usted no quiere recibir una deducción para los gastos no informados o cuyos comprobantes no se hayan presentado. Usted tiene la RESPONSABILIDAD de cooperar completamente con el personal estatal y federal que esté llevando a cabo los controles de calidad. SNAP APP-1 Rev

33 DECLARACIÓN DE ADVERTENCIAS DE SANCIONES DE SNAP PARA SOLICITANTES/BENEFICIARIOS Entiendo que: 1. Cualquier miembro de mi familia que intencionalmente infrinja una regla del SNAP puede ser excluido del Programa SNAP: *durante un (1) año por la primera infracción, con las excepciones que se mencionan en el punto 2 y 3 a continuación; *durante un período de dos (2) años por la segunda infracción, con las excepciones que se mencionan en el punto 3 a continuación; y, *de forma permanente por tercera vez de alguna infracción voluntaria al programa. 2. En el caso de que los tribunales locales, estatales o federales descubran que una persona usó o recibió beneficios del SNAP en una transacción que involucre la venta de armas de fuego, municiones o explosivos, no podrán ser elegidos para el programa SNAP a partir de la primera vez que ocurra tal violación. 3. Una persona condenada por haber traficado beneficios del SNAP por un monto total de quinientos dólares ($500) o más será descalificada del programa SNAP. 4. Las personas que el Departamento haya hallado culpables, o que tribunales estatales o federales hayan hallado culpables, de hacer una declaración fraudulenta para recibir múltiples beneficios simultáneamente según el programa SNAP, podrían no tener derecho a participar en el programa por un período de diez (10) años. NO proporcione información falsa ni oculte información para recibir o seguir recibiendo beneficios de SNAP. NO canjee ni venda tarjetas de transferencia electrónica de beneficios (Electronic Benefit Transfer, EBT). NO use los beneficios de SNAP para comprar artículos que no sean elegibles, como bebidas alcohólicas y tabaco. NO use la tarjeta de EBT de otra persona para su familia. El DHS puede usar o compartir la información de esta solicitud para la administración de los programas del DHS, además de para la administración de otros programas que cuentan con financiación federal, de acuerdo con las leyes, los contratos y las reglamentaciones estatales y federales. El DHS puede publicar información que no sea de identificación personal a los fines de investigación. Toda divulgación de información de identificación personal debe hacerse de acuerdo con las leyes estatales y federales. Entiendo las preguntas de esta solicitud y la sanción por ocultar la información o por dar información falsa o por infringir cualquiera de las reglas que figuran en esta Advertencia de sanciones. FIRME LA SOLICITUD en la página 3 SNAP APP-1 Rev

34 Notificación al solicitante que se inscribe para votar en Rhode Island La Junta de Elecciones del estado anima a todos sus ciudadanos a que se inscriban para votar. Su voto le beneficiará a usted y a su familia. Este paquete de formularios incluye un formulario de inscripción para votantes. Si desea inscribirse para votar, complete y firme el formulario y remítalo a su junta de elecciones local (el directorio está al dorso del formulario). Inscríbase para votar. Si no está inscrito/a para votar en el lugar donde vive actualmente, complete el formulario adjunto. El que solicite o no la inscripción como votante no afectará la cantidad de asistencia que le proporcione esta agencia. Si desea que alguien le ayude a completar el formulario de inscripción para votar, puede traerlo cuando venga a devolver los otros formularios completados de este paquete o puede llevarlo a la Junta de Elecciones de la ciudad/pueblo donde vive. (El directorio de ciudades/pueblos está al dorso del formulario de inscripción para votantes) La decisión en cuanto a pedir o aceptar esta ayuda le corresponde a usted. Si piensa que alguien ha interferido con su derecho a inscribirse para votar o a renunciar al mismo, o con su derecho a tomar la decisión sobre si inscribirse o solicitar la inscripción para votar en privado, o con su derecho a elegir su propio partido político u otra preferencia política, puede interponer una queja ante el Voter Registration Coordinator, Rhode Island Board of Elections, 50 Branch Avenue, Providence, R.I o llamando al (401)

35 RHODE ISLAND FORMULARIO DE INSCRIPCIÓN DE VOTANTE Sírvase usar tinta y escribir en letra de molde legible. A menos que esté marcada como optativa, toda la información solicitada es obligatoria. Puede usar este formulario para: Inscribirse para votar en Rhode Island. Cambiar su nombre o dirección en la inscripción. Escoger un partido político o cambiar de partido. INSTRUCCIONES Casilla 2: Obligatorio. Ciudadanos y residentes de Rhode Island de 16 años de edad pueden inscribirsen para votar usando este formulario. Si no marca alguna de estas casillas, se le devolverá el formulario. Si contesta NO, no complete este formulario. Casilla 3: Si es la primera vez que se inscribe por correo para votar en Rhode Island o si alguien entrega este formulario a nombre suyo, se le EXIGE que dé el número de su licencia de conductor o número de identificación estatal expedido por el Departamento de Automotores (DMV) de Rhode Island. Si no tiene ninguno de los dos, deberá dar su los últimos 4 dígitos de su número de Seguro Social. Si no da los datos indicados arriba o si estos no se pueden verificar, se le pedirá que antes de votar le muestre al funcionario electoral un documento de identidad. Los documentos de identidad aceptables se detallan en la sede de la Junta de Elecciones en puede comunicarse con la Junta de Escrutadores local (ver el dorso de este formulario). Para inscribirse para votar en RI, tiene que: Vivir en Rhode Island. Ser ciudadano de los Estados Unidos. Haber cumplido 16 años de edad. (Necesitas tener 18 años ó mas de edad para votar el día de las elecciónes) Casilla 5: Cada persona puede tener una sola residencia legal. Tiene que inscribirse con su residencia actual. Sólo puede indicar una casilla postal o ruta rural en la Casilla 6, "Dirección postal". Casilla 9: Si deseas inscribirse como miembro de un partido político, marque la casilla correspondiente. Si dejas la Casilla 9 en blanco, se inscribe sin afiliación. Casilla 10: Tiene que FIRMAR y FECHAR el formulario de inscripción. Si no lo hace, se le devolverá el formulario. Casilla 11: Si está actualizando su inscripción de votante porque cambió de nombre legalmente, indique su nombre legal anterior. Casilla 12: Si está actualizando su inscripción de votante porque cambió de dirección, indique su dirección anterior, incluso si era fuera del estado. Antes de que transcurran 3 semanas, recibirá un acuse de recibo del formulario de inscripción de votante. Si no lo recibe, comuníquese con la Junta de Escrutadores local (ver la lista al dorso). Si tiene preguntas o para averiguar más sobre las fechas límite, acuda a la sede en Internet de la Junta Electoral del estado en o póngase en contacto con la Junta de Escrutadores local (ver la lista al dorso). (Se autoriza la reproducción de este formulario) 1. Marque lo que corresponda: Inscripción votante nuevo Cambio dirección Cambio partido Cambio nombre Formulario de Inscripción de Votantes de Rhode Island 2. Soy ciudadano de EE.UU. y residente de Rhode Island Sí No Cumplido 16 años de edad. (Necesitas tener 18 años ó mas de edad para votar el día de las elecciónes) Sí No Si marcó NO en cualquiera de estas casillas, no complete este formulario. 3. No. de licencia de conductorde RI No. de tarjeta de identidad de RI: Si no tiene licencia o ID de RI, escriba los últimos 4 dígitos de su número de Seguro Social: Si no puso ningún número, vea arriba en Instrucciones, Casilla Apellido Nombre 2 nombre (o la inicial) 5. Dirección residencial (No puede ser una casilla postal) Apto. Ciudad/Pueblo Estado Código ZIP RI 6. Dirección postal (si es distinta de la dirección de la Casilla 5) Apto. Ciudad/Pueblo Estado Código ZIP 7. Fecha de nacimiento 8. No. de teléfono / Correo electrónico (optativo) 9. Selleccione su partido: Mes Día Año Republicano Sin afiliación Otro 10. Juro o afirmo que: Uso oficial para código de barras - No estoy recluido ni en cárcel ni prisión, condenado por un delito mayor. - No he sido declarado "incompetente mental" para votar por ningún juzgado. - A mi leal entender, la información que he dado es verídica, so pena de perjurio. Si doy información falsa, puedo ser multado, encarcelado o (si no soy ciudadano de EE.UU.) deportado del país o se me puede negar el ingreso a Estados Unidos. Firme aquí con su nombre completo o ponga su marca. Fecha de la firma MM/DD/AAAA Demócrata Moderado Le interesa trabajar en las urnas? (marque esta casilla) Advertencia: Si firma este formulario a sabiendas de alguna falsedad, pueden ser condenado y multado hasta $5,000 o encarcelado hasta 10 años. 11. Nombre anterior (si es disinto del de la Casilla 4) 12. Dirección de su inscripción anterior (Ciudad/Pueblo, Estado, ZIP y Condado) 02/2012 Regs Form Revised 12/2012

