The Pennsylvania Application for Benefits form is a critical document for individuals seeking assistance in the state. It serves as an application for cash, health care, and SNAP (Supplemental Nutrition Assistance Program) benefits. Key features of the form include accessibility options such as language translation, interpretation services provided at no cost, and adaptations for people with disabilities. Whether you're applying for the first time or navigating the complexities of domestic violence situations, this form plays a pivotal role in accessing essential services and support.
The Pennsylvania Application for Benefits form serves as a crucial gateway for residents seeking assistance through various state-provided services, including cash assistance, health care, and the Supplemental Nutrition Assistance Program (SNAP). Designed with accessibility in mind, the document ensures that language or disability does not hinder the application process. Assistance is available in multiple languages, and accommodations are made for individuals with disabilities, highlighting Pennsylvania's commitment to inclusivity. With the option to apply online, the form simplifies the process, encouraging residents to take the first step toward receiving support. Moreover, the application acknowledges the intersection of domestic violence and the need for assistance, offering tailored exemptions and specialized support for those affected. By connecting applicants with job-seeking resources through PA CareerLink® and emphasizing the importance of immediate aid through programs like Quick SNAP, the form serves not just as an application but as a comprehensive support system. It underscores the state's efforts to verify information for eligibility, ensuring fairness in the distribution of aid, and it encourages applicants to seek additional services that may benefit them, ranging from energy assistance to child support services. This integration of services, alongside a robust support system for victims of domestic violence, illustrates a holistic approach to assistance, ensuring that applicants are not merely applying for financial aid but are also provided with resources to improve their overall well-being.
Pennsylvania Application for Benefits
This is an application for cash, health care and SNAP benefits. If you need this application in another language or someone to interpret, please contact your local county assistance office. Language assistance will be provided free of charge.
Esta es una solicitud de beneficios de SNAP, asistencia médica y asistencia monetaria. Si necesita esta solicitud en otro idioma o alguien para que interprete, comuníquese con la oficina de asistencia de su condado. La ayuda bilingüe será gratuita.
If you have a disability and need this application in large print or another
format, please call our helpline at 1-800-692-7462.
Individuals who are deaf, hard of hearing, or have speech disabilities and wish to communicate with the helpline may call PA Relay Services by dialing 711.
You can apply online at: www.compass.state.pa.us.
PA 600 2/20
Family Safety: Information About Your Benefits and Domestic Violence
Domestic violence happens when someone in your life harms you. Abuse can be physical, sexual or emotional. It includes:
•Physically hurting you or your children
•Threatening or trying to hurt you, your children or your property
•Forcing you to have sex
•Sexually abusing your children
•Controlling where you go and who you see
•Not allowing you or your children to have food, clothing or medical care
•Keeping you from going to work or school
•Following or stalking you
If you are or have been a victim of domestic violence or are at risk of further violence, your caseworker can excuse you
from requirements for cash assistance if domestic violence prevents you from complying. Sometimes people cannot safely follow welfare requirements because they fear that they or their children will be abused if they do so. These include:
•
Support cooperation
Requirements that teen parents live at home
Time limits
Other requirements on a case-by-case basis
• Work (RESET)
Verification
If you need to be excused from welfare requirements because of domestic violence, tell your caseworker.
If you or your children are or have been victims of domestic violence, or are at risk of further violence, your caseworker can:
•Talk to you if you want to talk. You can ask to talk in private. Your caseworker and the staff will keep your personal information confidential. However, the law says that the Department of Human Services must report child abuse to the Children and Youth Agency.
•Help you find local programs where you can get counseling, safety planning, shelter, legal services and other help.
•Help you understand the rules for applying for cash assistance, and how they affect you if you apply. Certain TANF requirements may be waived based upon domestic violence.
For more information about crisis intervention, counseling, accompaniment to police, medical and court facilities, temporary emergency shelter, and prevention and education programs, call:
The Pennsylvania Coalition Against Domestic Violence
1-800-932-4632 (in PA)
303-839-1852 (National)
PA CareerLink® - Important Information
PA CareerLink® is a program of the Pennsylvania Department of Labor and Industry to help job seekers find jobs. The Labor and Industry staff knows about current labor market conditions and can give you information and resources to help your job search.
It is recommended that you register with PA CareerLink® to get started. You can register with PA CareerLink® at
www.pacareerlink.pa.gov/.
Application for Benefits
Pennsylvania receives information from other state and federal agencies to verify the information you give us. If you misrepresent, hide or withhold facts which may affect your eligibility for benefits, you may be required to repay your benefits and you may be prosecuted and disqualified from receiving certain future benefits.
