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: www.aarp.org/
quicklink.
Last updated: 9/2013
YOUR GUIDE
TO PUBLIC
BENEFITS IN
RHODE ISLAND
PAYING FOR HEALTH CARE AND PRESCRIPTION DRUGS
Medicare
Medicare Rx Extra Help
Benefit: Medicare is health insurance that helps
Benefit: This benefit lowers the cost of your
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: 1-800-772-1213 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:
1-800-MEDICARE (1-800-633-4227) or go to:
www.medicare.gov.
For help in your state, call the Rhode Island Senior
Health Insurance Program (SHIP) at: 401-4624000 or go to: www.dea.ri.gov/insurance.
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: 401-462-5300. To find
your local office, go to: www.dhs.ri.gov and click
on “Contact Us” then click on “DHS Offices” and
then choose the program.
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: 1-800-772-1213.
For help in your state, call the Rhode Island Senior
Health Insurance Program (SHIP) at: 401-4624000 or go to: www.dea.ri.gov/insurance.
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
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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: 401462-4444 or contact the Division of Elderly
Affairs at: 401-462-3000 or 401-462-0740 (TTY).
You can also go to: www.dea.ri.gov/programs/
prescription_assist.php.
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
Medicaid
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.
Benefit: Medicaid helps make medical coverage
How to apply: For more information and to find
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,
out how to apply, contact your local Department of
Human Services (DHS) at: 401-462-5300. To find
your local office, go to: www.dhs.ri.gov 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: 401-222-1111 (option 3) or
401-574-8829 or go to: www.tax.state.ri.us.
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: 401-574-9100. To find your closest
CAP office, go to: www.energy.ri.gov/lowincome/
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
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: 1-888-641-8722 or go to: www.lifelinesupport.
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.
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: 401-462-5300. To find
your local office, go to: www.dhs.ri.gov and click
on “Contact Us” then click on “DHS Offices” and
then choose the program.
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.
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: www.socialsecurity.gov 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: www.ssa.
gov/pgm/reach.htm and click on "Find an Office"
or call: 1-800-772-1213.
Supplemental Security Income (SSI)
Benefit: SSI provides a cash benefit to you every
month to make sure you have a minimum level of
4
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:
1-800-772-1213 or go to: www.ssa.gov/pgm/
links_ssi.htm.
OTHER INFORMATION
Eldercare Locator
Legal Help
The Eldercare Locator connects you to local
sources of information for senior services. You
can get help by calling: 1-800-677-1116 (hours of
operation are Monday–Friday, 9 am–8 pm ET) or
visiting: www.eldercare.gov.
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: 1-800-662-5034 (Providence) or
1-800-637-4529 (Newport) or go to: www.rils.org.
Senior Information Help Line
Benefits QuickLINK
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: 401-462-3000 or
401-462-0740 (TTY) or go to: www.dea.ri.gov. You
can also contact THE POINT, Rhode Island’s Aging
and Disability Resource Center, at: 401-462-4444
or 401-462-4445 (TTY) or go to: http://adrc.ohhs.
ri.gov.
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: www.aarp.
org/quicklink.
5
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Rhode Island Community Food Bank Regional Directory—2014
Appendix E – Services to Seniors & Adults with Disabilities
THE POINT
50 Valley St.
Providence, RI 02909
401-462-4444
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
401-462-0510
401-462-0740 (TTY)
www.dea.ri.gov
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 - http://www.dea.ri.gov/
or call 401-462-3000
Annual Pocket Manual — The Rhode Island Guide to Services for Seniors and Adults with
Disabilities http://www.dea.ri.gov/ or call 401-462-3000
*This guide includes a complete listing of Senior Centers in RI
United Way 2-1-1 or The Point, http://www.211ri.org/ or dial 2-1-1
Also see: rifoodbank.org >> Member Agencies >> Agency & Community Resources >> Community-Based Resources & Programs
Page 57
Rhode Island Community Food Bank Regional Directory—2014
Town
Senior Center
SHIP Agency
Barrington
Barrington SC, 281 County
Rd. 02806, 247-1926
Barrington SC, 247- East Bay CAP, 610
1926
Waterman, E Prov.,
435-7876
Bristol
Benjamin Church SC , 1020
Hope St. 02809, 253-8458
East Bay CAP, 610
Waterman, E Prov.,
435-7876
East Bay (Ocean State)
Nutrition Prog., 437-1000 @
Benjamin Church SC 253-8458
Tri-Town CAP,
Johnston, 709-2635
Senior Services, Inc., 766-3734
@ Pascoag-Bradford
East Bay CAP, 610
Waterman, E Prov.,
435-7876
Blackstone Health NP , 7289290 @ Forand Manor;
Progreso Latino; Wilfred
Manor
So. County CAP, So.
Kingstown, 789-3016
Westbay Program, 732-4660 @
Charlestown SC
Westbay CAP,
Warwick, 732-4660
Blackstone Health NP , 7289290 @ Coventry SC
Burrillville
Ralph J Hoden
Community Ctr,
727-7425
POINT Regional
Office
Nutrition Program
East Bay (Ocean State)
Nutrition Prog., 437-1000 @
Barrington SC, 247-1926
Central Falls
Ralph J. Holden Ctr., 361
Cowden St. 02863, 7277425
Charlestown
Charlestown SC, 100 Park
La. 02813, 364-9955
Coventry
Coventry SC, 50 Wood St.
02816, 822-9175
Cranston
Cranston SC, 1070 Cranston Cranston Senior
St. 02920, 461-1000
Services, 461-1000
Tri-Town CAP,
Johnston, 709-2635
Blackstone Health NP , 7289290 @ Cranston SC; Temple
David
Cumberland
Cumberland SC, 1464
Diamond Hill Rd. 02864,
334-2555
Tri-Town CAP,
Johnston, 709-2635
Senior Services, Inc., 766-3734
@ Chminey Hill Apts.;
Cumberland Manor;
Cumberland SC
East Greenwich
East Greenwich Senior
Services , 125 Main St.
02818, 886-8669
Westbay CAP,
Warwick, 732-4660
Westbay Program, 732-4660 @
St. Luke's Church
East Providence
East Providence SC, 610
East Providence SC, East Bay CAP, 610
Waterman Ave. 02914, 435- 435-7800
Waterman, E Prov.,
7800
435-7876
East Bay (Ocean State)
Nutrition Prog., 437-1000 @ E.
