The South Carolina Department of Social Services

TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF) APPLICATION

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) APPLICATION
REFUGEE CASH ASSISTANCE (RCA) APPLICATION

Do you need help filling out this application due to disability? Do you need an interpreter? Do
you need translated materials? If yes, please ask for help at your local DSS Office.
To get the address or phone number of your local office, call toll free: 1-800-616-1309 or view
online at [Link].

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

Temporary Assistance for Needy Families (TANF) and Supplemental Nutrition Assistance
Program (SNAP) 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 and 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 (NOV 19) All previous editions are obsolete. Client Copy
 USDA-HHS NON-DISCRIMINATION STATEMENT

This institution is prohibited from discriminating on the basis of race, color, national origin,
disability, age, sex and in some cases religion or political beliefs.

The U.S. Department of Agriculture also prohibits discrimination based on race, color, national
origin, sex, 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.

Persons with disabilities who require alternative means of communication for program
information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact
the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of
hearing or 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.

To file a program complaint of discrimination, complete the USDA Program Discrimination

Complaint Form, (AD-3027), found online at:
[Link] 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: U.S. Department of Agriculture

Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) Fax: (202) 690-7442; or
(3) Email: [Link]@[Link].

For any other information dealing with Supplemental Nutrition Assistance Program (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:
[Link]

To file a complaint of discrimination regarding a program receiving Federal financial assistance

through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office
for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call
(202) 619-0403 (voice) or (800) 537-7697 (TTY).

This institution is an equal opportunity provider.

You may also file a complaint of discrimination by contacting DSS. Write DSS Office of Civil
Rights, P.O. Box 1520, Columbia, SC 29202-1520; or call (800) 331-7220 or (803) 898-8080 or
TTY: (800) 311-7219