It’s easy to apply!
1.Fill out this form. 2. Sign and date it on page 1 and page 15
3. Bring, fax or mail your form to your county assistance office (CAO).
Are you interested in any other services?
Put a check in the box if you are interested in information on any of these other services:
Supplemental Security Income (SSI)
Intellectual disability services
LIHEAP (energy assistance)
Food banks
School meals (free or reduced cost)
Long Term Care (nursing home care)
Well Baby Clinic
Immunizations (shots)
Veterans’ services
Employment and training
Vocational rehabilitation Housing assistance
Child care
Head Start (for children ages 3 to 6)
Child support services
Family planning/birth control
Lifeline (reduced cost phone service)
WIC (Women, Infants and Children)
Home and Community Based Services (Waiver Services)
Special allowances for employment and training such as tools)
Other: _____________________________________
Questions?
Call your county assistance office or our CUSTOMER SERVICE CENTER at 1-877-395-8930.
In Philadelphia, call 1-215-560-7226.
We are here to help you. Call Monday thru Friday 8:30 a.m. to 5 p.m.
TDD Services are available by calling PA Relay Services at 711.
Medical Providers Use Only
PROVIDER NAME
PROVIDER NUMBER
EMERGENCY
CAO Use Only
APPLICATION REGISTRATION NUMBER
CASELOAD
COUNTY
DISTRICT
RECORD NUMBER
DATE STAMP
Quick SNAP!
Get SNAP Benefits Now!
(SNAP was formerly known as the Food Stamp program.)
•Does your household have $100 or less in available cash and bank accounts and expect to receive less than $150 in income this month?
•Are you a migrant or seasonal farm worker?
•Are your monthly gross income and cash and bank accounts less than your rent/mortgage and utility costs for this month?
If the answer to any of these questions is yes, you may have a right to expedited SNAP benefits.
This means you can get SNAP benefits within five calendar days of the date you apply.
Ask for more information by contacting the local county assistance office.
File your SNAP benefits application today!
It is your right to file an application today at any time before 5 p.m. The person at the county assistance office should date-stamp your application while you watch.
If you are denied expedited SNAP benefits, you have the right to an agency conference within two working days with a supervisor at the county assistance office. If you believe you are being denied your rights or services, or if the county assistance office does not take your application when you hand it in and date- stamp it while you watch, ask to talk with a supervisor or call the Helpline toll free at 1-800-692-7462.
You can get free legal help at the local legal services office.
Getting Started
What do you want to apply for?
Cash assistance
Health Care Coverage
SNAP (Supplemental Nutrition Assistance Program)
What language do you prefer? ¿Qué idioma prefiere usted? Do you need an interpreter? ¿Necesita un intérprete?
English/Inglés
Yes/Sí
No
Spanish/Español
Other/Otro (specify/especifique)
If yes, what language? En caso afirmativo, ¿de qué idioma?
Go paperless! Would you like to receive your notices online?
Go to www.compass.state.pa.us and enroll on your MyCOMPASS Account.
•We can start your application as soon as you write your name and address, and sign and return this application.
•We encourage you to answer as many questions as you can unless the instructions tell you that you can choose not to answer. The more complete information we have, the faster we can process your application.
•If you are eligible, SNAP benefits start from the date we receive your application. We will tell you within 30 days if you are eligible or not.
IMPORTANT: All persons applying must provide or apply for a Social Security number (SSN) and answer citizenship questions. Providing an SSN is optional for persons not applying for benefits, but providing it can speed up the application process. We use SSNs
to check income and other information to see who is eligible for help with health care coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit www.ssa.gov. TTY users should call 1-800-325-0778.
Note: If you are a non-citizen applying for Emergency Medical Services only, you do not need to provide information about your immigration status or apply for or provide an SSN.
Tell us about you, the applicant: We will need to contact an adult/parent/caretaker.
Name (Include first, middle initial, last, suffix - Jr./Sr./etc.):
Home address (Include street, apt. number, city, state & ZIP code+4)
School district:
Township or municipality:
How long have you lived at this address?
Phone number:
()
Phone type:
Home
Work
Cell
Second phone number:
Check here if you do not have a home address. You still need to give a mailing address.
Mailing address (if different from home address):
Quick SNAP: You may be able to get SNAP within 5 days! Answer these questions, then sign this application and give it to your county assistance office by 5 p.m. today! Your county assistance office will set up an interview with you.
Total monthly income, for you and anyone
Are you, or anyone you are applying
Do you pay for utilities other than telephone?
Yes
who is applying, before taxes are taken out:
for, getting SNAP now?