36 Remite Requiere franqueo. La Oficina Postal no hará entrega si no tiene el debido franqueo. Remitir a: BOARD OF CANVASSERS ******************************************************************Plegar aquí y pegar arriba con cinta********************************************************************* INSTRUCCIONES PARA REMITIR EL FORMULARIO DE INSCRIPCIÓN DE VOTANTE Todo solicitante que opte por remitir su formulario de inscripción de votante por correo, deberá hacerlo de la manera siguiente: 1. Plegar el formulario en la línea punteada y usar cinta pegante para pegar el borde inferior del formulario con su borde superior. 2. Ubicar, en la lista que figura a continuación, la dirección de la Junta de Escrutadores en la ciudad o pueblo en el que se está inscribiendo para votar. Inserte dicha dirección en el espacio correspondiente debajo de "Remitir a: BOARD OF CANVASSERS" en el costado de la dirección del formulario de inscripción de votante. Escriba su remite en el espacio indicado. NOTIFICACIÓN: Toda intromisión de su privacidad al inscribirse para votar o al escoger un partido político es contravención de la ley. Si usted considera que alguna persona ha interferido con su derecho a inscribirse o no inscribirse, o con su privacidad al tomar esta decisión, o al escoger un partido político, puede presentar una queja ante la Junta Estatal de Elecciones, 50 Branch Avenue, Providence, Rhode Island Barrington Town Hall 283 County Rd. Barrington, RI Bristol Town Hall 10 Court St. Bristol, RI Burrillville Town Hall, 105 Harrisville Main St., Harrisville, RI Central Falls City Hall 580 Broad St. Central Falls, RI Charlestown Town Hall, 4540 So. County Trail, Charlestown, RI Coventry Town Hall 1670 Flat River Rd. Coventry, RI Cranston City Hall 869 Park Ave. Cranston, RI Cumberland Town Hall 45 Broad St. Cumberland, RI East Greenwich Town Hall PO Box 111 East Greenwich, RI East Providence City Hall 145 Taunton Ave. East Providence, RI JUNTAS DE ESCRUTADORES LOCALES Exeter Town Hall 675 Ten Rod Rd. Exeter, RI Foster Town Hall 181 Howard Hill Rd. Foster, RI Glocester Town Hall 1145 Putnam Pike PO Drawer B, Glocester, RI Hopkinton Town Hall One Town House Rd. Hopkinton, RI Jamestown Town Hall 93 Narragansett Ave. Jamestown, RI Johnston Town Hall 1385 Hartford Ave Johnston, RI Lincoln Town Hall 100 Old River Rd. PO Box 100, Lincoln, RI Little Compton Town Hall PO Box 226 Little Compton, RI Middletown Town Hall 350 East Main Rd. Middletown, RI Narragansett Town Hall 25 Fifth Ave. Narragansett, RI New Shoreham Town Hall PO Drawer 220 Block Island, RI Newport City Hall 43 Broadway Newport, RI No. Kingstown Town Hall 80 Boston Neck Rd. North Kingstown, RI North Providence Town Hall 2000 Smith St. North Providence, RI North Smithfield Municipal Annex 575 Smithfield Rd, North Smithfield, RI Pawtucket City Hall 137 Roosevelt Ave. Pawtucket, RI Portsmouth Town Hall 2200 East Main Rd Portsmouth, RI Providence City Hall 25 Dorrance St. Providence, RI Richmond Town Hall 5 Richmond Townhouse Rd. Wyoming, RI Scituate Town Hall PO Box 328 North Scituate, RI Smithfield Town Hall 64 Farnum Pike Smithfield, RI So. Kingstown Town Hall 180 High St Wakefield, RI Tiverton Town Hall 343 Highland Rd. Tiverton, RI Warren Town Hall 514 Main St. Warren, RI Warwick City Hall 3275 Post Rd. Warwick, RI W. Greenwich Town Hall 280 Victory Highway W. Greenwich, RI West Warwick Town Hall 1170 Main St. West Warwick, RI Westerly Town Hall 45 Broad St. Westerly, RI Woonsocket City Hall P.O. Box B, 169 Main St. Woonsocket, RI Toda consulta sobre la inscripción de votantes puede dirigirse a: Rhode Island Board of Elections 50 Branch Avenue Providence, RI

