South Carolina Department of Social Services

APPLICATION FOR
SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP),
TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF), AND/OR
REFUGEE CASH ASSISTANCE (RCA)
Assistance with Filing an Application
• If you need help in filling out this application due to a disability, need an interpreter, or need translation
services, please ask for assistance at any DSS Office.
• To obtain the address or phone number of any DSS Office, call toll free: 1-800-616-1309 or view online at
www.dss.sc.gov.
• Your application is considered valid as long as it contains the name, address, and signature of a responsible
household member or the household’s authorized representative.

Solicitudes en español están disponibles en su oficina local del DSS o usted puede llamar al
1-800-616-1309 para pedir que se le envíe una por correo.

Fraud
• The information that you give DSS may be verified by federal, state, or local officials to determine if
the information is correct.
• If you give DSS information that is found to be incorrect for TANF or SNAP, your case may be denied
or closed.
• You may be subject to prosecution under federal and state laws for giving incorrect information.

Social Security Numbers – Citizenship – Immigration Status

Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF)
Applicants:
• You must provide or apply for a social security number (SSN) and citizenship/immigration status for all family
members whom you want cash benefits or SNAP benefits. Immigration status may be subject to verification
by United States Citizenship and Immigration Services (USCIS). The social security number is not required
to file an application for Refugee Cash Assistance (RCA) benefits. The refugee may provide a copy of the
SS-5 until the card is received.
• Benefits will not be provided to individuals who do not provide, or show proof of application for, their social
security number and citizenship/immigration status.
• Social security numbers are not required for non-applicants or persons ineligible for SNAP or cash benefits;
however, the proof of income must be provided for all members of the SNAP household and/or TANF
benefit group.
• If we need information on a person for whom you did not provide information, a DSS worker will contact you
to discuss the requirements.
• DSS does not share SSNs or citizenship/immigration status for non-applicants and individuals ineligible for
benefits with the US Department of Homeland Security.
• DSS will use social security numbers in the State Income and Eligibility Verification System and other
computer matching and program reviews. This information may be verified through other sources when
discrepancies are found and may also affect your household’s eligibility and benefit level.

DSS Form 3800 (APRIL 24) All previous editions are obsolete
 DO NOT SEND APPLICATIONS TO USDA OR HHS.

USDA-HHS NON-DISCRIMINATION STATEMENT

In accordance with federal civil rights laws and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the
USDA, its agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from
discriminating based on race, color, national origin, sex (including gender identity and sexual orientation), religious creed,
disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded
by USDA. Programs that receive federal financial assistance from the U.S. Department of Health and Human Services (HHS),
such as Temporary Assistance for Needy Families (TANF), and programs HHS directly operates are also prohibited from
discrimination under federal civil rights laws and HHS regulations.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print,
audiotape, American Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals
who are deaf, hard of hearing or who have speech disabilities may contact USDA through the Federal Relay Service at
(800) 877-8339. Additionally, program information may be made available in languages other than English.

CIVIL RIGHTS COMPLAINTS INVOLVING USDA PROGRAMS

USDA provides federal financial assistance for many food security and hunger reduction programs such as the Supplemental
Nutrition Assistance Program (SNAP), the Food Distribution Program on Indian Reservations (FDPIR) and others. To file a
program complaint of discrimination, complete the Program Discrimination Complaint Form, (AD-3027) found online
at: https://www.usda.gov/sites/default/files/documents/USDA-OASCR P-Complaint-Form-0508-0002-508-11-28-17Fax2Mail.pdf,
and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form.
To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. mail: Food and Nutrition Service, USDA

1320 Braddock Place, Room 334, Alexandria, VA 22314; or
2. fax: (833) 256-1665 or (202) 690-7442; or
3. phone: (833) 620-1071; or
4. email: [email protected].

For any other information regarding SNAP issues, persons should either contact the USDA SNAP hotline number at
(800) 221-5689, which is also in Spanish, or call the state information/hotline numbers (click the link for a listing of hotline
numbers by state); found online at: SNAP hotline.

CIVIL RIGHTS COMPLAINTS INVOLVING HHS PROGRAMS

HHS provides federal financial assistance for many programs to enhance health and well-being, including TANF, Head Start,
the Low Income Home Energy Assistance Program (LIHEAP), and others. If you believe that you have been discriminated
against because of your race, color, national origin, disability, age, sex (including pregnancy, sexual orientation, and gender
identity), or religion in programs or activities that HHS directly operates or to which HHS provides federal financial assistance,
you may file a complaint with the Office for Civil Rights (OCR) for yourself or for someone else.