If yes, which utilities?
$
Total resources (resources are money in cash,
Do you pay for telephone services?
Are you, or anyone you are applying for, a seasonal or migrant farm
checking and savings accounts):
worker?
Total monthly rent or mortgage for you and
Do you pay for heating or the cost to
Do you, or anyone you are applying for, live in a shelter for abused or
anyone who is applying:
run air conditioning?
battered women and children?
Sign here:
X
Your signature or your representative’s signature
Date
Page 1
Tell us about people in your home:
We need to gather information about everyone who lives at your address, even if they are not applying for benefits. For health care applicants, be sure to include anyone on your federal income tax return, even if they do not live with you.
Note: You do not need to file a tax return to get benefits.
Person 1 (Start with yourself)
CAO Use Only Line #:
Name (Include first, middle initial, last, suffix-Jr./Sr./etc.)
Are you applying for yourself?
Social Security number:
Birthdate (MM/DD/YYYY):
Sex
Driver’s license or state ID number
Marital
Single
Separated
Married
M
F
if you have one:
Status
Divorced
Widowed
Are you in school?
If yes, what grade?
Name of school:
Full-time student?
Are you pregnant?
If yes, due date?
How many babies are expected?
Answer the questions below if you are applying for yourself.
You do not
need to
answer these
questions if you are applying only for SNAP.
If not eligible for full Medical Assistance coverage, do you want to be reviewed for coverage for the Family Planning
Services program only?
If you are under 21, we will consider only your income in our determination for the Family Planning Services program. If you wish to
be reviewed for full Medical Assistance coverage, we will need to evaluate your household income, including your parent(s)’ income.
Do you want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage?
Regardless of age, are you afraid that information you may receive where you live about family planning services could
cause physical, emotional, or other harm from your spouse, parents, or other person?
Are you a U.S. citizen or national?
If you are not a U.S.
Do you have eligible
If yes, fill in the
Document type:
Document ID number:
document type
citizen or national,
immigration status?
and ID number:
answer the following
questions:
Do you have a sponsor?
Have you lived in the U.S. since 1996?
RACE (Optional)
Black or African American
Asian
Native Hawaiian or Pacific Islander
(Check all that apply)
American Indian or Alaska Native (See Appendix A)
White
Other _______________________________
ETHNICITY (Optional)
Hispanic or Latino
Non Hispanic or Latino
Page 2
Person 2
Are you applying for this person?
if this person has one:
How is this person related to you?
Spouse
Child
Stepchild
Not Related
Does this person live with you?
Other _____________________________________________
Is this person in school?
Is this person pregnant?
Answer the questions below if you are applying for this person.
If not eligible for full Medical Assistance coverage, does this person want to be reviewed for coverage for the Family
Planning Services program only?
If this person is under 21, we will consider only their income in our determination for the Family Planning Services program. If they wish
to be reviewed for full Medical Assistance coverage, we will need to evaluate their household income, including their parent(s)’ income.
Does this person want to be reviewed only for the Family Planning Services program and NOT for full Medical Assistance coverage?
Regardless of age, is this person afraid that information they may receive where they live about family planning services
could cause physical, emotional, or other harm from their spouse, parents, or other person?
Is this person a U.S. citizen or national?
If this person is not
Does this person have
eligible immigration
a U.S. citizen or
national, answer the
status?
following questions:
Does this person have a sponsor?
Has this person lived in the U.S. since 1996?
Person 3
Page 3
Person 4
Person 5
Page 4
Person 6
Person 7
Page 5
Other questions about people in your home:
Please answer these questions about you or anyone in your home who is applying for benefits.
Does anyone get cash assistance, Medical
If yes, what state and county?
Assistance or SNAP in another state now?
Have you or anyone in your household been
If yes, tell us who:
disqualified or agreed to be disqualified for
food stamps or SNAP benefits in another state?
Has anyone ever applied for any benefits using
If yes, please tell us the name and Social Security number:
a different name or Social Security number?
Is anyone in the U.S. military, or has anyone
Is anyone a widow, spouse, or child (under age 18) of anyone in
been in the U.S. military?
the U.S. military, or anyone who has been in the U.S. military?
Was anyone in foster care at age 18 or older?
If yes, who?
State:
Is anyone disabled, seriously ill, or in need of
What is the disability?
medical attention?
Does anyone have a medical condition that
requires health sustaining medication?
Does anyone live in a medical or long term care facility or have a physical, mental or emotional health condition that causes limitations
in activities (like bathing, dressing, daily chores, etc.)?
Does anyone have paid or unpaid medical bills
Has anyone been a victim of domestic abuse?
this month or the last three months?