37 DEPARTAMENTO DE SERVIÇOS HUMANOS DE RHODE ISLAND REQUERIMENTO AO SERVIÇO SNAP PARA MEMBROS IDOSOS DO AGREGADO FAMILIAR Portuguese Version For Office use only: Screener s Name: Date Screened: Intake: Fala inglês? Sim Não Em caso negativo, qual é o principal idioma falado em sua casa? Sabe ler e escrever em inglês? Sim Não Se não fala Inglês, algum adulto do seu agregado familiar fala inglês? Sim Não O seu apelido: Data de Nascimento: / / Mês Dia Ano O seu nome: Número de Segurança Social Inicial do 2º nome: A sua morada (onde vive): Nome de solteira /Outros nomes: Apartamento/Andar: Cidade: Estado: Cód. Postal: Endereço Postal (caso seja diferente) Apartamento/Andar: Cidade: Estado: Cód. Postal: O seu número de telefone (casa): Outro: Precisa de ajuda para preencher este formulário? Sim Não Se desejar autorizar alguém além de si a fazer o pedido em seu nome, indique a seguir: Nome: Data de Nascimento Número de Telefone: MM DD AAAA Rua Apt./Andar Cidade Estado Cód. Postal Podemos ajudá-lo(a) caso tenha alguma incapacidade ou condição que lhe dificulte compreender ou responder às perguntas indicadas neste formulário. Por exemplo, podemos ler o formulário consigo e escrever as respostas por si. Podemos disponibilizar outras acomodações, consoante a ajuda que precisar. Informe-nos. PODE OBTER BENEFÍCIOS DO PROGRAMA SNAP, CASO SEJA ELEGÍVEL, NO PRAZO DE 7 DIAS: 1. Se o rendimento bruto mensal do seu agregado familiar for inferior a $150 e os recursos do mesmo, tais como dinheiro, contas correntes ou contas poupança forem de um montante igual ou inferior a $100; 2. Se a sua renda/hipoteca e despesas com serviços públicos forem superiores ao rendimento bruto mensal combinado do seu agregado familiar e aos recursos líquidos; ou, 3. Se o seu agregado familiar for emigrante ou trabalhador agrícola sazonal. Caso se qualifique para este serviço, somos obrigados a conceder-lhe os benefícios SNAP no prazo de sete (7) dias a partir da data em que nos entregar este formulário dentro do horário normal de expediente e com a data carimbada. CERTIFICO QUE AS INFORMAÇÕES CONTIDAS NESTA PÁGINA SÃO VERDADEIRAS TANTO QUANTO É DO MEU CONHECIMENTO E CONVICÇÃO, E QUE EXISTEM SANÇÕES POR NÃO DIZER A VERDADE SOBRE MIM E A MINHA FAMÍLIA. Assine abaixo e continue nas páginas seguintes. Assinatura do Requerente Data SNAP APP-1 Rev

38 Indique TODAS AS PESSOAS da sua casa NESTE LADO da linha D.N. (mm/dd/aaaa) Parentesco Indique as informações DESTE LADO da linha apenas se a pessoa estiver a solicitar os benefícios do SNAP Cidadão dos EUA?* (Em caso NEGATIVO< serlhe-á solicitado que forneça documentação do seu Nº.S.S. estatuto de emigrante**) SIM NO SIM NO SIM Apelido Nome, IM Sexo M Próprio F M F M F NO M SIM F NO *A informação sobre o estatuto de emigrante pode ser sujeita a verificação através dos serviços USCIS e essas informações podem afectar a elegibilidade do agregado familiar, bem como o nível dos benefícios **A documentação sobre o estatuto de emigrante inclui: número de emigrante, país de origem, estatuto de emigrante, data de entrada: data do estatuto, informações sobre a pessoa responsável por si. O MEU acordo de habitação é (Assinalar uma opção): 01 Habitação para idosos/incapacitados 02 Centro de reabilitação de drogas/álcool 03 Casa para incapacitados/invisuais 04 Centro de acolhimento para mulheres mal tratadas 05 Abrigo 06 Habitação/caravana própria 07 Habitação/apartamento/atrelado alugado 08 Vive em casa/apartamento de outra pessoa 09 Sem morada permanente 10 Casa de reintegração 11 Não tradicional; corredor estrada, automóvel 12 Instituição de cuidados e apoio domiciliários 13 Instalação de Cuidados a Longo Prazo 99 Outro (especificar): Mudou-se para Rhode Island nos últimos três (3) meses? Sim Não Em caso afirmativo, data: Em caso afirmativo, qual o motivo da mudança para cá? (Marque uma opção) L Está à procura de emprego W Receber dinheiro, benefícios SNAP e/ou benefícios médicos D Violência doméstica R Para ficar perto de um familiar O Outro (especificar) Qual o local de onde veio: Presentemente recebe alguma ajuda? Sim Não Já fez algum pedido anteriormente, ou recebeu qualquer tipo de pagamentos de auxílio, benefícios ou benefícios do SNAP em R.I. ou noutro estado? Sim Não Em caso afirmativo, em que nome? Onde? Quando? Tipo? Está em fuga, ou alguém do seu agregado familiar, para evitar um processo, ser detido ou privado de liberdade após uma condenação ao abrigo das leis do local de onde está a fugir, por cometer um crime ou tentar cometer um crime que, segundo essas leis é considerado um crime grave, ou que, segundo as leis do Estado de New Jersey é considerado um delito grave, ou que viole uma condição de pena suspensa ou liberdade condicional ao abrigo de uma lei federal ou estadual? Sim Não Em caso afirmativo, indique o(s) nome(s) do(s) membro(s) do agregado familiar: Data Estado Foi considerado, ou outro membro do seu agregado familiar, pelo Departamento através do seu procedimento de Audiência Administrativa de ter feito ou ter sido condenado(a) por um tribunal Federal ou Estadual por ter feito uma declaração ou representação falsa a respeito da identidade de alguém ou local de residência, para receber múltiplos benefícios de assistência em simultâneo no âmbito do Programa RIW (TANF - Transitional Assistance for Needy Families), do Programa de Ajuda Suplementar à Nutrição (SNAP) ou do Programa de Assistência Médica (MA)? Sim Não Em caso afirmativo, indique o(s) nome(s) do(s) membro(s) do agregado familiar: Data Estado SNAP APP-1 Rev