DSS Form 3800 (NOV 19) PAGE 2 Client Copy

 Temporary Assistance for Needy Families (TANF), Refugee Cash Assistance (RCA) and
Supplemental Nutrition Assistance Program (SNAP)
YOUR RIGHTS AND RESPONSIBILITIES
Varied Benefits
Confidentiality ● If you receive child support through CSSD, your
The information that you give to DSS will be kept SNAP benefits may change from month to month because
confidential. of any changes in the child support you receive.
Exceptions:
Work/Training Program Requirements
1. Information may be disclosed to other federal and
state agencies for official examination and to law ● To receive TANF or RCA benefits, you must participate in a
enforcement officials for the purpose of apprehending work or training program, unless you are exempt from the
fleeing felons or probation/parole violators. work program requirement.
2. You agree that confidential information about you ● To receive SNAP benefits, some household members must
and/or your family may be released to other work, participate in an employment and training program
organizations if it is directly related to the operation and/or register for work. By signing your application, you will
of TANF, RCA and SNAP. be considered to have registered all household members
Social Security Numbers required to be registered.
In order to get benefits from the TANF, SNAP and other Time Limits
• TANF benefits may be time limited.
programs:
• RCA is limited to 8 months from the date of arrival in the
• You must provide or apply for a Social Security Number U.S.
(SSN) for those persons who want to receive TANF
• SNAP benefits may be limited to 3 months in a 36 month
and/or SNAP. Although SSNs are not required for non-
applicants or persons ineligible for TANF or SNAP, time period.
• The receipt of SNAP benefits has no effect on any other
income information must be included for all Household
(HH) / Benefit Group (BG) members. program’s time limits.
• If DSS needs the SSN on a person for whom you did not Verification
provide information, a DSS worker will contact you to • A DSS worker may need to contact other people or
discuss the reasons for requesting the number and what organizations (neighbors, banks, employers, etc.) in order
will happen if you do not give DSS the number. to verify your income, work program/employment status,
• SSNs will be used in computer matching programs and bank accounts, citizenship/immigration status,
medical/shelter expenses, insurance/retirement benefits,
other reviews and you cannot receive SNAP benefits for medical history and any other fact that relates to your
any person an SSN is not provided for. eligibility for TANF, RCA or SNAP benefits.
• If you do not have an SSN for an applicant, it will not • For SNAP, failure to report or verify any deductible
delay your application, provided he/she applies for one expenses will be seen as a statement that your household
immediately. DSS will help you apply for an SSN. does not want to receive a deduction for the unreported
• DSS will not share or give SSNs of non-applicants or expense.
individuals ineligible for benefits with the U.S. Benefit Repayment
Department of Homeland Security. • You may be required to repay benefits you received from
Citizenship and Immigration Status TANF (including child care and transportation), RCA and
• You must provide citizenship and immigration status SNAP benefits that you should not have received even if you
information for those persons who want to get TANF, received them through no fault of your own.
RCA and/or SNAP. • DSS may apply any benefits removed from your inactive
• DSS will not share the citizenship and immigration EBT account to repay an outstanding SNAP claim(s).
status of non-applicants or individuals ineligible for • DSS seeks repayment of claims from any federal and/or
benefits with the U.S. Department of Homeland state tax refunds that may be due you. The information that
Security. However, information provided by applicant
household members may be submitted to United States you give DSS, including SSNs, may be referred to
Citizenship and Immigration Services (USCIS) for federal/state agencies for claims collection action.
verification of immigration status. The information Fair Hearings
received from USCIS may affect the household’s • If you do not agree with a decision made in your case, you
eligibility and level of benefits. may request a Fair Hearing, orally or in writing for SNAP,
Assignment of Child Support TANF and RCA, by contacting your county DSS office or
• Any child support you receive or may receive for a SCDSS, Division of Individual and Provider Rights, P.O. Box
TANF eligible child must be assigned to DSS. 1520, Columbia, SC 29202-1520, 1-800- 311-7220 for TANF
• DSS may take action to collect child support from both and SNAP.
maternal and paternal grandparents if the child’s • You may speak for yourself at the hearing. You may
parent(s) are under age 18 and receive TANF. also bring a friend, relative, or lawyer to speak for
you.
Paternity Establishment
• To request continuation of your TANF, RCA or SNAP benefits,
• In order to get benefits from the TANF Program, you
must cooperate with the Child Support Services while you wait for the hearing, the request must be made
Division (CSSD) in establishing paternity and obtaining within 10 days from the date of the notice you receive
child support for your children. If you have a good reducing or stopping your benefits.
reason to believe cooperation may cause harm to you • If the hearing decision is not in your favor, the benefits
or your child(ren) ask your case manager about will have to be repaid.
establishing “good cause” for failure to cooperate. • The maximum time to request a hearing after you get a
notice reducing or stopping your benefits is: 60 days for
TANF and RCA and 90 days for SNAP benefits.

DSS Form 3800 (NOV 19) PAGE 3 Client Copy

 Application Filing Instructions

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. Benefits are provided within
30 days from the date the application is received by the agency. If you are applying for SNAP benefits, your
eligibility will be determined separately from any other programs and will not be denied solely because benefits
from other programs have been denied. The Agency will process all SNAP applications in accordance with SNAP
timeliness, notice, and fair hearing requirements, even if you are applying for other programs.
If you are a resident of an institution and jointly apply for SSI and food assistance prior to leaving the institution, the
filing date of the application is your date of release from the institution. Processing time will begin from the date the
application is received in the Department of Social Services.

• Please fill in all the blanks you can. If you need help or don’t understand a question, a DSS worker can help you.
➢ Make sure you PRINT YOUR NAME, PRINT TODAY’S DATE, and SIGN THE APPLICATION.
• Please tear off pages 1-6 and keep for yourself. Return pages 7-15 of this application to DSS. Once your
application has been received by the agency, you will be given a phone number to call for an interview no later
than 10 days from the date your application is received. You may request a face-to-face interview with a
worker in the county where you live if you want. You may bring someone with you to the interview who can
help you. If an interpreter is needed, DSS will provide one at no cost to you.
• Mail, fax, e-mail or take this application to the Department of Social Services (DSS).
• To get the address of your county DSS office, call toll free: 1-800-616-1309 or view online at [Link].