To file a complaint of discrimination for yourself or someone else regarding a program receiving federal financial assistance
through HHS, complete the form online through OCR’s Complaint Portal at https://ocrportal.hhs.gov/ocr/. You may also contact
OCR via mail at: Centralized Case Management Operations, U.S. Department of Health and Human Services, 200
Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201; fax: (202) 619-3818; or
email: [email protected]. For faster processing, we encourage you to use the OCR online portal to file complaints rather than
filing via mail. Persons who need assistance with filing a civil rights complaint can email OCR at [email protected] or call OCR
toll-free at 1-800-368-1019, TDD 1-800-537-7697. For persons who are deaf, hard of hearing, or have speech difficulties,
please dial 7-1-1 to access telecommunications relay services. We also provide alternative formats (such as Braille and large
print), auxiliary aids and language assistance services free of charge for filing a complaint.

You may also file a complaint of discrimination by contacting DSS. Write DSS Office of Civil Rights, P.O. Box 1520, Columbia,
S.C. 29202-1520; or call (800) 311-7220 or (803) 898-8080 or TTY: (800) 311-7219

This institution is an equal opportunity provider.

DO NOT SEND APPLICATIONS TO USDA OR HHS.

DSS 3800 (APRIL 2024) 2 Client Copy

 YOUR RIGHTS AND RESPONSIBILITIES
Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy
Families (TANF), and Refugee Cash Assistance (RCA)

Confidentiality Work/Training Program Requirements

The information that you give to DSS will be kept confidential. • To receive TANF or RCA benefits, you must participate in a work
Exceptions: or training program, unless you are exempt from the work program
1. Information may be disclosed to other federal and state requirement.
agencies for official examination and to law enforcement • To receive SNAP benefits, some household members must
officials for the purpose of apprehending fleeing felons or register for work. By signing your application, you will be
probation/parole violators. considered to have registered all household members required to
2. You agree that confidential information about you and/or your be registered. What this means is that the household must do the
family may be released to other organizations if it is directly following for those identified as registered for work:
related to the operation of SNAP, TANF, and RCA. 1. Provide sufficient information of job status and
availability, when requested.
Social Security Numbers 2. Accept a suitable job of 30 or more hours weekly, if offered.
In order to receive benefits from the SNAP, TANF, and 3. Not voluntarily quit a job of 30 hours or more; or reduce
other programs: work hours.
• You must provide or apply for a social security number (SSN) • To receive SNAP benefits, some household members identified
for those persons who want to receive SNAP and/or TANF. as Able-Bodied Adults Without Dependents (ABAWDs) must
Although SSNs are not required for non-applicants or persons meet work requirements and are subject to time-limited benefits.
ineligible for SNAP or TANF, income information must be
included for all Household (HH)/Benefit Group (BG) members. Time Limits
• If DSS needs the SSN on a person for whom you did not • TANF benefits may be time limited.
provide information, a DSS worker will contact you to discuss • RCA is limited to 8 months from the date of arrival in the U.S.
the reasons for requesting the number and what will happen if • SNAP benefits may be limited to 3 months in a 36-month
you do not give DSS the number. period for ABAWDs.
• SSNs will be used in computer matching programs and other • The receipt of benefits in one program has no effect on the time
reviews, and you cannot receive benefits for individuals in limits in another program.
which an SSN is not provided.
• If you do not have an SSN for an applicant, it will not delay your Verification
application, provided he/she applies for one immediately. DSS • A DSS worker may need to contact other people or organizations
will help you apply for an SSN. (neighbors, banks, employers, etc.) to verify your income, work
• DSS will not share or give SSNs of non-applicants or program/employment status, bank accounts,
individuals ineligible for benefits with the U.S. Department of citizenship/immigration status, medical/shelter expenses,
Homeland Security. insurance/retirement benefits, medical history and any other fact
that relates to your eligibility for SNAP, TANF, or RCA benefits.
• For SNAP, failure to report or verify any deductible expenses will
Citizenship and Immigration Status
be considered as a statement that your household does not want
• You must provide citizenship and immigration status
to receive a deduction for the unreported expense.
information for those persons who want to receive SNAP,
TANF, or RCA.
Benefit Repayment
• DSS will not share the citizenship and immigration status of
• You may be required to repay benefits you received from TANF
non- applicants or individuals ineligible for benefits with the
(including childcare and transportation), RCA and SNAP benefits
U.S. Department of Homeland Security. However, information
that you should not have received even if you received them
provided by applicant household members may be submitted to
through no fault of your own.
United States Citizenship and Immigration Services (USCIS)
• DSS may apply any benefits removed from your inactive EBT
for verification of immigration status. The information received
account to repay an outstanding SNAP claim(s).
from USCIS may affect the household’s eligibility and benefit
level. • DSS seeks repayment of claims from any federal and/or state tax
refunds that may be due you. The information that you give DSS,
including SSNs, may be referred to federal/state agencies for
Assignment of Child Support claims collection action.
• Support for TANF eligible children must be assigned to DSS.
• DSS may take action to collect child support from both maternal Fair Hearings
and paternal grandparents if the child’s parent(s) are under age • If you do not agree with a decision made in your case, you may
18 and receive TANF. request a Fair Hearing, orally or in writing for SNAP, TANF and
RCA, by contacting your county DSS office or SCDSS, Division of
Individual and Provider Rights, P.O. Box 1520, Columbia, SC
Paternity Establishment 29202-1520, 1-800-311-7220 for TANF and SNAP.
• In order to receive benefits from the TANF Program, you must • You may speak for yourself at the hearing. You may also bring
cooperate with the Child Support Services Division (CSSD) in a friend, relative, or lawyer to speak for you.
establishing paternity and obtaining child support for your • To request continuation of your TANF, RCA or SNAP benefits,
children. while you wait for the hearing, the request must be made within 10
• If you have a good reason to believe cooperation may cause days from the date of the notice you receive reducing or stopping
harm to you or your child(ren) ask your case manager about your benefits.
establishing “good cause” for failure to cooperate. • If the hearing decision is not in your favor, the benefits will have to
be repaid.
Quality Control Reviews • The maximum time to request a hearing after you receive a notice
reducing or stopping your benefits is: 60 days for TANF and RCA
You have the responsibility to fully cooperate with state and federal
and 90 days for SNAP benefits.
personnel if they are conducting a Quality Control (QC) review of
your SNAP case. Failure to do so may result in your case being
closed.

