Apply for Benefits Online

Application for

Food, Fuel, and Financial Assistance

   

 

Use this application  to apply for...

  •  3SquaresVT- Helps purchase more and better food.

  •  Reach Up - Services and financial assistance to help families with children become    more independent.

  •  Home Heating - Helps pay part of your home heating costs if you pay for heat directly, have heat included in your rent, or rent a room in someone else’s home.

  •  Essential Person - For people who  are  blind,  have a disability, or are  65 or older, to help meet expenses for someone who  lives with and provides care for them so they can  live at home.

 

Apply online

 

You can also apply for these programs  online by visiting MyBenefits.vt.gov.

 

What about health coverage?

YOU WILL NOT BE ABLE TO APPLY FOR HEALTH COVERAGE USING THIS APPLICATION.

If you would like to apply for Medicaid/Dr. Dynasaur you will need to obtain an Application for Health Coverage and Help Paying Costs from Vermont Health Connect. Vermont Health Connect is a new way for Vermonters to find health coverage that fits their needs and budget. If you

are not interested in Medicaid/Dr. Dynasaur, there are many other health coverage options available for you to choose from. If you would like to learn more, call Vermont Health Connect at 1-855-899-9600, or visit the website at HealthConnect.Vermont.gov.

 

If you want help to pay for long-term care ser vices for a person 65 or older or with a disability, call the Benefits Ser vice Center at 1-800-479-6151 to ask for an Application for Choices for Care Long-Term Care Medicaid. If you would like to request an application for SSI-related Medicaid or for the Pharmacy program, call Member Ser vices at 1-800-250-8427.

 

Get help with this application

 

•  Online: MyBenefits.vt.gov

•  Phone: Call our  Benefits Service  Center at 1-800-479-6151.

•  People who are  deaf or hard  of hearing can  call the statewide relay service at 711.

 

What happens

next?

Send your  completed and signed application to the following address:

 

DCF - Economic Services Division

Application and Document Processing Center

103 South Main Street

Waterbury, VT 05671-1500

 

NOTE: When  sending supporting documents, please send copies. Originals may not  be sent back.

 

If you are  applying for 3SquaresVT or Reach Up, an interview will be required. In most situations, your  3SquaresVT interview will be done by phone, and often your  Reach Up application will require a phone interview as well as attendance at an orientation. A worker will go over

this  form with you.  It is your  responsibility to give the worker all the information needed to

determine eligibility.

 

Additional

Resources

Find out  more about the Agency of Human Service’s programs for you and your  family by visiting the website at ScreenDoor.Vermont.gov. This website is designed to help Vermonters find

out  about the services that might be available to help them. You may  find additional services available in your  community by dialing 211 on your  phone or by visiting  the website for United Ways of Vermont at Vermont211.org.

 

If you need interpretation services…

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Si vous avez besoin de services d’interprétation, appelez le 1-855-247-3092. (French)

Mugihe woba ushaka impfashanyo yo gusigurirwa, hamagara uyu  murongo 1-855-247-3092. (Kirundi)

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Haddii  aad u baahan tahay adeegyo turjumaan, wac 1-855-247-3092. (Somali)

Si usted necesita servicios de interpretación, llame al 1-855-247-3092. (Spanish) Ikiwa unahitaji huduma za ukalimani, piga simu 1-855-247-3092. (Swahili)

Nếu quý vị cần dịch vụ thông ngôn, hãy gọi 1-855-247-3092. (Vietnamese)

 

You may detach and keep this page for future  reference. Your Rights and Responsibilities are on pages 16-18. Be sure to read through them. You can  review your  Rights  and  Responsibilities anytime by visiting the website at MyBenefits.vt.gov. If you need help understanding something, contact the Benefits Service Center at 1-800-479-6151.