39 Alguém do seu agregado familiar recebeu este mês algum rendimento de qualquer fonte? Sim Não Em caso afirmativo, qual foi o rendimento bruto? TIPO DE RENDIMENTO RSDI (SEGURANÇA SOCIAL) Rendimento Adicional do Seguro de Segurança Social (SSI) PENSÃO SUBSÍDIOS PARA VETERANOS INDEMNIZAÇÃO POR ACIDENTE/DOENÇA SALÁRIOS OUTRO (ESPECIFICAR) OUTRO (ESPECIFICAR) $ MONTANTE BRUTO FREQUÊNCIA (Semanal, mensal, etc.) NOME DO BENEFICIÁRIO Deixou de receber recentemente o único rendimento do seu agregado familiar? Sim Não Em caso afirmativo, quando? Porquê? Alguém do seu agregado familiar espera receber outro rendimento no final deste mês? Sim Não Em caso afirmativo, quanto? Quando? Quantas pessoas vivem em sua casa e tomam as refeições consigo? (incluir a si mesmo) Quanto paga mensalmente de renda ou hipoteca? Serviços Públicos Mensais: Aquecimento Ar Condicionado: Outros Serviços: Paga despesas médicas como receitas, medicamentos de venda livre, produtos para diabéticos, óculos, despesas dentárias, de aparelho auditivo, etc.? $ por mês? Confirmo, sob pena de perjúrio, que li (ou que alguém me leu) e compreendi o Aviso de Direitos, as Responsabilidades e as Sanções, e que as minhas respostas estão correctas e completas, incluindo as informações sobre a cidadania e o estatuto de emigrante, tanto quanto é do meu melhor conhecimento e convicção. Tenho conhecimento de que ao abrigo das Leis Gerais Estaduais de Rhode Island, Secção , pode ser imposta uma coima máxima de $1000 ou pena de prisão de até 95 anos, ou ambas, a uma pessoa que obtenha, tente obter, ajude ou incite alguém a obter ajuda pública à qual não tenha direito, ou que não comunique deliberadamente os rendimentos, recursos ou circunstâncias pessoais, bem como os respectivos aumentos que excedam o montante anteriormente comunicado. Prefere uma entrevista TELEFÓNICA ou nos NOSSOS SERVIÇOS? DATA ASSINATURA DO REQUERENTE ASSINATURA DO CÔNJUGE DO REQUERENTE ou OUTRO REQUERENTE ADULTO QUE FAÇA PARTE DO SEU AGREGADO FAMILIAR SNAP APP-1 Rev

40 APENAS PARA USO DO ESCRITÓRIO AUTORIZAÇÃO DE REGISTO DE PROCESSO PARA PARTICIPAÇÃO PESQUISA PERS REGISTO DE CASO ANTERIOR ESTATUTO LOCALIZAÇÃO DO REGISTO RIW/DINHEIRO Sim Não SNAP Sim Não MA Sim Não RITE CARE Sim Não GPA Sim Não CCAP Sim Não DATA DO PEDIDO DISPOSIÇÃO: Data de Entrada do Pedido SNAP Data de processamento Entrada Pedido SNAP Comentários: Assinatura do Examinador Data SNAP APP-1 Rev

41 IMPORTANTE: Este Aviso serve apenas para referência Não tem de assinar ou devolver esta página do formulário ao DHS DIREITOS E RESPONSABILIDADES de Requentes/Beneficiários do SNAP DIREITOS Tem o DIREITO de requerer e obter uma Audiência perante um Auditor do Departamento se não estiver satisfeito(a) com alguma decisão do Departamento, ou se este se atrasar a tomar uma decisão. No caso de requerer uma audiência, o seu recurso será ouvido de imediato. Pode fazer-se representar por um advogado ou qualquer outra pessoa que escolha para comparecer como seu representante. Os formulários da audiência, nos quais pode apresentar a sua reclamação, encontram-se disponíveis em todos os escritórios locais e estaduais. Se não estiver satisfeito(a) com qualquer decisão do Departamento relacionada com o seu pedido, tem o direito de requerer uma audiência. Deve requerer uma audiência no prazo de 90 dias a partir da data em que receber uma notificação por escrito para obtenção de benefícios do programa SNAP. Tem o DIREITO a tratamento não discriminatório. De acordo com o Título VI da Lei sobre Direitos Civis de 1964 (42 U.S.C. 2000d et seq.), Secção 504 da Lei de Reabilitação de 1973 e respectivas alterações (29 U.S.C. 794), a Lei dos Americanos Portadores de Deficiência (ADA) de 1990 (42 U.S.C et seq.), Título IX das Alterações de 1972 sobre a Educação (20 U.S.C et seq.), a Lei sobre Alimentação e Nutrição de 2008 (antiga lei Food Stamps Act), a Lei sobre a Discriminação Etária de 1975, o regulamento de aplicação do Departamento da Saúde e dos Serviços Humanos dos E.U.A. (45 C.F.R. Partes 80 e 84), os regulamentos de aplicação do Departamento da Educação dos E.U.A. (34 C.F.R. Partes 104 e 106), bem como o Departamento da Agricultura dos E.U.A., os Serviços de Alimentação e Nutrição dos E.U.A. (7 C.F.R ), o Departamento de Serviços Humanos (DHS) de Rhode Island não discriminam com base na raça, cor da pele, nacionalidade, deficiência, religião, ideologias políticas, idade, religião ou sexo ao aceitarem ou fornecerem serviços, emprego ou tratamento nos seus programas educacionais e noutros programas e actividades. Ao abrigo de outras disposições da lei aplicável, o DHS não discrimina com base na orientação sexual. Para mais informações sobre estas leis, regulamentos e os procedimentos de apresentação de reclamações por discriminação que o DHS tem estabelecidos para a resolução destes litígios, entre em contacto com o DHS em: 57 Howard Avenue, Cranston, Rhode Island 02920, ou através do número de telefone (para surdos e invisuais ou 711). O Funcionário de Ligação das Relações com a Comunidade é o coordenador da aplicação do Título VI; o Administrador do Gabinete dos Serviços de Reabilitação (ORS) ou a pessoa por ele designada coordena a aplicação do Título IX, Secção 504, bem como da Lei dos Americanos Portadores de Deficiência (ADA). Compete ao Director do DHS ou à pessoa por ele designada a responsabilidade geral de zelar pelo cumprimento dos direitos civis por parte do DHS. O Departamento da Agricultura dos E.U.A proíbe a discriminação contra os respectivos clientes, funcionários e candidatos a emprego com base na raça, cor da pele, nacionalidade, idade, deficiência, sexo, identidade sexual, religião, represálias e, sempre que aplicável, nas ideologias políticas, estado civil, familiar ou parental, orientação sexual ou devido ao facto de parte dos rendimentos de um indivíduo serem derivados de qualquer programa de auxílio público, ou de informações genéticas protegidas no emprego ou em qualquer programa ou actividade realizados ou financiados pelo Departamento (nem todas as bases proibidas se aplicarão a todos os programas e/ou actividades laborais). Se desejar apresentar uma reclamação por discriminação, preencha o Formulário de Reclamação do Programa contra a Discriminação do Departamento da Agricultura dos E.U.A, o qual poderá encontrar online em ou em qualquer gabinete do Departamento da Agricultura dos E.U.A, ou então ligue para o número (866) a solicitar o formulário. Poderá também escrever uma carta com todas as informações solicitadas no formulário. Envie o seu formulário de reclamação preenchido ou a sua carta por correio para U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C , por fax para o número (202) ou para o endereço de As pessoas surdas, com problemas auditivos SNAP APP-1 Rev