Is anyone in treatment for drug or alcohol
abuse?
Absent relatives: This section is for cash applicants.
If anyone is applying for a child who has parents not living in your home or if anyone applying has a spouse not living in your home, please answer these questions so that we can try to get support.
You do not need to fill out this section if providing this information or seeking support would put you or family members at risk of domestic violence or make it more difficult to escape domestic violence, or if your child was born as a result of rape or incest, or if you are considering adoption.
If it would be a problem for you to provide this information or seek support because of domestic violence, rape or incest or because you are considering putting a child up for adoption, check this box:
Name of person with an absent relative:
Name of absent relative:
Absent relative is a:
Parent
If you are applying for cash assistance, you must name the parents of any minor children and help the Domestic Relations Section (DRS) collect support by providing the information they need unless you have good cause. If you do not help the DRS by providing
the information needed and do not have a good reason for not helping, any cash assistance amount for which you are approved will be lowered by at least 25 percent.
If approved for cash assistance, you must give the Department and DRS the right to collect cash for you and others for whom you are applying. The law says that support rights will be assigned to the state if you accept cash assistance.
If support is paid for a child who gets cash assistance, the family may get some of the support in addition to the cash assistance grant.
Page 6
Filling out the Pennsylvania Application for Benefits form begins a crucial step towards accessing a variety of benefits that can support individuals and families through challenging times. Understanding the importance of accurately completing this application cannot be overstated, as it serves as the gateway to potentially receiving cash assistance, health care, and SNAP benefits. Below are the detailed steps to ensure the application is filled out properly, setting you on the path towards receiving the necessary support.
Once your application has been submitted, it will be reviewed by the county assistance office. You may be contacted for an interview or to provide additional information. Within 30 days, you will be notified if your application for benefits has been approved or denied. If approved, you will receive detailed information about how to access your benefits. Remember to keep a copy of your completed application for your own records.
What benefits can I apply for using the Pennsylvania Application for Benefits form?
The Pennsylvania Application for Benefits form allows you to apply for cash assistance, health care coverage, and SNAP (Supplemental Nutrition Assistance Program). These benefits are designed to provide financial and nutritional assistance to eligible individuals and families to help meet basic needs.
Can I receive assistance in another language or in an accessible format if needed?
Yes, if you need the application in another language or require someone to interpret, you can contact your local county assistance office for help. Language assistance services are provided free of charge. Additionally, if you have a disability and require the application in large print or another accessible format, you can call the helpline at 1-800-692-7462 for assistance. Deaf, hard of hearing, or individuals with speech disabilities can contact PA Relay Services by dialing 711.
Is it possible to apply for benefits online?
Yes, you can apply for benefits online by visiting www.compass.state.pa.us. The online application process is designed to be straightforward and user-friendly, allowing you to complete and submit your application conveniently.
I am a victim of domestic violence. Can I be excused from certain requirements for receiving cash assistance?
If you are or have been a victim of domestic violence or are at risk of further violence, your caseworker can excuse you from certain requirements for cash assistance. These requirements might include cooperation with child support, work requirements, or living arrangements for teen parents. It's important to inform your caseworker about your situation to get the necessary support and exemptions.
What is PA CareerLink®, and how can it assist me in finding a job?
PA CareerLink® is a program by the Pennsylvania Department of Labor and Industry aimed at assisting job seekers in finding employment. They offer services such as information on current labor market conditions, job search assistance, and resources to aid in your employment search. It is recommended that you register with PA CareerLink® to take advantage of these services.
What happens if I provide false information on my application?
Providing false information or failing to disclose facts that may affect your eligibility for benefits can lead to serious consequences. You may be required to repay any benefits you received based on false or incomplete information. Furthermore, legal actions could be taken against you, potentially resulting in disqualification from receiving certain future benefits.
Can I apply for other services through the Pennsylvania Application for Benefits form?
Yes, the form also includes a section where you can express interest in information on other services such as Supplemental Security Income (SSI), LIHEAP (energy assistance), food banks, school meals, veterans’ services, and more. Indicating your interest does not apply you directly to these programs but can help you get more information on them.
What should I do if I need emergency SNAP benefits?
If your household has very low income or resources and meets certain criteria, you might qualify for expedited SNAP benefits, which can be provided within five calendar days of applying. Specific conditions apply, such as having less than $100 in cash and bank accounts or expected income below $150 for the month. Contact your local county assistance office for more details and to see if you qualify.
How soon can I start receiving benefits if I am eligible?