DSS 3800 (APRIL 2024) 3 Client Copy

 Application Filing Instructions SNAP Warnings and Penalties
• Your application is considered valid as long as it contains • DO NOT buy ineligible items such as alcoholic beverages or
the name, address, and signature of a responsible
tobacco with SNAP benefits.
household member or the household’s authorized
representative. Benefits are provided within 30 days from • DO NOT use your EBT card to pay for food charged to a
the date the application is received by the agency. If you are credit account.
applying for SNAP benefits, your eligibility will be determined • Violators of the above rules may not be able to receive SNAP
separately from any other programs and will not be denied solely benefits for a period of one year to permanently and may be
because benefits from other programs have been denied. The fined up to $250,000 or imprisoned up to 20 years or both. A
Agency will process all SNAP applications in accordance with court can also add an additional 18-month SNAP
SNAP timeliness, notice, and fair hearing requirements, even if participation restriction for an individual.
you are applying for other programs. • DO NOT buy or sell firearms, ammunition, or explosives
• If you are a resident of an institution and jointly apply for SSI with SNAP benefits; if you do, you can never receive SNAP
and food assistance prior to leaving the institution, the filing benefits again.
date of the application is your date of release from the • DO NOT buy or sell illegal drugs with SNAP benefits; DO
institution. Processing time will begin from the date the NOT trade, sell or alter Electronic Benefit (EBT) cards; if you
application is received in the Department of Social Services. do, you cannot receive SNAP benefits for 24 months for the
• Please fill in all the blanks you can. If you need help or do not first offense and permanently for the second offense.
understand a question, a DSS worker can help you. • DO NOT trade, sell or share EBT cards or SNAP benefits. If
• Make sure you PRINT YOUR NAME, PRINT TODAY’S a court of law finds you guilty of selling benefits of $500 or
DATE, and SIGN THE APPLICATION. more, you will be permanently ineligible to participate in the
• Please tear off pages 1-6 and keep for yourself. Return pages program for the first offense.
7-13 of this application to DSS. Once your application has • DO NOT receive SNAP benefits in more than one state for the
been received by the agency, you will be given a phone same month. Any individual found to have made a fraudulent
number to call for an interview no later than 10 days from the statement, or fraudulent representation of identity or
date your application is received. You may request a face-to-
residence in order to receive benefits shall be ineligible to
face interview with a worker in the county where you live if
you want. You may bring someone with you to the interview receive SNAP benefits for 10 years.
who can help you. If an interpreter is needed, DSS will • Any member of your Household who intentionally breaks the
provide one at no cost to you. rules may not receive SNAP for 12 months for the first
• Mail, fax, e-mail or take this application to the Department of offense, 24 months for the second offense and permanently
Social Services (DSS). for the third offense.
• To get the address of your county DSS office, call toll free:
• DO NOT receive SNAP benefits in the same month. Any
1-800-616-1309 or view online at www.dss.sc.gov.
individual found to have made a fraudulent statement or
Report Changes fraudulent representation of program participation in order to
• You must report certain changes in your circumstances to receive benefits shall be ineligible to receive SNAP benefits
DSS. for 12 months on the first offense, 24 months for the second
• Your failure to report changes is considered withholding offense, and permanently for the third offense.
of information and will permit DSS to recover any benefits
paid to you in error.
• You may report in writing, by phone, electronically or by TANF ePay Card Restrictions
use of the Change Report Form to report changes between The ePAY card should not be used in any electronic transaction:
recertifications/redeterminations. • in any liquor store.
• casino, gambling casino or gaming establishment; or
SNAP Changes • retail establishment which provides adult-oriented entertainment
• You must report when your total gross income exceeds 130% in which performers disrobe or perform in an unclothed state for
of the federal poverty level, when a household member who is entertainment.
an ABAWD has work hours that fall below 20 hours weekly or
80 hours when averaged monthly, or when a member of your
household wins lottery or gambling winnings equal to or
greater than $4250 from a single game before taxes or other Temporary Assistance for Needy Families Information
withholdings. and Referral Services
• These changes must be reported by the tenth day of the • SNAP households with income at or below 130% of the federal
month after the month of the change. All other changes must poverty level (FPL) are authorized to receive the South Carolina
be reported at recertification. Temporary Assistance for Needy Families Information and
Referral Services brochure.
• This brochure may be requested from any local office or by calling
TANF and RCA Changes 1-800-616-1309 to request a brochure to be mailed to you.
You must report the following changes within 10 days:
• Employment Status (starting or losing a job)
• Unearned Income (amount or source) Refugee Cash Assistance Program (RCA)
• Change in Residence or Address • Refugee Cash Assistance is limited to eight (8) months from the
• Change in Benefit Group Composition date of arrival in the U.S.
• The RCA benefit amount is the same as the benefit amount for
TANF.
• RCA is only available to adult refugees without minor dependent
children.
• Your application for RCA will be completed at the local DSS
office but the payment will be mailed to you from the office in
Columbia, SC.