42 ou com incapacidades a nível da fala poderão contactar o Departamento da Agricultura dos E.U.A através do Federal Relay Service ligando para o número (800) ou (800) (Espanhol). Para qualquer outra informação relativa a questões sobre o Programa de Ajuda Suplementar à Nutrição (SNAP), deverá contactar a Linha de Apoio SNAP do Departamento da Agricultura dos E.U.A para o número (800) , que também está disponível em Espanhol, ou ligar para a Linha de Informação Estatal/Linhas de Apoio que poderá encontrar online em O USDA é um prestador de serviços e empregador que aplica a regra da igualdade de oportunidades. Tem o DIREITO à confidencialidade. O Departamento usa as suas informações e as dos outros membros do seu agregado familiar apenas para fins directamente relacionados com a administração dos programas e em conformidade com as Normas de Privacidade de Informação Médica Individualmente Identificável previstas na Lei sobre Titularidade e Responsabilidade dos Seguros de Saúde (HIPPA - Health Insurance Portability and Accountability Act). O Departamento não divulga informações sobre si ou sobre outros membros do seu agregado familiar sem o seu consentimento, excepto conforme previsto nas Leis Gerais de Rhode Island nº e , bem como nos regulamentos estipulados nos Manuais das Políticas do DHS e do programa SNAP. Qualquer pessoa culpada por violação das disposições das Leis Gerais de Rhode Island será considerada culpada de uma contravenção. Os infractores estão sujeitos a uma coima máxima de duzentos dólares ($200) ou a pena de prisão até seis (6) meses, ou ambos. RESPONSABILIDADES Tem a RESPONSABILIDADE de fornecer ao Departamento informações exactas e fornecer provas sobre os seus rendimentos, recursos e alojamento. Tem a RESPONSIBILIDADE de nos informar imediatamente (no prazo de dez [10] dias) sobre quaisquer alterações aos seus rendimentos, recursos, composição familiar e qualquer outra alteração que afecte o seu agregado familiar. Em termos do programa SNAP, se for um relator simples ("simplified reporter"), deve comunicar quando os seus rendimentos excederem 130% do Nível de Pobreza Federal. Tem a RESPONSABILIDADE de fornecer os seus números de segurança social, bem como os dos membros do seu agregado familiar, ou solicitá-los, se a tal for obrigado, como requisito de elegibilidade. O seu número de Segurança Social, bem como o número de segurança social de cada membro do agregado familiar, está autorizada ao abrigo da Lei "Food Stamp" de 1977, e respectivas alterações, 7 U.S.C As informações serão utilizadas para determinar se o seu agregado familiar é elegível ou se continua a ser elegível para participar no programa SNAP. Verificaremos estas informações através de programas informáticos de cruzamento de dados. Estas informações serão igualmente utilizadas para controlar a conformidade com os regulamentos do programa e para a gestão do mesmo. Estas informações poderão ser divulgadas a outras agências federais e estaduais para inspecção oficial, bem como a autoridades policiais para fins de detenção de pessoas que não cumpram a lei. Se surgir uma reclamação contra o seu agregado familiar relativa ao programa SNAP, as informações sobre este formulário, incluindo todos os números de segurança social, podem ser comunicados a agências federais e estaduais, bem como a agências de cobrança privadas para acções de cobrança de créditos. O fornecimento das informações solicitadas, incluindo o número de segurança social (SSN) de cada membro do agregado familiar, é voluntário. Contudo, o não fornecimento de um SSN resultará na recusa de benefícios do programa SNAP a cada indivíduo que não forneça um SSN. Quaisquer SSN fornecidos serão utilizados e divulgados da mesma forma que os SSN de membros elegíveis do agregado familiar. Tem a RESPONSABILIDADE de comunicar e apresentar comprovativos das suas despesas; receberá o montante máximo permitido de benefícios do programa SNAP. A não comunicação ou apresentação de comprovativos das suas despesas será considerado como uma declaração de que não pretende receber uma dedução da despesa não comunicada ou não provada. Tem a RESPONSABILIDADE de cooperar totalmente com os funcionários estaduais e federais que realizam as análises de controlo de qualidade. SNAP APP-1 Rev

43 DECLARAÇÃO DE REQUERENTE/BENEFICIÁRIO DE BENEFÍCIOS DO PROGRAMA SNAP ADVERTÊNCIAS SOBRE SANÇÕES Tomei conhecimento de que: 1. Qualquer membro do meu agregado familiar que infrinja intencionalmente uma regra do SNAP pode ser excluído do Programa SNAP: *Por um período de um (1) ano pela primeira infracção, com ressalva do disposto nos números 2. e 3. a seguir; *Por um período de dois (2) anos após a segunda infracção, com ressalva do disposto nos números 2. e 3. a seguir; *Permanentemente pela terceira vez que infrinja de forma intencional qualquer norma do programa. 2. Se um tribunal federal, estadual ou local considerar que alguém usou ou recebeu benefícios do programa SNAP numa transacção que envolva venda de armas, munições ou explosivos, estas pessoas serão permanentemente consideradas não elegíveis para o programa SNAP aquando da primeira ocorrência dessa infracção. 3. As pessoas condenadas por tráfico de benefícios do programa SNAP com valor igual ou superior a quinhentos dólares ($500) serão permanentemente desqualificadas do programa SNAP. 4. As pessoas que o Departamento considerar terem prestado, ou terem sido condenadas por um tribunal federal ou estadual por terem prestado uma declaração ou representação fraudulenta relativamente aos seus benefícios de forma simultânea ao abrigo do programa SNAP serão desqualificadas durante um período de dez (10) anos. NÃO preste informações falsas nem oculte informações para obter ou continuar a obter benefícios do programa SNAP. NÃO troque nem venda cartões de EBT. NÃO utilize os benefícios do programa SNAP para comprar artigos não elegíveis, tais como bebidas alcoólicas e tabaco. NÃO utilize o cartão de EBT de outra pessoa do seu agregado familiar. O DHS pode utilizar ou partilhar as informações contidas neste formulário para a administração dos programas DHS, bem como para a administração de outros programas de ajuda financiados a nível federal, de acordo com a legislação estadual e federal, contratos e regulamentos. O DHS pode divulgar informações não identificáveis para fins de investigação. Qualquer divulgação de informações identificáveis deverá ser efectuada em conformidade com a legislação estadual e federal. Tomei conhecimento das perguntas presentes neste formulário e das sanções por ocultar ou prestar informações falsas, ou por infringir qualquer regra indicada neste Aviso de Sanções. ASSINE O FORMULÁRIO, Página 3 SNAP APP-1 Rev