If you are eligible for SNAP benefits, your benefits typically start from the date the office receives your completed application. The county office will review your application and inform you within 30 days about your eligibility status.
What information do I need to provide when applying for benefits?
All applicants must provide or apply for a Social Security number (SSN) and answer citizenship questions. Providing an SSN is optional for persons not applying for benefits themselves, but it may expedite the application process. For health care coverage assistance, SSNs are used to verify income and other eligibility criteria. If you need help obtaining an SSN, contact the Social Security Administration.
Not providing complete information on all required questions. When applicants skip questions or provide incomplete responses, it can slow down the review process or result in a denial of the requested benefits. It's important to answer each question fully unless the instructions specify that you can choose not to answer.
Failing to sign and date both the first and last page of the application. The application process cannot begin until the form is signed and dated as instructed. Failure to do so can lead to delays in processing.
Incorrectly reporting household income and resources. Accurately reporting the total monthly income before taxes for you and anyone else who is applying, along with the total resources, is crucial. Underreporting or overreporting can affect eligibility and the amount of benefits received.
Overlooking the need to apply for or provide a Social Security number (SSN) for all persons applying for benefits. SSNs are used to check income and other information to determine eligibility. Not providing an SSN for each applicant can delay or prevent processing of the application.
Not checking the appropriate boxes for other services of interest. Applicants often miss the opportunity to receive information on additional services for which they may be eligible, such as LIHEAP (energy assistance), food banks, or employment and training services, by not indicating their interest on the application form.
It's important to carefully review all instructions and ensure that information is accurate and complete when submitting the Pennsylvania Application for Benefits. Doing so helps to avoid common mistakes that can delay the processing of your application or affect your eligibility for benefits. Remember, assistance is available if you have questions or need help with your application.
When individuals in Pennsylvania set out to apply for benefits such as cash assistance, health care, and SNAP through the PA Application for Benefits form, they often need to provide additional documentation to support their application. The process is designed to ensure that the assistance reaches those who are most in need and that the information provided is accurate and comprehensive.
Gathering these documents and filling out the PA Application for Benefits form is the first step for individuals and families in Pennsylvania to access the vital support services they need. This comprehensive approach ensures that assistance is tailored to the specific situations of applicants, providing them with the resources necessary to improve their quality of life. The compilation and submission of these forms and documents, while sometimes tedious, are crucial steps in accessing the assistance many individuals and families depend on for their basic needs.
The Pennsylvania Application for Benefits form is similar to several other important documents individuals might encounter when applying for various types of assistance or services. These similarities are found in the structure, purpose, and type of information requested.
Federal 1040 Income Tax Return: Like the Pennsylvania Application for Benefits, the Federal 1040 Income Tax Return form collects personal information, income details, and family composition to determine eligibility for benefits or tax obligations. Both forms require accurate reporting of income and household members to allocate resources or tax liabilities correctly. However, the tax return focuses more on calculating the amount of tax owed or the refund due from the government, whereas the benefits application determines eligibility for social services.
Free Application for Federal Student Aid (FAFSA): This form also shares similarities with the Pennsylvania Application for Benefits, particularly in the way it assesses an individual's or family's financial situation to determine eligibility for aid. The FAFSA is designed to collect financial information about students and their families to allocate federal and state educational funding. Both forms require detailed financial information, including income, assets, and the number of dependents, to aid in the determination process.
Medicaid Application Forms: Medicaid applications across various states can resemble the Pennsylvania Application for Benefits form, especially in sections dedicated to health care coverage. Both forms assess financial eligibility for health care assistance, requiring detailed information on income, household size, and insurance needs. They are designed to help officials determine which applicants may qualify for health care programs based on financial criteria and need.
Despite the differences in their primary focus—whether it's tax liability, educational funding, health coverage, or other benefits—these documents similarly seek to understand an applicant's financial situation and dependents to allocate assistance appropriately.
When filling out the Pennsylvania Application for Benefits form, it's important to approach the process with care to ensure that your application is accurate and complete. Here are some key dos and don'ts to guide you:
There are several common misconceptions about the Pennsylvania Application for Benefits form. Understanding what the form actually entails can help individuals navigate their way through applying for assistance with greater clarity.
By clarifying these misconceptions, applicants can better understand how the Pennsylvania Application for Benefits form works and ensure they receive the assistance they qualify for without undue burden or misapprehension.
Transfer Car Title to Family Member - Proof of payment of Heavy Vehicle Use Tax is required for vehicles over 55,000 pounds as stated on the MV-140 form.
Cancel Plates Online - Pennsylvania residents who no longer require their registration plate due to various circumstances use the MV-141 form for official surrender.