DSS 3800 (APRIL 2024) 4 Client Copy

 Supplemental Nutrition Assistance Program (SNAP)
Able-Bodied Adults without Dependents (ABAWD) Information

An ABAWD is an able-bodied individual, 18 years of age or older but under 53, who has no household member(s) in the SNAP
budget under the age of 18. An ABAWD can only receive three (3) months of SNAP benefits in a three (3) year period unless
also meeting the ABAWD work requirement or an exception to the work requirement.

ABAWD Work Requirement:

• Work at least 20 hours weekly, averaged as 80 hours monthly (in exchange for money, in-kind benefits, or with an established
volunteer agency); or
• Participate in and comply with requirements of a work program at least 20 hours weekly, averaged as 80 hours monthly
(such as SNAP E&T, WIOA, etc.); or
• Any combination of working and participating in a work program at least 20 hours weekly, averaged as 80 hours monthly; or
• Participating in or complying with a workfare program.

Exceptions to ABAWD Work Requirement:

• Physically or mentally unable to work; or
• Pregnant; or
• Veteran; or
• 24 years old or younger and aged out of foster care; or
• Considered homeless (as defined by Federal regulations); or
• Already meeting an exemption from the General Work Requirements (caretaker for someone, regular participant in a drug or alcohol
program, student enrolled at least half-time, receiving unemployment benefits, or applied for but not yet receiving unemployment
benefits).

An ABAWD who has already received three (3) months of benefits during this three (3) year period may regain eligibility by providing
proof of meeting the work requirement for 30 consecutive days, meeting an exception, or when the three (3) year period starts over
again.

DSS 3800 (APRIL 2024) 5 Client Copy

 Application Checklist
The SNAP/TANF Eligibility Checklist is designed to provide examples of some of the information that may need to be
verified in order to determine your eligibility for SNAP/TANF benefits. Please be aware that a DSS worker may request
additional information during the interview. You may mail, fax, or drop off this information at any DSS office.

IF APPLYING FOR SNAP ONLY

□ Identification of person applying and authorized representative, if applicable. Examples include: driver’s
license, state ID card, work or school ID, ID for health benefits, assistance from another social services
program, other acceptable forms of ID, or voter registration card.

□ Social security numbers for each family member for whom you are applying, both children and adults.

□ Income: Pay stubs for the last four (4) weeks of work, if you are currently working, or most current tax
returns if self-employed (Please send entire tax return). Verification of the last four (4) weeks of child
support payments if you are receiving child support. Copies of award letters for unemployment, Social
Security, Retirement, etc.

□ Household expenses: Lease agreement, rent or mortgage payment receipts and utility bills
(optional).

□ Medical expenses for anyone disabled or aged 60 or older. Examples include: Medical bills,
prescription co-pays, health insurance premium receipts, mileage to and from doctor
appointments, etc.

IF APPLYING FOR TANF ONLY

□ Birth certificates for you and your children

□ Social security numbers for each family member for whom you are applying-children and adults.

□ Identification of person applying and of the authorized representative, if applicable. Examples

include: driver’s license, state ID card, work or school ID, ID for health benefits, assistance from
another social services program, other acceptable forms of ID, or voter registration card.