Providence SC, 435-7872;
Goldsmith Manor, 434-7645;
Harbor View Manor
(Riverside), 270-2107
Coventry SC, 8229175
Exeter
So. County CAP, So.
Kingstown, 789-3016
Foster
181 Howard Hill Rd., 02825,
392-9200
Tri-Town CAP,
Johnston, 709-2635
Glocester
1210 Putnam Pike, 02814,
567-4557
Tri-Town CAP,
Johnston, 709-2635
Senior Services, Inc., 766-3734
@ Glocester SC
Hopkinton
Main St. Crandall House,
Ashaway, 02804, 377-7795
So. County CAP, So.
Kingstown, 789-3016
Crandall House - Limited
Service, 377-7795
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Rhode Island Community Food Bank Regional Directory—2014
Town
Senior Center
SHIP Agency
Jamestown
Jamestown SC, 6 West St.
02835, 423-2658
Child & Family Service Westbay Program, 732Newport Cnty,
4660 @ Jamestown SC
Middletown, 8492300
Johnston
Johnston SC, 1291
Johnston SC, 944Hartford Ave. 02919, 944- 3343
3343
Tri-Town CAP,
Johnston, 709-2635
Blackstone Health NP , 7289290 @ Johnston SC
Lincoln
Lincoln SC, 150 Jenckes
Hill Rd, 02865, 753-7000
Tri-Town CAP,
Johnston, 709-2635
Senior Services, Inc., 7663734 @ Lincoln SC
Lincoln SC, 7242000
Little Compton
POINT Regional
Office
Nutrition Program
Child & Family Service
Newport Cnty,
Middletown, 8492300
Middletown
Middletown SC, 650
Green End Ave. 02842,
849-8823
Child & Family Service East Bay (Ocean State)
Newport Cnty,
Nutrition Prog., 437-1000 @
Middletown, 849Middletown SC, 849-8823
2300
Narragansett
Narragansett SC, 53
Mumford Rd. 02882, 7820675
So. County CAP, So.
Kingstown, 789-3016
New Shoreham
So. County CAP, So.
Kingstown, 789-3016
Newport
Edward King House , 35
King St. 02840, 8467426 // Martin Luther
King Ctr., 20 West
BRd.way 02840, 8464828 // Park Holm SC, 1
Eisenhower Rd., 02840,
846-3887
Child & Family Service East Bay (Ocean State)
Newport Cnty,
Nutrition Prog., 437-1000 @
Middletown, 849Donovan Manor, 619-1949
2300
No. Kingstown
North Kingstown SC, 44
Beach St. 02852, 2681590
No. Providence
Salvatore Mancini Ctr., 2 Salvatore Mancini
Atlantic Boulevard 02911, Ctr., 231-0742
231-0742
No. Kingstown SC,
268-1590
No. Smithfield
Pawtucket
Leon Mathieu SC, 420
Leon Mathieu SC,
Main St. 02860, 728-7582 728-7582
Page 59
So. County CAP, So.
Kingstown, 789-3016
Blackstone Health NP , 7289290 @ Beechwood House
Tri-Town CAP,
Johnston, 709-2635
Blackstone Health NP , 7289290 @ Steve Piccillo Ctr.;
Salvatore Mancini Ctr
Tri-Town CAP,
Johnston, 709-2635
Senior Services, Inc., 7663734 @ The Meadows
East Bay CAP, 610
Waterman, E Prov.,
435-7876
Blackstone Health NP , 7289290 @ Leon Mathies SC
Rhode Island Community Food Bank Regional Directory—2014
Town
Senior Center
SHIP Agency
POINT Regional
Office
Portsmouth
Portsmouth SC, 110
Bristol Ferry Rd. 02871,
683-4106
Portsmouth SC,
683-7943
Child & Family Service East Bay (Ocean State)
Newport Cnty,
Nutrition Prog., 437-1000 @
Middletown, 849Portsmouth SC, 683-2223
2300
Providence
Capital City Senior
Programs, 85 Chalkstone
Ave. 02908, 455-3888 //
DaVinci Community Ctr.,
470 Charles St. 02904,
272-7474 // Federal Hill
Community Ctr., 9
Courtland St. 02903, 4214722 // Fox Point SC, 90
Ives St. 02906, 7512217 // Hamilton House,
276 Angell St. 02906, 831
-1800 // Hartford Park
SC, 20 Syracuse St.
02909, 521-1180 //
Jewish Community Ctr. ,
401 Elmgrove Ave.
02906, 861-8800 // Lillian
Feinstein Ctr., 1085
Chalkstone Ave., 02908,
455-3888 // Nickerson
House SC, 133 Delaine St.
02909, 351-2241 // Silver
Lake Ctr., 529 Plainfield
St. 02909, 944-8300
(Voice/TTY) // St. Martin
dePorres SC , 160
Cranston St. 02907, 2746783 // Washington Park
Ctr., 42 Jillson St. 02905,
461-6650 // West End
Community Ctr., 109
Bucklin St. 02907, 7814242
DaVinci Ctr., 2727474; Hamilton
House, 831-1800;
Lillian Feinstein
Ctr., 455-3888; St.
Martin dePorres
Ctr. 274-6783;
Westminster SC,
274-6900
United Way (4624444); St. Martin
dePorres (274-6783)
Richmond
Richmond Adult Center,
1168 Main St. 02898, 539
-6144
So. County CAP, So.
Kingstown, 789-3016
Scituate
ScituateSC, 1315
Chopmist Hill Rd. 02857,
647-2662
Tri-Town CAP,
Johnston, 709-2635
Page 60
Nutrition Program
Meals on Wheels, 351-6700
@ Carrol Towers, Ctr. for
Southeast Asians, Federal
Hill House, Fox Point SC, St.
Elizabeth's Place, St. Martin
dePorres // Blackstone
Health NP , 728-9290 @
DaVinci Ctr.; Elmwood
Community Ctr.; Lillian
Feinstein SC; Jewish
Community Ctr.
