Sample - Important Notice to Applicants

There are questions on this application you may not have to answer.

This application asks you to tell us about the citizenship and immigration status of people in your household. It also asks you to give us social security numbers (SSNs) for everyone in your household.

You may not need to give us this information in all situations. This notice tells you when you must give us the information and when it is strictly voluntary.

• NOTE:  If you don’t have a social security number,
• we can help you get one.
• If you apply for a social security number today, we can still take your application.
• Your application will not be delayed.
• We only use social security numbers to help us verify your income.
• We will not share your social security number with the INS.

[For Medicaid and Medicaid expansion programs under SCHIP) - Insert state-specific program name] -

• Anyone who wants to receive [Medicaid] benefits must tell us about their own citizenship or immigration status. You also must give us your social security number if you have one. If you do not have a social security number, you must get one. We can help you do this. This will not delay your application.
• If you or anyone else in your family or household does not want to get [Medicaid] benefits, then you DO NOT have to give us information about your citizenship, immigration status or your social security number. You can give us SSNs voluntarily. If you do, we will use this information to verify your family’s income.
• If you are applying only for emergency [Medicaid], you do not need to give us information about your immigration status or your social security number.

[For separate child health programs under SCHIP - Insert state-specific name]

• If you are applying for [SCHIP] benefits for a child, you must give us information about the citizenship and immigration status of the child. However, you do not have to give us information about the citizenship or immigration status of other family or household members because they are not eligible to receive [SCHIP] benefits.
• No one in your family or household, including your child, has to give us their social security number in order for your child to get [SCHIP] benefits. You can give us SSNs voluntarily. If you do, we will use them to verify your family’s income.

[For Food Stamps - Use if your state chooses to permit household members to be designated as non-applicants early in the application process].

• When your household applies for Food Stamps, you must tell us about the citizenship and immigration status of everyone in your household. All persons in your household also must give us their social security number. If they don’t have one, they must apply for one. We can help. This will not delay your household’s application.
• If anyone in your household does not want to give us information about his or her citizenship, immigration status or social security number, that person can be designated a non-applicant. This means that person will not be considered an applicant and will not be eligible for Food Stamps. That person will still need to answer other questions about his or her income, etc. Other members of your household will still be able to get Food Stamps if they are eligible for benefits.

[For TANF - Insert name of state-specific program].

• When your family applies for [TANF] benefits, you must tell us about the citizenship and immigration status of everyone in your family. Each person in your family also must give us his or her social security number. If they don’t have one, they must get one. We can help. This will not delay your family’s application.

[Alternative 1- Use if your state allows family members to choose to be designated as non-applicants early in the application process].

• If anyone in your family does not want to give us information about his or her citizenship, immigration status or social security numbers, then that person can be designated a non-applicant. This means that person will not be considered an applicant and will not be eligible for [TANF]. However, other family members may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any family members are eligible for [TANF] benefits, you will still need to tell us about their citizenship or immigration status and give us their SSN. You also will still need to tell us about your family’s income and answer the other questions on this form.

[Alternative 2 - Use when your state has a "child-only" rule or other policy that excludes individual family members from the family based on eligibility but does not allow family members to designate themselves as non-applicants early in the application process].

• We may decide that certain members of your family are ineligible for benefits because, for example, they do not have the right immigration status. If that happens, other family members including [specify] may still be able to get benefits if they are otherwise eligible. If you want us to decide whether other family members are eligible for [TANF] benefits, you will still need to tell us about their citizenship or immigration status and give us their SSNs. You also will need to tell us about your family’s income and answer the other questions on this form.

[Alternative 3 - Use if your state does not have a "child-only" rule or other policy that allow individuals to be excluded from the family based on eligibility or family choice].

• If anyone in your family does not want to give us information about their citizenship, immigration status or social security number, your family will not be eligible for [TANF] benefits. However, you and your family can still apply for Medicaid, SCHIP and/or Food Stamps.

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