□ Income: Pay stubs for the last four (4) weeks of work, if you are currently working, or most current
tax returns if self-employed (Please send entire tax return). Copies of award letters for
unemployment, Social Security Administration (SSA) benefits, Veteran’s Administration (VA)
income, retirement, etc.

□ Bank/financial account statements, if applicable. Examples include, but are not limited to,
statements for: checking, savings, money market, saving certificate, trust funds, Individual
Retirement Accounts (IRA), and/or any other bank/financial account.

□ Vehicle registration or personal property tax information, if applicable.

IF APPLYING FOR SNAP AND TANF

Please provide as many of the verification items listed above.

DSS 3800 (APRIL 2024) 6 Client Copy

 DSS USE ONLY
□ New Application □ Reapplication □ Recertification Expedited Screener’s Name: Dated Filed:
□ TANF Redetermination □ Add TANF BG Member □ Cure Sanction
CHIP Case Number: Worker: Expedited? ☐ Yes ☐ No
□ Not Enough Info.

This information, including the Social Security Number (SSN) of each household member, is authorized under the Food and Nutrition Act of 2008. This
information will also be used to monitor compliance with program regulations and for program management. 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 members.

Expedited Service Information

• You may receive SNAP benefits within 7 calendar days if: your SNAP household has less than $150 in monthly gross income and liquid
resources such as cash, checking or savings accounts are less than or equal to $100 or your rent/mortgage and utilities are more than
your household’s combined monthly income and liquid resources, or a member of your household is a migrant or seasonal farm worker
who is considered destitute.
• Failure to answer the questions on this application may result in our inability to determine your eligibility for expedited service.
PLEASE PRINT CLEARLY.
Section 1: Interpreter, Translation, and Authorized Representative Information
Do you need an interpreter? ☐Yes ☐No If yes, what language do you use the most?
Do you need translated material? ☐Yes ☐No If yes, what language do you use the most?
Are you deaf or hard of hearing? If yes, and you need assistance when communicating, please check all that apply:
□ TTY/Video Relay ☐ Sign Language ☐Other
You may designate someone to help you with the application and interview. This person should know your household’s situation well
enough to give any information needed to determine eligibility. You are still responsible for the information that anyone acting as your
authorized representative gives, including any information that may be incorrect.
Would you like for someone not in your household to complete this application or interview for you as your authorized representative?
☐Yes ☐No If yes, tell us who and sign below:
Name of Representative: Telephone Number:
Signature of Applicant/Client
You may designate a second person or use the same person to assist you with utilizing benefits on your EBT card on your behalf.
Name of Second Representative: Telephone Number:
Signature of Applicant/Client:
Signature of two witnesses, if signed with an “X”: (1) (2)

Section 2: For which program(s) are you applying?

□ Supplemental Nutrition Assistance Program (SNAP) ☐ Refugee Cash Assistance (RCA)
□ Temporary Assistance for Needy Families (TANF)
Section 3: Tell us about yourself.
Last Name: First Name: Middle Initial: Suffix:

Home Phone Number: Cell Phone Number: Another Telephone Number Where Best Time to Call:
You Can Be Contacted:

Where do you live?

Street Address: (Include Apt./Lot No.) City: State: Zip Code: County:

If you receive your mail someplace else, please complete the section below.
Mailing Address: (If different, Include Apt./Lot No.) City State: Zip Code County:

IMPORTANT: Please read and sign this statement/application.

I certify under penalty of perjury that the information I or my authorized representative has provided on this application, including information
concerning citizenship and immigration status, is true to the best of my knowledge. I give permission for the Department of Social Services to
make any necessary contacts to check my statements. I know that I could be penalized if I knowingly give false information. I certify I received
the Your Rights and Responsibilities handout included in this application packet.

Signature of Applicant/Authorized Representative: Date: _

Signature of two witnesses, if signed by an “X”: (1) (2)