Blackstone Health NP , 7289290 @ Scituate Sc
Rhode Island Community Food Bank Regional Directory—2014
Town
Senior Center
SHIP Agency
Smithfield
Smithfield SC, 1 William J. Smithfield SC, 949- Tri-Town CAP, JohnsHawkins Trail 02828, 949- 4590
ton, 709-2635
4590
Senior Services, Inc., 7663734 @ Smithfield SC
So. Kingstown
The Center , 25 St. Dominic Rd. 02879, 789-0268
So. Kingstown SC,
789-0268
So. County CAP, So.
Kingstown, 789-3016
Westbay Program, 7324660 @ Larry Tetreault Ctr.
Tiverton
Tiverton SC, 207 Canonicus Rd. 02878, 625-6790
Tiverton SC, 6256790
Child & Family Service East Bay (Ocean State) NuNewport Cnty, Midtrition Prog., 437-1000 @
dletown, 849-2300
Tiverton SC, 625-6790
Warren
Warren SC, 20 Libby Lane
02885, 247-1930
East Bay CAP, 610
Waterman, E Prov.,
435-7876
East Bay (Ocean State) Nutrition Prog., 437-1000 @
Warren SC, 245-2474
Warwick
JONAH Community Cen- Pilgrim SC, 468ter, 830 Oakland Beach
4500
Ave. 02889, 738-2000 //
Pilgrim SC, 27 Pilgrim
Parkway 02888, 468-4090
Westbay CAP, Warwick, 732-4660
Westbay Program, 7324660 @ Pilgrim SC; Shalom
Housing; Sparrow I Housing;
Sparrow III Housing, Harding
Brook Housing
West Greenwich
POINT Regional Office
Nutrition Program
Westbay CAP, Warwick, 732-4660
West Warwick
West Warwick SC, 145
Washington St. 02891,
822-4450
Westbay CAP, Warwick, 732-4660
Westbay Program, 7324660 @ West Warwick SC
Westerly
Westerly SC, 39 State St.
02891, 596-2404
So. County CAP, So.
Kingstown, 789-3016
Westbay Program, 7324660 @ Westerly SC; Parview Manor
Woonsocket
Woonsocket SC, 84 Social Woonsocket RSVP, Tri-Town CAP, JohnsSt. 02895, 766-3734
766-2300
ton, 709-2635
Senior Services, Inc., 7663734 @ Woonsocket SC,
Parkview Manor, Kennedy
Manor, Crepeau Court
Westerly SC, 5962404
For information or corrections, contact:
Mev Miller
Community Resource Manager
[email protected]
401-230-1707
Rhode Island Community Food Bank
200 Niantic Ave
Providence, RI 02907
www.rifoodbank.org
401-942-6325
2014 Edition
Current Version—May
Page 61
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OSCIL
1944 Warwick Avenue
Warwick, RI 02889
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
1944 Warwick Ave
Warwick, RI 02889
738-1013 x 13
1-866-857-1161 (Toll Free)
401-244-7792 (VP)
Email: [email protected]
Website: oscil.org
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.
ADVOCACY SERVICES
HOUSING
OSCIL provides both individual and systems
advocacy services. Consumers are provided
information and support to become self
advocates.
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.
INFORMATION & REFERRAL
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.
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, e-mail, 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.
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.
SNAP INCOME GUIDELINES
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.
People in
household
Gross monthly
Income
1
$1,916
2
$2,586
3
$3,256
4
$3,926
Each Additional
$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, 401-230-1701 | Mev Miller, 401-230-1707
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
Blank page
RHODE ISLAND DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR SNAP SERVICE
FOR ELDERLY HOUSEHOLDS
For Office use only:
Screener’s Name:
Do you speak English?
Date Screened:
Yes
No
Can you read and write in English?
Yes
Intake:
If no, what is the primary language spoken?
No
If you do not speak English, does any adult member of the household speak English?
Your Last Name:
Your Date of Birth:
Month
Your First Name:
Your Middle Initial:
/
/
Day
Year
Maiden / Other Names:
Apartment/Floor:
State:
Zip:
Your Mailing Address (if different)
City:
No
Your Social Security Number
Your Address (where you live):
City:
Yes
Apartment/Floor:
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. 01-14
Date
1
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
D.O.B.
Relationship
provide Alien
Last Name
First Name, MI Sex
(mm/dd/yyyy)
to you
S.S.N.
documentation**)
M
Self
YES
F
NO
M
YES
F
NO
M
YES
F
NO
M
YES
F
NO
*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):
List EVERY ONE in your home on THIS SIDE of the line
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. 01-14
2
Has anyone in the household received any income from any source so far this month?
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.)
Did your household’s only income recently stop?
Yes
If Yes, when?
Why?
Yes
No
NAME OF RECIPIENT
No
Does anyone in your household expect to receive other income later this month?
If Yes, how much?
When?
Yes
No
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 40-6-15, 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
DATE
SNAP APP-1 Rev. 01-14
or an IN-OFFICE
APPLICANT’S SIGNATURE
interview?
SIGNATURE OF APPLICANT’S
SPOUSE or OTHER ADULT
APPLICANT LIVING IN THE
HOUSEHOLD
3
FOR OFFICE USE ONLY
CASE RECORD CLEARANCE FOR PARTICIPATION
PERS SEARCH
PREVIOUS CASE RECORD
RIW/CASH
Yes
No
SNAP
Yes
No
MA
Yes
No
RITE CARE
Yes
No
GPA
Yes
No
CCAP
Yes
No
STATUS
RECORD LOCATION
REQUEST DATE
DISPOSITION:
SNAP Intake Appt Date
Expedited SNAP Intake Appt Date
Comments:
Signature of Screener
SNAP APP-1 Rev. 01-14
Date
4
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. 12101 et seq.), and Title IX of the Education
Amendments of 1972 (20 U.S.C. 1681 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. 272.6); 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 462-2130 (for deaf/hearing impaired
462-6239 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 http://www.ascr.usda.gov/complaint_filing_cust.html, or
at any USDA office, or call (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 use by mail at
the U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. Individuals
who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339; or (800) 845-6136 (Spanish).
SNAP APP-1 Rev. 01-14
5
5
For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues,
persons should either contact that USDA SNAP Hotline Number at (800) 221-5689, which is also in
Spanish
or
call
the
State
Information/Hotline
Numbers
found
online
at
http://www.fns.usda.gov/snap/contact_info/hotlines.htm. 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 40-6-12 and 40-6-12.1, and
regulations set forth in the DHS and SNAP Policy Manuals. Any person found guilty of violating the
provisions of Rhode Island General Laws 40-6-12 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. 2011-2036. 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. 01-14
6
6
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. 01-14
7
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:
¿Habla inglés?