44 Informações aos Requerentes Registo eleitoral em Rhode Island A Comissão de Eleições (State Board) apela a todos os cidadãos que façam o seu registo eleitoral. O seu voto beneficiá-lo-á e à sua família. Este pacote de formulários inclui um formulário de registo eleitoral. Se pretender registar-se como eleitor, preencha e assine o formulário e envie-o por correio para os seus Agentes Eleitorais (Board of Canvassers) locais. (lista de endereços no verso do formulário) Registo eleitoral Se não fez o registo eleitoral na sua área de residência, preencha o formulário em anexo. O registo ou recusa do registo eleitoral não afectará o montante da ajuda prestada por esta agência. Se precisar de ajuda para preencher o formulário de registo eleitoral, pode trazê-lo consigo quando devolver os outros formulários preenchidos deste pacote ou então dirigir-se aos seus Agentes Eleitorais (Board of Canvassers) locais da cidade/vila onde vive. (lista de moradas da cidade/vila no verso do formulário de registo eleitoral). Cabe-lhe a si tomar a decisão de procurar e aceitar ajuda. Se considerar que alguém interferiu com o seu direito de registo eleitoral ou recusa do registo eleitoral ou no direito à liberdade de decisão ou de escolha do seu partido político, pode apresentar uma reclamação ao Coordenador dos Registos Eleitorais, 50 Branch Avenue, Providence, Rhode Island ou ligar para o número (401)

45 RHODE ISLAND FORMULÁRIO DE REGISTO ELEITORAL Use uma caneta e preencha com letra de imprensa. Todas as informações são obrigatórias, excepto quando indicado que são opcionais. PODE UTILIZAR ESTE FORMULÁRIO PARA: TEM DE: PARA A INSCRIÇÃO ELEITORAL EM RI Fazer o registo eleitoral em Rhode Island. * Ser residente legal de Rhode Island. Alterar o seu nome e/ou morada no seu registo. * Ser cidadão dos Estados Unidos. Escolher um partido político ou mudar de partido. *Ter pelo menos 16 anos de idade. (Tem de ter pelo menos 18 anos de idade para votar no Dia das Eleições). Caixa 2: OBRIGATÓRIO. Os cidadãos de Rhode Island que tenham pelo menos 16 anos de idade podem fazer um préregisto eleitoral preenchendo este formulário. Se não marcar uma destas caixas, este formulário ser-lhe-á devolvido. Se marcou NÃO em alguma destas afirmações, não preencha este formulário. Caixa 3: Se está a fazer o registo eleitoral pela primeira vez em Rhode Island por correio ou se alguém o está a fazer por si, é OBRIGATÓRIO indicar o número da sua carta de condução ou o número do B.I. estadual emitido pelo Departamento de Veículos Motorizados de Rhode Island (Department of Motor Vehicles - DMV). Se não tiver nenhum deste documentos, deve indicar os 4 últimos dígitos do seu Número de Segurança Social. Se não fornecer as informações acima, ou se as mesmas não puderem ser verificadas, terá de se identificar perante um agente eleitoral antes da votação. Os formulários de identificação aceitáveis encontram-se disponíveis no site da Comissão de Eleições (Board of Elections) em ou contacte os seus Agentes Eleitorais (Board of Canvassers) (consulte o verso deste formulário). INSTRUÇÕES Caixa 5: Uma pessoa apenas pode ter uma residência legal. Pode registar-se a partir da sua residência legal. Um apartado ou uma estrada rural apenas podem ser usados como Endereço Postal" na Caixa 6. Caixa 9: Se pretender afiliar-se para votar, escolha um partido. Se deixar em branco a Caixa 9, será listado como não afiliado. Caixa 10: Deve ASSINAR e DATAR o formulário de registo. Se não assinar nem datar o formulário, este ser-lhe-á devolvido. Caixa 11: Se estiver a actualizar o registo eleitoral porque mudou legalmente de nome, escreva o seu nome legal anterior. Caixa 12: Se estiver a actualizar o registo eleitoral porque mudou de morada, introduza a sua morada anterior, mesmo se for fora do estado. Receberá um aviso de recepção deste formulário de registo eleitoral no prazo de 3 semanas. Se não o receber, contacte os seus Agentes Eleitorais (Board of Canvassers) locais (consulte o verso do formulário para ver a lista). Para perguntas e prazos relacionados com este formulário, vá ao site da Comissão de Eleições em ou contacte os seus Agentes Eleitorais locais (consulte o verso do formulário para ver a lista de moradas). (Este formulário pode ser reproduzido) 1. Seleccione as caixas que se aplicam: Novo registo eleitoral Alteração de morada Alteração de partido Alteração de Nome 2. Sou cidadão dos EUA e resido em RI Sim Não 3. Carta de condução ou Número de B.I. de RI: Tenho pelo menos 16 anos de idade Sim Não (tem de ter pelo menos 18 anos de idade para votar). Se não tem carta de condução ou B.I. de RI, introduza os 4 últimos dígitos do seu número de segurança social: Se marcou NÃO em alguma destas afirmações, não preencha este formulário. Se não tem nenhum destes números, veja as instruções para a Caixa Apelido Sufixo (caso tenha) Nome Nome do Meio (ou inicial) 5. Morada (Não introduza um apartado) Apt. Cidade/Vila Estado Código Postal RI 6. Endereço Postal (se diferente da Caixa 5) Apt. Cidade/Vila Estado Código Postal 7. Data de Nascimento 8. N.º de Telefone/Endereço de (mm/dd/aaaa) (opcional) 9. Filiação partidária: Americans Elect Democrata Moderado Republicano Não Mês Dia Ano filiado Outro 10. Juro ou afirmo que: - Não estou detido em nenhum estabelecimento prisional por condenação criminal. Official Use For Barcode - Actualmente nenhum tribunal me considerou mentalmente incapaz de votar. - As informações que prestei são verdadeiras tanto quanto é do meu conhecimento sob pena de perjúrio. Caso tenha prestado informações falsas, posso ser multado, detido ou (caso não seja cidadão dos EUA) deportado ou ser-me negada a entrada nos Estados Unidos. ASSINE O NOME COMPLETO OU COLOQUE UMA MARCA ABAIXO Data: Assinado (mm/dd/aaaa) Está interessado em trabalhar nas votações? (assinale a caixa abaixo) Aviso: se assinar este formulário sabendo que o mesmo é falso, pode ser condenado e multado com uma coima de $5000 ou ficar sujeito a uma pena de prisão de até 10 anos. 11. NOME ANTERIOR (se diferente da Caixa 4) 12. MORADA DE REGISTO ANTERIOR (Cidade, Estado, CP e Condado) 2/2012

46 **************************DOBRE AQUI E COLE NA PARTE SUPERIOR************************** INSTRUÇÕES PARA ENVIAR POR CORREIO O FORMULÁRIO DE REGISTO ELEITORAL Um requerente que opte por enviar por correio o formulário de registo eleitoral pode fazê-lo da seguinte forma: 1. Dobre o formulário na linha pontilhada e cole a parte inferior à parte superior deste formulário. 2. Da lista abaixo, localize a morada dos agentes eleitorais na cidade/vila onde está a fazer o registo eleitoral e escreva essa morada no espaço apropriado, por baixo de Enviar para: BOARD OF CANVASSERS no lado endereçado do formulário de registo eleitoral. Escreva o seu endereço de remetente no espaço fornecido. AVISO: Todos aqueles que interfiram no seu direito à liberdade de registo eleitoral ou de escolha de um partido político serão punidos nos termos da lei. Se entender que alguém interferiu com o seu direito de se registar ou não ou no direito à liberdade de decisão ou de escolha do seu partido político, pode apresentar uma reclamação à Comissão de Eleições, 50 Branch Avenue, Providence, Rhode Island AGENTES ELEITORAIS LOCAIS As perguntas sobre o registo eleitoral podem ser dirigidas a:rhode Island Board of Elections 50 Branch Avenue Providence, RI