DSS 3800 (APRIL 2024) 7 Return to DSS

 Section 4: Tell us about you and your household members.
• List everyone who lives with you. Answer all questions for each household member.
• Verification of information about all household members may be required. You only have to provide the SSN or date of
SS-5 and citizenship/immigration status of the persons for whom you are applying. SSN and citizenship/immigration status
are voluntary for non- applicants and ineligible persons in your household.
Race
Code
Name (First, Middle, Last) Relationship Social Security Number (Choose Hispanic Blind
List names as they appear on the to Person on Date of Sex or one or or or US
person’s social security card. Line 1 Birth Age M/F Date of SS-5 more.) Latino Disabled Citizen Working
1. □ Yes □ Yes □ Yes □ Yes
(Self) □ No □ No □ No □ No
2. □ Yes □ Yes □ Yes □ Yes
□ No □ No □ No □ No
3. □ Yes □ Yes □ Yes □ Yes
□ No □ No □ No □ No
4. □ Yes □ Yes □ Yes □ Yes
□ No □ No □ No □ No
5. □ Yes □ Yes □ Yes □ Yes
□ No □ No □ No □ No
6. □ Yes □ Yes □ Yes □ Yes
□ No □ No □ No □ No
7. □ Yes □ Yes □ Yes □ Yes
□ No □ No □ No □ No
*Race: BL - Black or African American; WH - White; AS - Asian; AI - American Indian/Alaska Native; NH - Native Hawaiian or Other Pacific
Islander. The collection of ethnic and racial information from the applicant is voluntary and will not affect eligibility or the level of benefits the
applicant may receive. The information is collected to assure that the program benefits are distributed without regard to race, color, or national
origin.
Please provide information below if you or anyone in your household is a student.
Current or Last Grade
Name of Student Level Completed Name of School Enrollment Status
□ Less Than Half-Time
□ Half-Time
□ Full-Time
□ Less Than Half-Time
□ Half-Time
□ Full-Time
□ Less Than Half-Time
□ Half-Time
□ Full-Time
□ Less Than Half-Time
□ Half-Time
□ Full-Time
□ Less Than Half-Time
□ Half-Time
□ Full-Time

Indicate any other people who live in the same house with you, but you do not want included in your SNAP household because they do
not purchase and prepare food with you or those noncitizens who do not wish the agency to contact USCIS to verify their immigration
status. (Use another sheet of paper to add other people if there is not enough room for everyone here.)
Does this person give you or Does this person pay any part
Relationship anyone listed above any money? of the household bill(s)?
Name Age to You Yes/No If yes, reason? Yes/No If yes, what bill(s)?
□ Yes □ Yes
□ No □ No
□ Yes □ Yes
□ No □ No
□ Yes □ Yes
□ No □ No

DSS 3800 (APRIL 2024) 8 Return to DSS

 Tell us about you and your household members (Continued from Page 8).
1. Have you or anyone for whom you are applying received TANF before? ☐ Yes ☐ No
If yes:
• In which state(s) did you and/or your household member(s) receive TANF benefits? ___________________________
• When were TANF benefits last received?_____________________________________________________________
• Which household member(s) received TANF benefits?___________________________________________________
• Do you still have a South Carolina ePay card? ☐ Yes ☐ No
2. Have you or anyone for whom you are applying received SNAP before? ☐ Yes ☐ No
If yes:
• In which state(s) did you and/or your household member(s) receive SNAP benefits? ____________________________
• When were SNAP benefits last received?_____________________________________________________________
• Which household member(s) received SNAP benefits?__________________________________________________
• Do you still have a South Carolina EBT card? ☐ Yes ☐ No
3. Have you or anyone in your household received $4250 or more in lottery or gambling winnings (at one time) within the last 12 months?
If yes, who?_______________________________ When?_______________________________
4. Are you or anyone in your household a fleeing felon or probation/parole violator? ☐ Yes ☐ No
If yes, who?_______________________________
5. Have you or anyone in your household been found guilty of a state or federal drug-related felony (possession, use, and/or distribution) committed
after August 22, 1996? ☐ Yes ☐ No
If yes, who?_______________________________

6. Have you or anyone in your household been found guilty of receiving TANF (cash benefits) or SNAP benefits in two or more states at the same
time? ☐ Yes ☐ No
If yes, who?_______________________________
7. Have you or anyone in your household been found guilty of committing one of the following offenses after September 22, 1996?
• Trading SNAP benefits for drugs ☐ Yes ☐ No
If yes, who?_______________________________
• Buying or selling SNAP benefits over $500? ☐ Yes ☐ No
If yes, who?_______________________________
• Trading SNAP benefits for guns, ammunitions, or explosives? ☐ Yes ☐ No
If yes, who?_______________________________
8. Have you or anyone in your household been convicted after February 7, 2014, of aggravated sexual abuse, murder, exploitation of a child,
sexual assault as defined in the Violence Against Women Act of 1994, or a similar state law and is also not in compliance with the
terms of the sentence(s)? ☐ Yes ☐ No
If yes, who?_______________________________

9. Are you or anyone in your household living in any of the following special settings:
• Shelter for battered women and children; ☐ Yes ☐ No
• Homeless shelter; ☐ Yes ☐ No
• Drug addiction or alcoholic (DAA) treatment or rehabilitation facility; ☐ Yes ☐ No
• Group living arrangement (GLA) for blind or disabled individuals; ☐ Yes ☐ No
• Other institution? ☐ Yes ☐ No

If you or anyone is your household is living in a special setting listed above, please provide the information below. Who lives in a
special setting?_________________________________________ Facility Type:__________________________________________
Facility Name:____________________________________________________