Date Screened:
Sí
¿Puede leer y escribir en inglés?
No
Sí
Intake:
Si la respuesta es no, ¿cuál es su idioma principal?
No
Si no habla inglés, ¿hay algún miembro adulto de la familia que hable inglés?
Fecha de nacimiento:
Apellido:
Sí
No
/
mes
Nombre:
/
día
año
N. º de seguro social
Inicial del segundo nombre:
Nombre de soltera/otros nombres:
Dirección (dónde vive):
Ciudad:
Departamento/piso:
Estado:
Código postal:
Dirección postal (si es diferente):
Ciudad:
Departamento/piso:
Estado:
Número de teléfono (particular):
Código postal:
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:
Fecha de nacimiento:
Nombre:
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
SNAP APP-1 Rev. 01-14
Fecha
1
Mencione información en ESTA
COLUMNA únicamente si la
persona solicita los beneficios del
SNAP.
¿Es ciudadano de los
Estados Unidos?
Nombre, inicial del segundo
Fecha de nacimiento
(SI LA RESPUESTA
nombre
(mm/dd/aaaa)
Relación N. º de ES NO, deberá
Apellido
Sexo
con usted seguro presentar la
social documentación para
extranjeros
correspondiente**)
M
Usted
SÍ
F
NO
M
SÍ
F
NO
M
SÍ
F
NO
M
SÍ
F
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):
Mencione a TODOS los miembros de su hogar en ESTA COLUMNA
06 Hogar propio/casa rodante
11 No tradicional: vestíbulo,
01 Vivienda para personas ancianas o
calle, auto
07 Casa/dpto./casa rodante alquilado
discapacitadas
12 Geriátrico y
08 Vivo en la casa/el dpto. de otra
02 Centro de rehabilitación de
residencia asistida
persona.
drogas/alcohol
13 Centro de cuidados a largo plazo
09 Sin dirección permanente
03 Hogar para grupos de personas
discapacitadas/ciegas
10 Casa de rehabilitación
99 Otro (especifique):
04 Albergue para mujeres maltratadas
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
¿Dónde?
¿Cuándo?
¿Tipo?
nombre?
¿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
Fecha
Estado
del hogar
¿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. 01-14
2
¿Hay alguien en el hogar que haya recibido ingresos de alguna fuente hasta ahora este mes?
SI LA RESPUESTA ES SÍ, ¿cuál es el monto del ingreso bruto?
TIPO DE INGRESO
$ DEL MONTO
BRUTO
FRECUENCIA
(por semana, por
mes, etc.)
Sí
No
NOMBRE DE LA
PERSONA QUE
RECIBE EL 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
SALARIO
OTRO (ESPECIFIQUE)
OTRO (ESPECIFIQUE)
¿Hace poco que dejaron de percibir el único ingreso del hogar?
Sí
Si la repuesta es sí, ¿cuándo?
¿Por qué?
No
¿Hay alguien en el hogar que espera recibir otro ingreso más adelante este mes?
Si la repuesta es sí, ¿cuál es la suma?
¿cuándo?
Sí
No
¿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 406-15, 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
FECHA
SNAP APP-1 Rev. 01-14
o una entrevista EN LA OFICINA
FIRMA DEL SOLICITANTE
?
FIRMA DEL CÓNYUGE DEL
SOLICITANTE U OTRO ADULTO
SOLICITANTE QUE VIVA EN EL
HOGAR
3
PARA USO EXCLUSIVO DE LA OFICINA
AUTORIZACIÓN PARA UTILIZAR EL EXPEDIENTE
POR BÚSQUEDA
EXPEDIENTE ANTERIOR
RIW/DINERO
EN EFECTIVO
SNAP
Asistencia
Médica (MA)
RITE CARE
Asistencia
Pública General
(GPA)
CCAP
Sí
No
Sí
Sí
No
No
Sí
Sí
No
No
Sí
No
ESTADO
UBICACIÓN DEL
EXPEDIENTE
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
SNAP APP-1 Rev. 01-14
Fecha
4
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. 12101 et
seq.), el Título IX de las Enmiendas a la Ley de Educación de 1972 (20 U.S.C. 1681 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. 272.6), 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 462-2130 (los individuos que sean sordos o tengan dificultades auditivas pueden llamar al 462-6239 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 http://www.ascr.usda.gov/complaint_filing_cust.html, o bien llame a cualquier oficina del USDA o al (866)
632-9992 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. 20250-9410, envíe un fax al (202) 690-7442 o envíe un correo electrónico a
[email protected]. Los individuos que sean sordos, tenga dificultades auditivas o tengan problemas en
SNAP APP-1 Rev. 01-14
5
5
el habla se podrán comunicar con el USDA al Servicio Federal de Transmisiones al (800) 877-8339, o bien al
(800) 845-6136 (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) 221-5689, en la que
también se brinda asistencia en español o llamar a los números de línea directa/información estatal que podrá
encontrar http://www.fns.usda.gov/snap/contact_info/hotlines.htm. 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 40-6-12 y 40-6-12.1 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 40-6-12 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. 2011-2036.
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. 01-14
6
6
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. 01-14
7
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. 02904 o
llamando al (401) 222-2345.
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.
Para inscribirse para votar en RI, tiene que:
Puede usar este formulario para:
Vivir en Rhode Island.
Ser ciudadano de los Estados Unidos.
Haber cumplido 16 años de edad.
Inscribirse para votar en Rhode Island.
Cambiar su nombre o dirección en la inscripción.
Escoger un partido político o cambiar de partido.
(Necesitas tener 18 años ó mas de edad para votar el día de las elecciónes)
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 http://www.elections.ri.gov puede comunicarse con
la Junta de Escrutadores local (ver el dorso de este formulario).
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 http://www.elections.ri.gov 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
2. Soy ciudadano de EE.UU. y residente de Rhode Island
Sí
No
Sí
No
Formulario de Inscripción de Votantes de Rhode Island
Cumplido 16 años de edad. (Necesitas tener 18 años ó
mas de edad para votar el día de las elecciónes)
Si marcó NO en cualquiera de estas casillas,
no complete este formulario.