 Information for Applicants

 

3SquaresVT Federal Requirements. 3SquaresV T is the State of Vermont ’s title for the Federal Supplemental Nutrition Assistance Program (SNAP). The State must process applications for 3SquaresV T in accordance with SNAP procedures, including timeliness, notice, and fair hearing requirements, regardless of whether the application is for 3SquaresV T and other programs. An applicant may  not be denied 3SquaresV T benefits solely because they were denied benefits from other programs. If the applicant is in an institution and applying for 3SquaresV T and SSI at the same time, the filing date will be the date of release from the institution.

 

In accordance with federal law, you MUST NOT: lie or hide information to get benefits that your  household should not get; use food assistance benefits to buy nonfood items, such as alcohol or cigarettes, or to pay on credit accounts; use, or have in your  possession, EBT cards that are not yours and you must not let someone else use your  card; and you must not trade or sell EBT cards or use someone else’s card.

 

The Food  and Nutrition Act of 2008  (formerly the Food  Stamp Act), as amended, 7 U.S.C. 2011-2036, authorizes the collection of information on the application, including the Social Security number of each household member, to be used to determine whether you are eligible or continue to be eligible to receive 3SquaresV T benefits. 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.

 

Social Security Numbers.  Everyone applying for benefits must provide a Social Security number. If your  household is applying for home heating fuel assistance, everyone in the household  must provide a Social Security number.   If you do not have a Social Security number, we will help you apply for one. People not applying for benefits do not have to provide their Social Security numbers.  However, they will have to provide information such as income and resources.

 

For additional information on Social Security numbers, including circumstances in which  an exemption for religious objections may  be available, see the section called “Social Security number” under Rights and Responsibilities, beginning on page 16 of this application.

 

Important Information for Immigrants. Only U.S. citizens and certain non-citizens can  get benefits.  If your  household includes people who  are not eligible because of their immigration status, you can  still apply for and get benefits for other eligible members. We will verify the immigration status of non-citizens who  apply for benefits with the U.S. Citizenship and Immigration Services. People not applying for benefits do not have to give immigration information.  However, they will have to provide information such as income and resources.

 

If you are an immigrant and get assistance from us, it may  affect your  sponsor or your  immigration status.  Before you apply, you may  want to talk with Vermont Legal Aid at 1-800-889-2047, or with an agency that helps immigrants with legal questions.

 

Proof of Citizenship, Immigration Status, and Identity. For certain programs, we must verify your  citizenship, immigration status, and identity.  We will try to do this by looking up your  information in available government records.  However, if we are unable to find a match, we may  ask you to provide the necessary proof. Do not send anything at this time.  We will tell you more about this after we get your  application.

 

Nondiscrimination Statement. The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases 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 all or 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 Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing _cust.html, or at any USDA office, or call 1-866-632-9992 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 us by mail at U. S. Department of Agriculture, Director, Office of Adjudication, 1400  Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax 1-202-690-7442 or email at program.intake@usda.gov.

 

Individuals who  are deaf, hard of hearing or have speech disabilities may  contact USDA through the Federal Relay Service at

1-800-877-8339; or 1-800-845-6136 (Spanish).

 

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at 1-800-221-5689, which  is also  in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found at http://www.fns.usda.gov/snap/contact_info/hotlines.htm.

 

USDA is an equal opportunity provider and employer.

 

Americans with Disabilities Act (ADA). The ADA gives people with disabilities certain rights.  If you think you might have a physical or mental condition that considerably limits a major life activity like moving, seeing, or thinking, contact us for help.  You may  be entitled to reasonable changes and accommodations in our  requirements to help you take part in our  programs.

 

Rights and Responsibilities.  When you sign the application, you are stating that you have read and understand your  Rights and Responsibilities (pages 16-18).   If you do not understand your  Rights and Responsibilities, or if you would like a copy  of them, call the Benefits Service Center at 1-800-479-6151.  You can  ask for your  copy  to be in larger print.  You can  also  review your  Rights and Responsibilities online at MyBenefits.vt.gov.


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