10. Are you or anyone in your household homeless, but not living in a homeless shelter? ☐ Yes ☐ No
If yes, who?_______________________________

11. Are you or anyone in your household a regular participant in a drug or alcohol program? ☐ Yes ☐ No
If yes, who?_______________________________
12. Are you or anyone in your household pregnant? ☐ Yes ☐ No
If yes, who?_______________________________ Due Date:_________________________

13. Are you or anyone in your household, age 18-52, unable to work? ☐ Yes ☐ No
If yes, who?_______________________________
Why is this person unable to work?_____________________________________________
14. Are you or anyone in your household a veteran? ☐ Yes ☐ No
If yes, who?_______________________________

15. Are you or anyone in your household age 24 years old or younger and aged out of foster care? ☐ Yes ☐ No
If yes, who?_______________________________

DSS 3800 (APRIL 2024) 9 Return to DSS

Section 5: Tell us about your household income.
1. Are you or anyone in your household working? ☐ Yes ☐ No If yes, who?
2. Enter GROSS pay, not take-home pay below received in the last four weeks.
• Gross pay is pay before any deductions.
• Note: If you do not have your paystubs or do not receive payment in the form of money for your work, such as in-kind
work or volunteering with an established volunteer organization, then have the person you work for complete this section.
Name of Person Working: Name of Person Working:

Name and Address of Employer: Name and Address of Employer:

Telephone Number of Employer: Fax Number of Telephone Number of Employer: Fax Number of
Employer: Employer:

Amount Earned Each Pay Period Before Taxes: Amount Earned Each Pay Period Before Taxes:
$ $
☐Weekly ☐Every 2 Weeks ☐Twice Per Month ☐Monthly ☐Weekly ☐Every 2 Weeks ☐Twice Per Month ☐Monthly
Number of Hours Worked Each Week: Number of Hours Worked Each Week:
Week

Week
Date Pay Received Total Date Pay Received Total
Gross Pay Tips Gross Pay Tips
Hours Hours
Month Day Year Month Day Year
1 1
2 2
3 3
4 4

Employer’s Signature Telephone Number Employer’s Signature Telephone Number

Employer’s Printed Name: Employer’s Printed Name:

3. Do you or anyone in your household receive money from any other source(s)? ☐ Yes ☐ No
If yes, please complete the section below.

How often do you or anyone in your Which family member receives this
Other Income Amount household receive this income? income?
Child Support $ ☐Weekly ☐Monthly
☐Every 2 Weeks ☐Other (Explain)
☐Twice Per Month
Supplemental Security $ ☐Weekly ☐Monthly
Income (SSI) ☐Every 2 Weeks ☐Other (Explain)
☐Twice Per Month
Social Security Benefits $ ☐Weekly ☐Monthly
☐Every 2 Weeks ☐Other (Explain)
☐Twice Per Month
Unemployment Benefits $ ☐Weekly ☐Monthly
☐Every 2 Weeks ☐Other (Explain)
☐Twice Per Month
Veterans Benefits $ ☐Weekly ☐Monthly
☐Every 2 Weeks ☐Other (Explain)
☐Twice Per Month
Retirement/Pensions $ ☐Weekly ☐Monthly
☐Every 2 Weeks ☐Other (Explain)
☐Twice Per Month
Other (Explain) $ ☐Weekly ☐Monthly
☐Every 2 Weeks ☐Other (Explain)
☐Twice Per Month

DSS 3800 (APRIL 2024) 10 Return to DSS

Section 6: Tell us about your household resources.
1. Does anyone own any cars, trucks, other assets, or land/buildings other than where you live? ☐Yes ☐No
If yes, please list all assets._____________________________________________________________________________________________
2. How much does the household have in cash $ , checking $ , and/or savings account(s) $_____________?
Section 7: Tell us about your household expenses.
1. Do you or anyone in your household pay someone to take care of your child(ren)? ☐Yes ☐No

2. Do you or anyone in your household pay someone to take care of a dependent adult? ☐Yes ☐No

3. Do you or anyone in your household pay child support? ☐Yes ☐No

If yes, how much? How often? Is it court ordered? ☐Yes ☐No

4. If anyone in your household is disabled or age 60 or older, does he/she have out-of-pocket medical expenses over $35 each
month? ☐Yes ☐No If yes, who? _______________________

Section 8: Tell us about your household circumstances for SNAP expedited service screening.
1. What is the total income you and your household have already received and expect to receive this month? $
2. Is anyone in your household a migrant or seasonal farm worker? ☐Yes ☐ No
(If yes, answer the following questions.)
• Did all of your household income recently stop? ☐Yes ☐ No
If yes, when did you receive your last pay? What was the total amount?
• Does anyone in your household expect to receive income from a new source this month? ☐Yes ☐ No
If yes, how much? Do you expect to receive it within 10 days? ☐Yes ☐ No
3. How much does the household have in cash $ , checking $ , and/or savings account(s) $ ?