Cambio dirección
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 3.
4. Apellido
Nombre
5. Dirección residencial (No puede ser una casilla postal)
Apto.
6. Dirección postal (si es distinta de la dirección de la Casilla 5)
Apto.
7. Fecha de nacimiento
Mes
Día
Cambio nombre
Cambio partido
2° nombre (o la inicial)
Ciudad/Pueblo
Estado
Código ZIP
RI
Ciudad/Pueblo
8. No. de teléfono / Correo electrónico (optativo)
9. Selleccione su partido:
Republicano
Año
Estado
Demócrata
Sin afiliación
Código ZIP
Moderado
Otro________________
Uso oficial para código de barras
10. Juro o afirmo que:
- 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
MM/DD/AAAA
¿Le interesa
trabajar
en las urnas?
(marque esta casilla)
firma
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
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 02904.
JUNTAS DE ESCRUTADORES LOCALES
Barrington Town Hall 283 County Rd.
Barrington, RI 02806
Bristol Town Hall 10 Court St.
Bristol, RI 02809
Burrillville Town Hall, 105 Harrisville Main
St., Harrisville, RI 02830
Central Falls City Hall 580 Broad St.
Central Falls, RI 02863
Charlestown Town Hall, 4540 So. County
Trail, Charlestown, RI 02813
Coventry Town Hall 1670 Flat River Rd.
Coventry, RI 02816
Cranston City Hall 869 Park Ave.
Cranston, RI 02910
Exeter Town Hall 675 Ten Rod Rd.
Exeter, RI 02822
Foster Town Hall 181 Howard Hill Rd.
Foster, RI 02825
Glocester Town Hall 1145 Putnam Pike
PO Drawer B, Glocester, RI 02814
Hopkinton Town Hall One Town House Rd.
Hopkinton, RI 02833
Jamestown Town Hall 93 Narragansett Ave.
Jamestown, RI 02835
Johnston Town Hall 1385 Hartford Ave
Johnston, RI 02919
Lincoln Town Hall 100 Old River Rd.
PO Box 100, Lincoln, RI 02865
Cumberland Town Hall 45 Broad St.
Cumberland, RI 02864
Little Compton Town Hall PO Box 226
Little Compton, RI 02837
East Greenwich Town Hall PO Box 111
East Greenwich, RI 02818
East Providence City Hall 145 Taunton
Ave. East Providence, RI 02914
Middletown Town Hall 350 East Main Rd.
Middletown, RI 02842
Narragansett Town Hall 25 Fifth Ave.
Narragansett, RI 02882
Toda consulta sobre la inscripción de votantes
puede dirigirse a:
New Shoreham Town Hall PO Drawer 220
Block Island, RI 02807
Newport City Hall 43 Broadway
Newport, RI 02840
No. Kingstown Town Hall 80 Boston Neck Rd.
North Kingstown, RI 02852
North Providence Town Hall 2000 Smith St.
North Providence, RI 02911
North Smithfield Municipal Annex 575
Smithfield Rd, North Smithfield, RI 02896
Pawtucket City Hall 137 Roosevelt Ave.
Pawtucket, RI 02860
Portsmouth Town Hall 2200 East Main Rd
Portsmouth, RI 02871
Providence City Hall 25 Dorrance St.
Providence, RI 02903
Smithfield Town Hall 64 Farnum Pike
Smithfield, RI 02917
So. Kingstown Town Hall 180 High St
Wakefield, RI 02879.
Tiverton Town Hall 343 Highland Rd.
Tiverton, RI 02878
Warren Town Hall 514 Main St.
Warren, RI 02885
Warwick City Hall 3275 Post Rd.
Warwick, RI 02886
W. Greenwich Town Hall 280 Victory
Highway W. Greenwich, RI 02817
West Warwick Town Hall 1170 Main
St. West Warwick, RI 02893
Richmond Town Hall 5 Richmond Townhouse
Rd. Wyoming, RI 02898
Woonsocket City Hall P.O. Box B,
169 Main St. Woonsocket, RI 02895
Scituate Town Hall PO Box 328
North Scituate, RI 02857
Rhode Island Board of Elections
50 Branch Avenue
Providence, RI 02904
[email protected]
Westerly Town Hall 45 Broad St.
Westerly, RI 02891
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:
Fala inglês?
Sim
Date Screened:
Não
Sabe ler e escrever em inglês?
Intake:
Em caso negativo, qual é o principal idioma falado em sua casa?
Sim
Não
Se não fala Inglês, algum adulto do seu agregado familiar fala inglês?
Sim
Não
O seu apelido:
Data de Nascimento:
/
Mês
O seu nome:
Inicial do 2º nome:
/
Dia
Ano
Número de Segurança Social
Nome de solteira /Outros nomes:
A sua morada (onde vive):
Apartamento/Andar:
Cidade:
Estado:
Cód. Postal:
Endereço Postal (caso seja diferente)
Apartamento/Andar:
Cidade:
Estado:
O seu número de telefone (casa):
Cód. Postal:
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
SNAP APP-1 Rev. 01-14
Data
1
Indique as informações DESTE LADO da
Indique TODAS AS PESSOAS da sua casa NESTE LADO da linha
linha apenas se a pessoa estiver a solicitar os
benefícios do SNAP
Cidadão dos EUA?*
(Em caso NEGATIVO< serlhe-á solicitado que forneça
D.N.
Parentesco
documentação do seu
Apelido
Nome, IM
Sexo (mm/dd/aaaa)
Nº.S.S.
estatuto de emigrante**)
M
Próprio
SIM
F
NO
M
SIM
F
NO
M
SIM
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:
SNAP APP-1 Rev. 01-14
Data
Estado
2
Alguém do seu agregado familiar recebeu este mês algum rendimento de qualquer fonte?
Em caso afirmativo, qual foi o rendimento bruto?
TIPO DE RENDIMENTO
$ MONTANTE
BRUTO
FREQUÊNCIA
(Semanal, mensal, etc.)