SNAP Warnings and Penalties

• DO NOT buy ineligible items such as alcoholic beverages or tobacco with SNAP benefits.
• DO NOT use your EBT card to pay for food charged to a credit account.
• Violators of the above rules may not be able to get SNAP benefits for a period of one year to permanently
and may be fined up to $250,000 or imprisoned up to 20 years or both. A court can also add an
additional 18-month SNAP participation restriction for an individual.
• DO NOT buy or sell firearms, ammunition or explosives with SNAP benefits; if you do, you can never get
SNAP benefits again.
• DO NOT buy or sell illegal drugs with SNAP benefits; DO NOT trade, sell or alter Electronic Benefit (EBT)
cards; if you do, you cannot get SNAP benefits for 24 months for the first offense and permanently for
the second offense.
• DO NOT trade, sell or share EBT cards or SNAP benefits. If a court of law finds you guilty of selling
benefits of $500 or more, you will be permanently ineligible to participate in the program for the first
offense.
• DO NOT receive SNAP benefits in more than one state for the same month. Any individual found to have
made a fraudulent statement, or fraudulent representation of identity or residence in order to receive
benefits shall be ineligible to receive SNAP benefits for 10 years.
• Any member of your Household who intentionally breaks the rules may not get SNAP for 12 months for
the first offense, 24 months for the second offense and permanently for the third offense.

Temporary Assistance for Needy Families Program (TANF)

The ePAY card should not be used in any electronic transaction:
• in any liquor store;
• casino, gambling casino or gaming establishment; or
• retail establishment which provides adult-oriented entertainment in which performers disrobe or perform in an
unclothed state for entertainment.

Refugee Cash Assistance Program (RCA)

Refugee Cash Assistance is limited to eight (8) months from the 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 Form 3800 (NOV 19) PAGE 4 Client Copy

 Supplemental Nutrition Assistance Program (SNAP)
An ABAWD is an able-bodied individual, 18 years of age or older but under 50, 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 time 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, Project Hope, etc.); or
• Any combination of working and participating in a work program at least 20 hours weekly, averaged as
80 hours monthly.

Exceptions to ABAWD Work Requirement:

• Physically or mentally unable to work; or
• Pregnant; 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 time 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 time period starts over again.

Temporary Assistance for Needy Families Information and Referral Services

SNAP households with income at or below 130% of the federal poverty level (FPL) are
authorized to receive the South Carolina Temporary Assistance for Needy Families Information
and Referral Services brochure. This brochure may be requested from the local office or by
calling 1-800-616- 1309 to request a brochure to be mailed to you.

Report Changes
• You must report certain changes in your circumstances to DSS.
• Your failure to report changes is considered to be withholding 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 use of the Change Report Form
to report changes between renewal/redeterminations.
SNAP
You must report when your total gross income exceeds 130 % of the federal poverty level, when a
household member who is 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 $3500 from a single game before taxes or other withholdings. These
changes must be reported by the tenth day of the month after the month of the change. All other
changes must be reported at renewal.

Temporary Assistance for Needy Families Program (TANF) and

Refugee Cash Assistance Program (RCA)
Report these changes within 10 days:
• Change in any income, hours of employment, rate of pay or new source of income, change in your
address or residence, person(s) moving in or out of your home.
Report this change within 5 days:
• Any household member temporarily living away from the household who has decided not to
return to the household.

DSS Form 3800 (NOV 19) PAGE 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 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.

 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, VA,
Retirement, etc.

 Bank account statements.

IF APPLYING FOR SNAP AND TANF

Please provide as many of the verification items listed in the two boxes above.