4. How much is your household billed for?

Rent/Mortgage $ Lot Space Rent $ House Taxes $
House Insurance $ Condominium Fees $

5. Is your household billed to heat or cool your home? ☐Yes ☐ No

If yes, how do you heat or cool your home:

6. Does your household receive LIHEAP (Low Income Home Energy Assistance Program)? ☐Yes ☐ No

7. If you answered NO to questions 5 and 6, what is the amount of your household’s billed monthly utilities other than phone?
$ ___________________

DSS 3800 (APRIL 2024) 11 Return to DSS

Section 9: Temporary Assistance for Needy Families (TANF) Only
Absent Parent Information:
Provide the following information below for each child listed in Section 4 whose mother and/or father is not in the home. Additional
information may be requested during the eligibility interview.
Absent Parent’s Name, Last Known Address, and Phone Number Social Security Number
The absent Name:
parent is:
□ Mother Last Known Address:
Date of Birth
□ Father
Phone Number:

Please list the names of the child(ren) for which this person is the absent parent. Is this the child(ren)’s legal parent?
□ Yes
□ No

Employer’s Name Employer’s Address Employer’s Phone Number

Absent Parent’s Name, Last Known Address, and Phone Number Social Security Number
The absent Name:
parent is:
□ Mother Last Known Address:
Date of Birth
□ Father
Phone Number:

Please list the names of the child(ren) for which this person is the absent parent. Is this the child(ren)’s legal parent?
□ Yes
□ No

Employer’s Name Employer’s Address Employer’s Phone Number

Absent Parent’s Name, Last Known Address, and Phone Number Social Security Number
The absent Name:
parent is:
□ Mother Last Known Address:
Date of Birth
□ Father
Phone Number:

Please list the names of the child(ren) for which this person is the absent parent. Is this the child(ren)’s legal parent?
□ Yes
□ No

Employer’s Name Employer’s Address Employer’s Phone Number

Absent Parent’s Name, Last Known Address, and Phone Number Social Security Number
The absent Name:
parent is:
□ Mother Last Known Address:
Date of Birth
□ Father
Phone Number:

Please list the names of the child(ren) for which this person is the absent parent. Is this the child(ren)’s legal parent?
□ Yes
□ No

Employer’s Name Employer’s Address Employer’s Phone Number

IMPORTANT: For TANF, please read and sign below.

I do hereby attest under penalty of perjury that the above information is true and correct to the best of my knowledge
and belief and is given for the purpose of receiving services under Title IV-D of the Social Security Act. By signing this
DSS Application for Public Assistance below, I understand that these assertions are true and will be used in legal
pleadings against the absent parent.

Signature of Applicant/Authorized Representative: Date:__________________

Signature of two witnesses, if signed by an “X”: (1)_____________________________ (2)______________________________

DSS 3800 (APRIL 2024) 12 Return to DSS

 South Carolina Department of Social Services
VOTER PREFERENCE FORM

If you are not registered to vote where you live now, would you like to apply to register to vote?
(Please check one.)

□ Yes, I would like to register to vote.

□ I am registered, but not at my current address.
□ No, I am registered at my current address.
□ No, but I will use the Voter Registration Mailed Application.
□ No. I do not wish to register to vote at this time.
□ No. I am not eligible to vote.
□ No. I am refusing to register.
IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER
TO VOTE AT THIS TIME.

Signature of Applicant/Declinee Date

Important Notices
▪ If you believe that someone has interfered with your right to register or to decline to register to vote, your
right to privacy in deciding whether to register or in applying to register to vote, or your right to choose
your own political party preference or other political preference, you may file a complaint with the
following: Executive Director at South Carolina Election Commission, 1122 Lady St. Suite 500, P.O. Box
5987 Columbia, SC 29205 or call 803- 734-9060, fax to 803-734-9366, or email
[email protected]. This address is for complaints only regarding your right to vote.

▪ If you would like help in filling out the voter registration application, we will help you. The decision
whether to seek or accept help is yours. For assistance in completing the voter registration application
form outside our office, call 1-800-616-1309.

▪ Applying to register or declining to register to vote will not affect the amount of assistance that you will
be provided by this agency.

▪ If you do register to vote, the location where your application was submitted will remain confidential. If
you decline to register to vote, this fact will remain confidential. Applying to register or declining to register
to vote will be used only for voter registration purposes.

RETURN FORMS TO DSS:

South Carolina Department of Social Services Centralized Scan Center
P.O. Box 100203 Columbia, SC 29202-3203

DSS Form 1663 (JUL 18) 13 Return to DSS