Sim
Não
NOME DO
BENEFICIÁRIO
RSDI (SEGURANÇA
SOCIAL)
Rendimento Adicional do
Seguro de Segurança Social
(SSI)
PENSÃO
SUBSÍDIOS PARA
VETERANOS
INDEMNIZAÇÃO POR
ACIDENTE/DOENÇA
SALÁRIOS
OUTRO (ESPECIFICAR)
OUTRO (ESPECIFICAR)
Deixou de receber recentemente o único rendimento do seu agregado familiar?
Em caso afirmativo, quando?
Porquê?
Sim
Alguém do seu agregado familiar espera receber outro rendimento no final deste mês?
Em caso afirmativo, quanto?
Quando?
Não
Sim
Não
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 40-6-15, 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
DATA
SNAP APP-1 Rev. 01-14
ou nos NOSSOS SERVIÇOS
ASSINATURA DO REQUERENTE
?
ASSINATURA DO CÔNJUGE DO
REQUERENTE ou OUTRO
REQUERENTE ADULTO QUE
FAÇA PARTE DO SEU
AGREGADO FAMILIAR
3
APENAS PARA USO DO ESCRITÓRIO
AUTORIZAÇÃO DE REGISTO DE PROCESSO PARA PARTICIPAÇÃO
PESQUISA PERS
REGISTO DE CASO ANTERIOR
RIW/DINHEIRO
SNAP
MA
RITE CARE
GPA
CCAP
Sim
Sim
Sim
Sim
Sim
Sim
ESTATUTO
LOCALIZAÇÃO DO
REGISTO
DATA DO PEDIDO
Não
Não
Não
Não
Não
Não
DISPOSIÇÃO:
Data de Entrada do Pedido SNAP
Data de processamento Entrada Pedido SNAP
Comentários:
Assinatura do Examinador
SNAP APP-1 Rev. 01-14
Data
4
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. 12101 et seq.), Título IX das
Alterações de 1972 sobre a Educação (20 U.S.C. 1681 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. 272.6), 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 462-2130 (para surdos e invisuais 462-6239 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 http://www.ascr.usda.gov/complaint_filing_cust.html, ou em qualquer gabinete do
Departamento da Agricultura dos E.U.A, ou então ligue para o número (866) 632-9992 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. 20250-9410, por fax para o número (202)
690-7442 ou para o endereço de e-mail [email protected]. As pessoas surdas, com problemas auditivos
SNAP APP-1 Rev. 01-14
5
5
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) 877-8339 ou (800) 845-6136 (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) 221-5689, que também está disponível em Espanhol, ou ligar para a Linha de Informação Estatal/Linhas
de Apoio que poderá encontrar online em http://www.fns.usda.gov/snap/contact_info/hotlines.htm. 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 40-6-12 e 40-6-12.1, 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 40-6-12 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. 2011-2036. 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. 01-14
6
6
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. 01-14
7
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 02904 ou ligar para o número (401)222-2345.
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).
INSTRUÇÕES
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 http://www.elections.ri.gov ou
contacte os seus Agentes Eleitorais (Board of Canvassers)
(consulte o verso deste formulário).
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 http://www.elections.ri.gov 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:
Alteração de Nome
2. Sou cidadão dos EUA e resido em RI
Novo registo eleitoral
Sim
Tenho pelo menos 16 anos de idade
Sim
(tem de ter pelo menos 18 anos de idade para votar).
Não
Não
Alteração de morada
Alteração de partido
3. Carta de condução ou Número de B.I. de RI:
Se não tem carta de condução ou B.I. de RI, introduza os 4 últimos
Se marcou NÃO em alguma destas afirmações, não preencha este
formulário.
4. Apelido
Sufixo (caso tenha)
dígitos do seu número de segurança social: Se não tem nenhum destes números, veja as instruções para a
Caixa 3.
Nome
Nome do Meio (ou inicial)
5. Morada (Não introduza um apartado)
Apt.
Cidade/Vila
Estado
RI
Código Postal
6. Endereço Postal (se diferente da Caixa 5)
Apt.
8. N.º de Telefone/Endereço de E-mail
7. Data de Nascimento
(opcional)
(mm/dd/aaaa)
Cidade/Vila
Estado
Código Postal
Mês
Dia
9. Filiação partidária:
Democrata
Ano
Americans Elect
Moderado
Republicano
Não
filiado
Outro ____
10. Juro ou afirmo que:
Official Use For Barcode
- Não estou detido em nenhum estabelecimento prisional por condenação criminal.
- 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
**************************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 02904.
AGENTES ELEITORAIS LOCAIS
As perguntas sobre o registo eleitoral podem ser dirigidas a:Rhode Island Board of Elections
50 Branch Avenue
Providence, RI 02904
[email protected]
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 10.1.13
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 1-866-306-0270 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 1866-306-0270 or visit the www.eatbettertoday.com website. You may also visit the Rhode Island
Department of Human Services website for a list of participating restaurants at www.dhs.ri.gov.
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 (1-888-979-9939), or
visit www.ebtedge.com. 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 (1-888979-9939).
Need more information about the Restaurant Meals Program?
Call 1-866-306-0270 or visit www.eatbettertoday.com
State of Rhode Island and Providence Plantations
Department of Human Services
Division of Elderly Affairs
RELEASE: December 12, 2013
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-
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
401-462-0931. 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!
###
State of Rhode Island and Providence Plantations
Department of Human Services
Division of Elderly Affairs
Revised: 1-06-14
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) 728-929 [email protected]
• 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) 437-1000 [email protected]
• 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 / 2nd Floor
74 West Road, Cranston, RI 02920
Telephone 401-462-3000, Fax 401-462-0503, TTY 401-462-0740
Web Site: www.dea.ri.gov
•
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) 351-6700 [email protected]
• 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) 766-3734 [email protected]
• 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) 732-4660 [email protected]
• 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 / 2nd Floor
74 West Road, Cranston, RI 02920
Telephone 401-462-3000, Fax 401-462-0503, TTY 401-462-0740
Web Site: www.dea.ri.gov
Narragansett Indian Tribe, (1 meal site)
Parrish Noka, Social Services (401) 213-6880, ext. 13 [email protected]
• Charlestown – Narragansett Tribe Community Center
John O. Pastore Center, Hazard Building / 2nd Floor
74 West Road, Cranston, RI 02920
Telephone 401-462-3000, Fax 401-462-0503, TTY 401-462-0740
Web Site: www.dea.ri.gov
Senior Medicare Patrol
What is the Senior Medicare Patrol?