DSS Form 3800 (NOV 19) PAGE 6 Client Copy

 CHECK BOX FOR EACH PROGRAM YOU WANT TO APPLY FOR:
Temporary Assistance for Needy Families Supplemental Nutrition Assistance Refugee Cash Assistance
DSS USE New Application Reapplication Cure Sanction Date Filed:
ONLY: TANF Redetermination Expedited Screener:
CHIP Case Worker’s Interview Expedited?
No.: Name: Date: 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.
PLEASE PRINT CLEARLY
Do you need an interpreter? If yes, what language do you use the most?
Do you need translated material? Yes No
Are you deaf or hard of hearing? If yes, and you need assistance when communicating with us, please check all
that apply: TTY/Video Relay Sign Language Interpreter Other:
You may designate someone to help you with the application and the interview. This person should know your household’s
situation well enough to give any information needed to determine your 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:
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 2nd Representative: Telephone:
Signature of Applicant/Client:
Signature of two witnesses, if signed by an “X”: (1) (2)
Expedited Service
You may get 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.
Section 1: Tell Us About Yourself
Last Name: First Name: MI: Suffix:

Home Phone No.: Cell Phone No.: 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 FILL IN SECTION BELOW
Mailing Address: (If Different, Include Apt./Lot No.) City: State: Zip Code: County:

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 Form 3800 (NOV 19) PAGE 7 Return to DSS

Section 2: Tell Us About 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 are applying. SSN and citizenship/immigration status is
voluntary for non- applicants and ineligible persons in your household.
His- Race Blind
Name (First, Middle, Last) Relationship Social Security US
Date of Sex panic Code or In Work-
List names as they appear on the to Person Age (Choose Number or Date of Citi- School
person’s Social Security Card.
Birth M/F or one or
Dis- ing
on Line 1 SS-5 zen
Latino more) abled

Yes Yes Yes Yes Yes

1. (Self) No No No No No
Yes Yes Yes Yes Yes
2. No No No No No
Yes Yes Yes Yes Yes
3. No No No No No
Yes Yes Yes Yes Yes
4. No No No No No
Yes Yes Yes Yes Yes
5. No No No No No
Yes Yes Yes Yes Yes
6. No No No No No
Yes Yes Yes Yes Yes
7. No No No No No
* Race: BL - Black or African American; WH - White; AS - Asian; AI - American Indian/Alaskan 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.

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 of
Name Age Relationship
anyone listed above any money? the household bill?
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

For Temporary Assistance for Needy Families only:

Is any teenager listed above (male or female) a parent? Yes No
If yes, who:
Is anyone listed above pregnant? Yes No
If yes, who: Due date:

Is anyone listed above living in a special setting such as a shelter for battered women and children, homeless shelter, drug
or alcohol treatment or rehabilitation facility (DAA), group home for blind or disabled individuals (GLA), or other institution?
Yes No
If yes, who: Type of Facility:
Facility Name:
Telephone Number:

Is anyone in your household a regular participant in a drug or alcohol program? Yes No (If yes, send proof)
If yes, who:

DSS Form 3800 (NOV 19) PAGE 8 Return to DSS

Are you or anyone who lives with you a fleeing felon or probation/parole violator? Yes No
If yes, who:

Have you or anyone who lives with you been found guilty of committing one of the following offenses after August 22, 1996:
• A drug-related felony? Yes No If yes, who:
• Receiving TANF (cash benefits) or SNAP benefits from two or more states at the same time? Yes No
If yes, who:
• 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:

Have you or anyone for whom you are applying received TANF or FI before? Yes No
If yes, in what state(s) were benefits received?
Do you have a South Carolina ePAY card? Yes No
Have you or your household received SNAP benefits (formerly food stamps) before? Yes No
If yes, in what state did you last receive benefits? When?
Do you have a South Carolina EBT Card? Yes No

DSS Form 3800 (NOV 19) PAGE 9 Return to DSS

Section 3: For Temporary Assistance for Needy Families Only
Absent Parent Information: Provide the following information below for each child listed in Section 2 whose mother
and/or father is not in the home. Additional information may be requested during your interview.
Absent Parent’s Name, Last Known Address and Phone No. Social Security No.

Mother
Date of Birth
Father

Employer’s Name Employer’s Address Employer’s Phone No.

Is this the child’s legal Parent?
Yes No
Child(ren) Child(ren

Absent Parent’s Name, Last Known Address and Phone No. Social Security No.

Mother
Date of Birth
Father

Employer’s Name Employer’s Address Employer’s Phone No.

Is this the child’s legal Parent?
Yes No
Child(ren) Child(ren

Absent Parent’s Name, Last Known Address and Phone No. Social Security No.