47 Restaurant Meal Program SOME SUBWAY RESTAURANTS ACCEPT SNAP! Use your EBT Card at: 255 Weybossett Street, Providence 2 Kennedy Plaza, Providence 719 Westminster Street, Providence 583 Elmwood Avenue, Providence 962 Cranston Street, Cranston This program is ONLY for Seniors (age 60 or older) Look for this logo! Disabled (designated by government entity) Homeless Prepared by RI Community Food Bank for use by our Member Agencies & their guests All information has been confirmed using reliable sources. Last Updated

48 RHODE ISLAND DEPARTMENT OF HUMAN SERVICES SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) RESTAURANT MEALS PROGRAM FREQUENTLY ASKED QUESTIONS FOR PARTICIPANTS 1. What is the SNAP Restaurant Meals Program? The Restaurant Meals Program allows homeless, elderly (age 60 or over) and disabled Supplemental Nutrition Assistance Program (SNAP) households to use their SNAP benefits to purchase prepared meals using their SNAP Electronic Benefit Transaction (EBT) card at participating restaurants. 2. How can I find out if I am eligible for the Restaurant Meals Program? You may be eligible if you are Elderly, Disabled or Homeless. Contact or contact your local Department of Human Services (RI DHS) office. 3. Do I have to apply for the Restaurant Meals Program separately? No, if you are an eligible SNAP client and meet the specific requirements mentioned above, an additional application is not required. 4. How do I find out if a restaurant is participating in the program? Participating restaurants will have signage that states Participating Restaurant: SNAP Restaurant Meals Program with the Fork & Knife logo displayed on the door or window. For a list of restaurants, call or visit the website. You may also visit the Rhode Island Department of Human Services website for a list of participating restaurants at 5. Do I have to show an identification card aside from my EBT card to purchase a meal? No, an identification card is not required. All you need is your EBT card and authorized PIN (personal identification number) to purchase a meal. 6. After purchasing a meal, do I get a sales receipt showing my SNAP benefits balance? Yes, your sales receipt will show the cost of your meal and your SNAP (Food Stamp) benefit balance. 7. Will I be charged a service gratuity or sales tax if I purchase a meal with my SNAP EBT Card? No, the participating restaurant is not allowed to charge a service gratuity or sales tax under the Restaurant Meals Program. 8. If my EBT SNAP benefit is not enough to purchase a meal, can I use the EBT cash benefit to cover the difference for payment? Yes, you must inform the cashier that you will use a mixed transaction (EBT SNAP and RI Works EBT cash combined). Before you buy a meal, to check the balance of your EBT SNAP account, you can check your last receipt, call the toll-free EBT Customer Service Center number ( ), or visit You may also use cash or a credit card to pay for the balance. 9. What do I do if my EBT SNAP transaction is denied by a participating restaurant? You must call your SNAP Eligibility Worker or call the EBT Customer Service Center Number ( ). Need more information about the Restaurant Meals Program? Call or visit

49 State of Rhode Island and Providence Plantations RELEASE: December 12, 2013 Department of Human Services Division of Elderly Affairs BY: Catherine Taylor, Director, Rhode Island Division of Elderly Affairs A FRESH LOOK FOR SENIOR NUTRITION IN RHODE ISLAND Do you want to attend a congregate meal site? Although the venues are friendly and inviting and the food is healthy and delicious, the name conjures up something old-fashioned and, to many potential diners, not entirely appealing. Welcome to the Café! The Senior Nutrition Program in Rhode Island is rolling out a new look for 2014 that reflects how we are already catering to the changing appetites of older Rhode Islanders. Each regional nutrition program now has a new name: Blackstone Café, East Bay Café, Westbay Café, Northern Rhode Island Café (run by Senior Services, Inc. of Woonsocket) and Capitol City Café (run by Meals on Wheels of Rhode Island). Our five programs are delivering three meal choices daily to your local community or senior center for your noontime dining enjoyment. The spa option for the health conscious features lighter fare such as a main course salad. The pub option offers a sandwich for those who want a traditional, wholesome lunch. And the hearty option provides a full, hot dinner for those who prefer their main meal at midday. Our diners have been requesting more flexible dining hours, a range of menu offerings and healthier fare, and we are responding by extending the popular Café concept statewide to all senior meal sites. This new initiative is complemented by Meals on Wheels growing cooperative arrangements with select local restaurants that honor vouchers to seniors, expanding the geographical reach of senior dining as well as offering occasional breakfast and dinner opportunities. -more-

50 Director Taylor s January 2014 column-page 2 The Café welcomes all diners 60 and over (in the case of a married couple, only one spouse must be over 60), regardless of ability or income. Lunches are served five days a week. There is a suggested participant donation of $3 per meal to help sustain the program, which is funded by federal Older Americans Act dollars. SNAP beneficiaries may use their SNAP benefits to contribute toward their meal. And the Cafés can always use your help as a volunteer. During the year ending September 30, 2013, senior community meals sites served nearly 338,000 meals. States receive an incentive payment from the U.S. Administration on Aging for the number of meals we report so, the more diners that join us, the more we can serve! For more information, or to find the most convenient Café, call the Division of Elderly Affairs at At least 24 hours notice is required for reservations. (We need to balance serving everyone who wants to join us with avoiding expensive waste.) Transportation to the nearest meal site and/or senior center is available through the RIde program, at a cost of $2 each way. Refresh with a chef salad after a Zumba workout at Blackstone Café at Leon Mathieu in Pawtucket. Relax in front of the fire with soup and sandwich at Westbay Café at The Center in South Kingstown. Dig into Yankee Pot Roast on a winter s afternoon at Northern RI Café in Woonsocket. Whatever your taste, come find it at the Café! ###