S
enior 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.
P
rotecting 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?
S
MP 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?
I
n 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
Find an SMP at www.smpresource.org
In 1997, because of the Omnibus Consolidated
Appropriation Act of 1997 (Public Law 104-208), 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 104-368 noted that “senior citizens
are our best front line defense against these losses.”
Tell me about the scope of the SMP
program today.
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
B
ased 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?
S
ince 1997 almost 27 million people have been
reached during community education events,
more than 5 million beneficiaries have been educated
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 02920
Aleatha Dickerson, SMP Director, 401-462-0931,
[email protected]
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
Medicare & the Health Insurance Marketplace
The Health Insurance Marketplace, a key part of the Affordable Care Act, will
take effect in 2014. It’s a new way for individuals, families, and employees of small
businesses to get health coverage.
If I have Medicare, do I need to do anything?
No. Medicare isn’t part of the Marketplace. If you have Medicare, you’re covered and
don’t need to do anything about the Marketplace.
The Marketplace won’t affect your Medicare choices or benefits. No matter how you
get Medicare, whether through Original Medicare or a Medicare Advantage Plan (like
an HMO or PPO), you won’t have to make any changes.
Note: The Marketplace doesn’t offer Medicare Supplement Insurance (Medigap)
policies or Medicare drug plans (Part D).
Does Medicare coverage meet the Affordable Care Act’s
requirement that all Americans have health insurance?
If you have Medicare Part A (Hospital Insurance), you’re considered covered and won’t
need a Marketplace plan. Having Medicare Part B (Medical Insurance) alone doesn’t
meet this requirement.
Can I get a Marketplace plan in addition to Medicare?
No. It’s against the law for someone who knows that you have Medicare to sell you a
Marketplace plan. This is true even if you have only Part A or only Part B.
If you want coverage designed to supplement Medicare, visit Medicare.gov to learn
more about Medigap policies. You can also visit Medicare.gov to learn more about
other Medicare options, like Medicare Advantage Plans.
Can I choose Marketplace coverage instead of Medicare?
Generally, no. As noted above, it’s against the law for someone who knows you have
Medicare to sell you a Marketplace plan. However, there are some situations where
you can choose Marketplace coverage instead of Medicare:
• You can choose Marketplace coverage if you’re eligible for Medicare but haven’t
enrolled in it (because you would have to pay a premium, or because you’re not
collecting Social Security benefits).
• If you’re paying a premium for Part A, you can drop your Part A and Part B coverage
and get a Marketplace plan.
Before making either of these choices, there are 2 important points to consider:
1. If you enroll in Medicare after your initial enrollment period ends, you may have to
pay a late enrollment penalty for as long as you have Medicare.
2. Generally, you can enroll in Medicare only during the Medicare general enrollment
period (from January 1—March 31). Your coverage won’t begin until July of that
year.
What if I become eligible for Medicare after I join a
Marketplace plan?
You can get a Marketplace plan to cover you before your Medicare begins. You can
then cancel the Marketplace plan once your Medicare coverage starts.
Once you’re eligible for Medicare, you’ll have an initial enrollment period to sign up.
For most people, the initial enrollment period for Medicare starts 3 months before
their 65th birthday and ends 3 months after their 65th birthday.
In most cases it’s to your advantage to sign up when you’re first eligible because:
• Once you’re eligible for Medicare, you won’t be able to get lower costs for a
Marketplace plan based on your income.
• If you enroll in Medicare after your initial enrollment period ends, you may have to
pay a late enrollment penalty for as long as you have Medicare.
Note: You can keep your Marketplace plan after your Medicare coverage starts.
However, once your Part A coverage starts, any premium tax credits and reduced costsharing you get through the Marketplace will stop.
If I have Medicare, can I get health coverage from an
employer through the SHOP Marketplace?
Yes. Coverage from an employer through the SHOP Marketplace is treated the same
as coverage from an employer group health plan. If you’re getting health coverage
from an employer through the SHOP Marketplace based on you or your spouse’s
current employment, Medicare Secondary Payer rules apply. Visit Medicare.gov to
learn more about how Medicare works with other insurance.
If I’m getting health coverage from an employer through the
SHOP Marketplace, can I delay enrollment in Part B without a
penalty?
Yes. You can delay enrollment if you’re getting health coverage from an employer
through the SHOP Marketplace based on you or your spouse’s current employment.
You have a Special Enrollment Period to sign up for Part B without penalty:
• Any time you’re still covered by the group health plan based on you or your
spouse’s current employment.
• During the 8-month period that begins the month after the employment ends or
the coverage ends, whichever happens first.
If you don’t sign up during this Special Enrollment Period:
• You may have to pay a late enrollment penalty.
• You can only enroll during the General Enrollment Period which occurs each year
from January—March with coverage beginning July 1.
Can I get a stand-alone dental plan through the Marketplace?
In most cases, no. If the Marketplace in your state is run by the federal government,
you won’t be able buy a stand-alone dental plan for 2014. If your state is running its
own Marketplace, you may be able to purchase a stand-alone dental plan for 2014, if
one is available.
Will Medicare Advantage plans still be available after the
Marketplace starts?
Yes. The Medicare Advantage program isn’t changing as a result of the Affordable
Care Act.
Is prescription drug coverage through the Marketplace
considered creditable prescription drug coverage for Medicare
Part D?
While prescription drug coverage is an essential health benefit, prescription drug
coverage in a Marketplace or SHOP plan isn’t required to be at least as good
as Medicare Part D coverage (creditable). However, all private insurers offering
prescription drug coverage, including Marketplace and SHOP plans, are required to
determine if their prescription drug coverage is creditable each year and let you know
in writing. Visit Medicare.gov for more information about creditable coverage.
How can I get help paying for my Medicare costs?
• If you need help with your Part A and B costs, you can apply for a Medicare Savings
Program. Call your state Medical Assistance (Medicaid) office. To get their phone
number, visit Medicare.gov/contacts, or call 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048.
• If you need Extra Help to pay for Medicare prescription drug costs, visit
socialsecurity.gov/i1020, or call Social Security at 1-800-772-1213. TTY users should
call 1-800-325-0778.
Where can I get more information?
• To learn more about Medicare enrollment, coverage, and plan choices, visit
Medicare.gov, or call 1-800-MEDICARE.