Mother
Date of Birth
Father

Employer’s Name Employer’s Address Employer’s Phone No.

Is this the child’s legal Parent?
Yes No
Child(ren) Child(ren)

Absent Parent’s Name, Last Known Address and Phone No. Social Security No.

Mother
Father Date of Birth

Employer’s Name Employer’s Address Employer’s Phone No.

Is this the child’s legal Parent?
Yes No
Child(ren) Child(ren

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, I understand that these assertions are true and will
be used in legal pleadings against the absent parent.

DSS Form 3800 (NOV 19) PAGE 10 Return to DSS

Section 4: Tell Us About Your Household Income
Are you or anyone in your household working? Yes No
If yes, who is working?

Enter GROSS pay, not take home pay below.

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

Amount Each Pay Period Before Taxes:$ Amount Each Pay Period Before Taxes:$
❑Weekly ❑ Every 2 Weeks ❑ Twice a Month ❑ Monthly ❑Weekly ❑ Every 2 Weeks ❑ Twice a Month ❑ Monthly
Hours Worked Each Week: Worked Each Week:
DATE PAY DATE PAY
RECEIVED TOTAL RECEIVED TOTAL
GROSS PAY TIPS GROSS PAY TIPS
HOURS HOURS
MO DAY YEAR MO DAY YEAR

1. 1.

2. 2.

3. 3.

4. 4.

Employer Signature Telephone No. Employer Signature Telephone No.

Printed Name: _ Printed Name: _

Is anyone in your household, aged 18-49, unable to work? Yes No

If yes, who:

Why is this person unable to work?

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

How Often Do You Get

Other Income Amount Which Family Member Gets This Income?
This Income?
Child Support $
SSI $

Social Security Benefits $

Unemployment Benefits $
Veterans Benefits $

Retirement/Pensions $
Other
(Explain) $

DSS Form 3800 (NOV 19) PAGE 11 Return to DSS

What is the total income you and your household have already received and expect to receive this month? $
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

Section 5: Tell Us About Your Household Resources

How much does the household have in cash $ , checking $ , and/or savings account(s) $ ?
For TANF, please provide the most recent account statement.

Does anyone own any cars, trucks, other assets or land/buildings other than where you live? Yes No
If yes, for TANF, please provide proof.

Section 6: Tell Us About Your Household Expenses

Rent/Mortgage: $ Lot Space Rent: $ House Taxes: $ House Insurance: $
Condominium Fees: $
Do you pay to heat or cool your home? Yes No
If yes, how do you heat or cool your home?
Does your household receive LIHEAP (Low-Income Home Energy Assistance Program)? Yes No
If you answered NO to both of the questions above, what is the amount of your monthly utilities other than phone?
Do you pay someone to take care of your child(ren)? Yes No
Do you pay someone to take care of a dependent adult? Yes No
Does anyone in your household pay child support? Yes No
If yes, how much? $ How often? Is it court ordered? Yes No
If anyone in your household is disabled or over 60, does he/she have out of pocket medical expenses over $35 each month?
Yes No

Section 7: CONSENT FOR THE RELEASE OF INFORMATION (Optional)

The Department of Social Services (DSS) keeps the information you provide confidential, but in order for other government
agencies to furnish services to you and/or members of your family it may be necessary for DSS to share some information
contained in your files with other government agencies that have confidentiality standards like those of DSS. DSS may
release information about you and/or your family with community agencies upon receipt of your written permission.

The answer to this optional question has no effect on your eligibility to participate in the SNAP and/or TANF programs. You
may cancel this consent at any time by notifying DSS in writing. The cancellation will become effective no later than 60 days
after it is received.

I grant DSS permission to release my name, address, telephone number, TANF/SNAP recipient status and benefit
issuance history to community agencies that desire to assist me with services or in-kind assistance.

I do not want DSS to release my confidential information to any community agencies.

Client’s Signature: Date:

DSS Form 3800 (NOV 19) PAGE 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 Mail 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 elections@[Link]. 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 (AUG 18)