51 State of Rhode Island and Providence Plantations Department of Human Services Division of Elderly Affairs Revised: Cities and Towns Served by RI Title IIIC Nutrition Programs There are Title IIIC congregate meal sites in 34 cities and towns in Rhode Island. Several sites also serve seniors living in nearby cities/towns. Blackstone Health Nutrition Program, (16 meal sites): Alyssa Joyce, Director of Nutrition, 401) North Kingstown Beechwood House Coventry Senior Center Cranston Senior Services Providence DaVinci Senior Center Providence - Elmwood Community Center Central Falls - Forand Manor Johnston Senior Center Pawtucket - Leon Mathieu Senior Center Providence - Lillian Feinstein Senior Center North Providence - Steve Piccillo Center Central Falls - Progresso Latino North Providence - Salvatore Mancini Senior Center Scituate Senior Center Cranston - Temple David Central Falls - Wilfrid Manor Providence - Jewish Community Center East Bay Nutrition Program, (10 meal sites): Sue Lewis, Program Director, (401) East Providence Senior Center East Providence Goldsmith Manor East Providence Harbor View Manor Barrington Senior Center Warren Senior Center Bristol Senior Center Portsmouth Senior Center Middletown Senior Center Tiverton Senior Center John O. Pastore Center, Hazard Building / 2 nd Floor 74 West Road, Cranston, RI Telephone , Fax , TTY Web Site:

52 Newport Donovan Manor Cities and Towns Served by RI Title IIIC Nutrition Programs-page 2 Meals on Wheels Congregate Nutrition Program, (6 meal sites): Heather Amaral, Executive Director, (401) Providence - Carrol Towers Providence - Federal Hill House Providence - Fox Point Senior Center Providence-St. Elizabeth s Place Providence Socio-Economic Development Center for Southeast Asians (SEDC) Providence - St. Martin de Porres Center Senior Services, Inc. Nutrition Program, (12 meal sites): Barbara Waterman, Executive Director, (401) Woonsocket Senior Center Woonsocket Parkview Manor Woonsocket Kennedy Manor Woonsocket Crepeau Court Cumberland - Chimney Hill Apartments Cumberland Senior Center Cumberland - Cumberland Manor Lincoln Senior Center Smithfield Senior Center Glocester Senior Center Pascoag - Bradford North Smithfield - The Meadows Westbay Nutrition Program, (12 meal sites): Paul Salera, Director of Elder services, (401) South Kingstown Larry Tetreault Center Charlestown Senior Center Westerly Senior Center Westerly Parkview Manor West Warwick Senior Center Jamestown Senior Center East Greenwich - St. Luke s Church Warwick-Pilgrim Senior Center(noon and evening) Warwick Shalom Housing (noon and evening) Warwick - Sparrow I Housing (noon and evening) Warwick - Sparrow III Housing (noon and evening) Warwick - Harding Brook housing (evening only) John O. Pastore Center, Hazard Building / 2 nd Floor 74 West Road, Cranston, RI Telephone , Fax , TTY Web Site:

53 Narragansett Indian Tribe, (1 meal site) Parrish Noka, Social Services (401) , ext. 13 Charlestown Narragansett Tribe Community Center John O. Pastore Center, Hazard Building / 2 nd Floor 74 West Road, Cranston, RI Telephone , Fax , TTY Web Site:

54

55 Senior Medicare Patrol What is the Senior Medicare Patrol? Senior Medicare Patrol programs, or SMPs, help Medicare and Medicaid beneficiaries prevent, detect, and report health care fraud. They not only protect older persons, they also help preserve the integrity of the Medicare and Medicaid programs. Because this work often requires face-to-face contact to be most effective, SMPs nationwide rely on more than 5,600 volunteers who are active each year to help in this effort. Tell me about SMP volunteers. Protecting older persons from criminals and saving precious health care dollars at the same time is a mission that attracts many civic-minded Americans. Most SMP volunteers are both retired and on Medicare, so they are well-positioned to assist their peers. How, exactly, do SMPs fight fraud? SMP staff and volunteers work with individual beneficiaries to review Medicare Summary Notices for accuracy, make presentations to groups about how to avoid getting taken by scam artists, exhibit at community health fairs, and more. Their primary goal is to teach Medicare beneficiaries how to protect their personal identity, identify and report errors on their health care bills and identify deceptive health care practices, such as illegal marketing, providing unnecessary or inappropriate services, and charging for services that were never provided. In some cases, SMPs do more than educate: When Medicare and Medicaid beneficiaries are unable to act on their own behalf to address these problems, the SMPs work to address the problems, making referrals to the Centers for Medicare & Medicaid Services (CMS) and their anti-fraud contractors; the Office of Inspector General (OIG); state attorneys general offices; local law enforcement; State Health Insurance Assistance Programs (SHIP); state insurance divisions; and other outside organizations that are able to intervene. What is the background of the program? In 1995, the U.S. Administration on Aging (AoA) became a partner in a government-led effort to fight fraud, error, and abuse in the Medicare and Medicaid programs through the implementation of a ground-breaking demonstration project called Operation Restore Trust (ORT). ORT s purpose was to coordinate and target federal, state, local, and private resources on those areas most plagued by abuse. Operation Restore Trust was announced at the 1995 White House Conference on Aging. It created a partnership in the U.S. Department of Health & Human Services (HHS) between CMS, the OIG, and the AoA, which continue to work as a team in a coordinated anti-health care fraud effort at the local, state, and national levels. continued

56 Find an SMP at In 1997, because of the Omnibus Consolidated Appropriation Act of 1997 (Public Law ), AoA established 12 local demonstration projects designed to recruit and train retired professionals such as doctors, nurses, teachers, lawyers, accountants, and others to identify and report error, fraud, and abuse. Senate Report noted that senior citizens are our best front line defense against these losses. Tell me about the scope of the SMP program today. Based on the success of these demonstration projects, the SMP program is now in every state, as well as the District of Columbia, Puerto Rico, Guam, and the Virgin Islands. Under Title IV of the Older Americans Act, approximately $9.3 million in grants are provided annually. Beginning in FY2010, CMS provided additional funds to double SMP program efforts. To implement this expansion, the AoA has awarded $9 million in additional annual funds to the nationwide network of SMPs to enhance their volunteer programs and outreach efforts. What has the SMP program achieved over the years? Since 1997 almost 27 million people have been reached during community education events, more than 5 million beneficiaries have been educated and served, and more than 30,000 volunteers have been active. Total savings to Medicare, Medicaid, beneficiaries and other payers attributed to the SMP projects is $106 million. (Source: May 2011 OIG Performance Report) What are examples of fraud and waste seen by SMPs? Equipment or insurance plan providers tricking senior center participants into giving up their personal information (including Medicare numbers) on sign-in sheets Medicare Summary Notices showing billing for services or supplies that were never provided Equipment suppliers providing expensive scooter wheelchairs not ordered by a physician or needed by the beneficiary Luring beneficiaries into providing their Medicare numbers for free services, then billing Medicare Kickbacks paying beneficiaries to receive service from a particular provider or company Where can I learn more? In Rhode Island, contact: Rhode Island Dept. of Human Services, Div. of Elderly Affairs Hazard Building, 2nd Flr, 74 West Rd., Pastore Complex, Cranston, RI Aleatha Dickerson, SMP Director, , Supported by grant number 90NP0001/03 from the U.S. Administration for Community Living (ACL), Administration on Aging (AoA), Department of Health and Human Services

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