• If you have family and friends who don’t have health coverage, or if they want to
explore new health plan options, tell them to visit HealthCare.gov.
CMS Product No. 11694
December 2013
2014 Medicare Costs
Medicare Part A (Hospital Insurance) Costs
Part A Monthly Premium
Most people don’t pay a Part A premium because they paid Medicare taxes while working.
If you don’t get premium-free Part A, you pay up to $426 each month.
Hospital Stay
In 2014, you pay
■■ $1,216 deductible per benefit period
■■ $0 for the first 60 days of each benefit period
■■ $304 per day for days 61–90 of each benefit period
■■ $608 per “lifetime reserve day” after day 90 of each benefit period
(up to a maximum of 60 days over your lifetime)
Skilled Nursing Facility Stay
In 2014, you pay
■■ $0 for the first 20 days of each benefit period
■■ $152 per day for days 21–100 of each benefit period
■■ All costs for each day after day 100 of the benefit period
Medicare Part B (Medical Insurance) Costs
Part B Monthly Premium
You pay a Part B premium each month. Most people will pay the standard premium
amount. However, if your modified adjusted gross income as reported on your IRS tax
return from 2 years ago is above a certain amount, you may pay more.
If your yearly income in 2012 was
You pay (in 2014)
File individual File joint
File married &
tax return
tax return
separate tax return
$85,000 or less
above $85,000
up to $107,000
above $107,000
up to $160,000
above $160,000
up to $214,000
above $214,000
$170,000 or less
above $170,000
up to $214,000
above $214,000
up to $320,000
above $320,000
up to $428,000
above $428,000
$85,000 or less
N/A
$104.90
$146.90
N/A
$209.80
above $85,000
up to $129,000
above $129,000
$272.70
$335.70
If you have questions about your Part B premium, call Social Security at 1‑800‑772‑1213.
TTY users should call 1-800-325-0778. If you pay a late enrollment penalty, these amounts
may be higher.
Part B Deductible—$147 per year
Medicare Advantage Plans (Part C) and Medicare
Prescription Drug Plans (Part D) Premiums
Visit Medicare.gov/find-a-plan to get plan premiums. You can also call
1‑800‑MEDICARE (1-800-633-4227). TTY users should call 1‑877‑486‑2048.
You can also call the plan or your State Health Insurance Assistance Program.
Part D Monthly Premium
The chart below shows your estimated prescription drug plan monthly premium based
on your income. If your income is above a certain limit, you will pay an income-related
monthly adjustment amount in addition to your plan premium.
If your yearly income in 2012 was
You pay (in 2014)
File individual File joint
File married &
tax return
tax return
separate tax return
$85,000 or less
above $85,000
up to $107,000
above $107,000
up to $160,000
above $160,000
up to $214,000
above $214,000
$170,000 or less
above $170,000
up to $214,000
above $214,000
up to $320,000
above $320,000
up to $428,000
above $428,000
$85,000 or less
N/A
N/A
above $85,000
up to $129,000
above $129,000
Your plan premium
$12.10 + your plan
premium
$31.10 + your plan
premium
$50.20 + your plan
premium
$69.30 + your plan
premium
2014 Part D National Base Beneficiary Premium—$32.42
This figure is used to estimate the Part D late enrollment penalty and the income-related
monthly adjustment amounts listed in the table above. The national base beneficiary
premium amount can change each year. See your Medicare & You handbook or visit
Medicare.gov for more information.
For more information about Medicare costs, visit Medicare.gov.
CMS Product No. 11579
Revised October 2013
What You Can Do Online
www.socialsecurity.gov
APPLY FOR BENEFITS
Apply for Social Security
retirement/spouse’s benefits
www.socialsecurity.gov/applyforbenefits
Apply for Social Security disability benefits
www.socialsecurity.gov/applyfordisability
Apply for Medicare
www.socialsecurity.gov/medicareonly
Apply for Extra Help with your Medicare
prescription drug costs
www.socialsecurity.gov/i1020
ESTIMATE YOUR FUTURE BENEFITS
Create a my Social Security account to get
your Social Security Statement:
• Check your earnings record; and
• See estimates of your potential benefit amounts.
www.socialsecurity.gov/myaccount
Get your retirement benefit estimate
www.socialsecurity.gov/estimator
Use our benefit planners to calculate your
retirement, disability, and survivors benefits
www.socialsecurity.gov/planners
IF YOU GET BENEFITS
Create a my Social Security account and:
• Get your benefit verification letter;
• Check your benefit and payment information
and your earnings record;
• Change your address and phone number; and
• Start or change direct deposit of your
benefit payment.
Get a form SSA-1099/1042
(Social Security Benefit Statement)
Get a replacement Medicare card
www.socialsecurity.gov/myaccount
www.socialsecurity.gov/1099
www.socialsecurity.gov/medicarecard
Find answers to frequently asked questions at
www.socialsecurity.gov/faq
Social Security Administration
SSA Publication No. 05-10121
ICN 444812
Unit of Issue - HD (one hundred)
December 2012 (Recycle prior editions)
Printed on recycled paper
my Social Security
How To Create An Online Account
Step 1
Visit www.socialsecurity.gov/myaccount and select:
Step 2
Select “Create An Account.”
To create a my Social Security
account, you must be at least
18 years old and have:
• A valid E-mail address;
• A Social Security number; and
• A U.S. mailing address.
Step 3
Provide some personal information
to verify your identity.
Step 4
Choose a username and password
to create your account.
(over)
After you create a my Social Security account, you can access your Social Security
Statement to check your earnings and get your benefit estimates.
If you receive benefits, you also can:
• Change your address and phone number;
• Start or change your direct deposit; and
• Get your benefit verification letter.
How To Get Your Benefit Verification Letter
You can use your benefit verification letter as proof of your:
• Income when you apply for a loan or mortgage, assisted housing or other
state or local benefits;
• Current Medicare health insurance coverage;
• Retirement or disability status; and
• Age.
To get your benefit
verification letter:
• Sign into your account; and
• Select “Get a Benefit
Verification Letter.”
Your letter will be displayed and
you may print it or save it for
later use.
Social Security Administration
SSA Publication No. 05-10540
ICN 459261
Unit of Issue - HD (one hundred)
March 2013 (Recycle prior editions)
Printed on recycled paper