Selfservice controller

**Keep in mind that you do not need to mail this print-out to your local agency.**

Thank you for using COMPASS to apply for benefits!

Mark Ostrander, your application has been submitted to Online Services on June 20, 2012 at 05:19 P.M.

If you have questions regarding your online application please contact Online Services at 1-877-423-4746.

Your application tracking number is 5035962555.

Be sure to write this number down or print this page for your records.

In your application, you have asked for these benefits:
• Food Stamps

As a next step, your worker may ask for proof of some of the things you told us in your application. This checklist will help
you gather these items. If you can't find something, your worker may be able to help you get the proof you need.

Keep in mind that this list is based only on what you told us today. There may be other items that your worker will ask you
to provide.

Proof of Identity
Proof of who you are, like a driver's license, ID card.

Social Security Number
Social Security numbers for everyone you want to receive benefits. Immigrants may potentially be eligible for benefits
without a social security number.

Proof of Citizenship or Immigration Status (Only for those seeking benefits)
Proof of citizenship such as a birth certificate, U.S. passport, hospital record. Proof of immigration status such as resident
immigration card, passport, visa, I-94, I-181, or other Department of Homeland Security (DHS) documentation.
Additional examples of Proof of Citizenship for Medicaid applicants can be found in Form 218.

Proof of Job Income
For everyone who has a job or has had a job in the last three months, you will need to prove how much money they earn
at each job they have. You can give your case worker pay stubs from employer(s) by providing at least one month or 4
weeks of pay for each week paid in the month.

COMPASS Apply For Benefits Page 1 www.compass.ga.gov

Application Summary
Here is a summary of what you told us, as well as important information about your rights and responsibilities.

Help from Others

Applying on Your Behalf
A friend or family member

Basic Information

Your Name Date of Birth Gender County
Mark A Ostrander 10/14/1963 Male Gwinnett
Received Food Stamps this month in GA or another No
state?
Visually Impaired? No
Hearing Impaired? No
Interpreter needed for interview? No
Do you and/or the applicant need assistance when
communicating with us? If so, check all that apply?
Primary Language English
If you are not registered to vote where you live now, No
would you like to apply to register
to vote here today?
Is anyone in your home a If yes, did his or her job If yes, will he or she get more than $25 from a new job
migrant or seasonal farm ended recently? or other source in the next 10 days?
worker?
No
Where You Live Mailing Address
1740 McDowell CT
Lawrenceville, GA 30044
Contact Information
Primary Phone (770) 864-5525
Alternative Phone (678) 787-1768
Work Phone
Email Address mostra1963@bellsouth.net
Best way to get in touch with you Alternative Phone
Phone Type (if Deaf or Hard of Hearing)
Best time to get in touch with you Late Afternoon

People In Your Home


Person Date of Birth Gender Marital Status
Mark A Ostrander 10/14/1963 Male Married
Age: 48 Previously Received Programs Requested
Benefits?
No Food Stamps
Is this person known by Alternative Name
any other name?
No
SSN SSN Application Date US Citizen?
419-04-8024 US Citizen
When did this person When did this person get qualified, legal status in the
come to the U.S. to live? U.S.?

Does this person have a What country is this person from?
sponsor?

If this person has an Type of refugee If other, please specify
immigrant registration
number, what is it?

Is this person a veteran or Military Service Number Veteran Status
a spouse of a veteran?
(not required for Food
Stamp eligibility)
Yes 419048024 Unknown
Resident of GA? Where does he/she live?
Yes In This Home
Ethnicity and Race
Is this person Hispanic?

White


Lisa R Ostrander 03/24/1963 Female Married
Benefits?
No Food Stamps
any other name?
No

sponsor?

number, what is it?

Stamp eligibility)
No
Yes In This Home
Ethnicity and Race
Is this person Hispanic? No

White


Randall H Kirkley 08/27/1980 Male Never Married
Benefits?
No Food Stamps
any other name?
No

sponsor?

number, what is it?

Stamp eligibility)
No
Yes In This Home
Ethnicity and Race
Is this person Hispanic? No

White

Relationship Information

Person Relationships Do they buy food and eat meals
together?
Mark is the husband of Lisa Yes
Age: 48 is the stepfather of Randall Yes
Person Relationships Do they buy food and eat meals
together?
Lisa is the mother of Randall Yes
Age: 49

Questions About the People In Your Home


Person Blind or Drug Sanctioned Food Avoiding Violating Out of
Disabled Felonies by FSET Stamp Prosecutio Parole State
Disqualific n Benefits
ation
Mark No No No No No No No
Age: 48
Lisa No No No No No No No
Age: 49
Randall No No No No No No No
Age: 31

Liquid Asset Information

Person Type Value Account Number Bank Name Other Owners
Mark Checking Account $66.41 8810842966 Sun Trust
Age: 48

Job Income Information

Person Name of Employer Address of Employer
Mark Wallace Electric
Age: 48

Job Start Date Job End Date Date of First Paycheck

Is currently on Last paycheck date Final Paycheck Amount
strike

Pay Period Amount Average Hours Hourly rate of pay
Weekly $641 32 21
Additional Comments About Your Job Is this job part of a federal or state
funded work-study program?
No

Self Employment Information

You told us that no one in your home has this kind of income, benefit, or bill.

Other Income Questions

Person Getting income from providing room and/or board?
Mark No
Age: 48
Lisa No
Age: 49
Randall No
Age: 31


Other Income Information


Housing Bills Questions

Does your household get housing or rent assistance? No
If your household gets Public Housing Assistance, are you charged with a utility
expense?

Room and Meals

Person Paying for room and meals?
Mark No
Age: 48
Lisa No
Age: 49
Randall No
Age: 31

Housing Bills Information

Rent or Lot Rent $900.00

Landlord's Information

Name Address
Chris Compton , GA
Phone Number:(770) 682-7735

Utility Bills Questions

What is your household's primary heating or cooling source? Gas And Electric
Has your household received help from Low Income Energy Assistance Program No
(LIHEAP) at your current address, during the past 12 months?

Utility Bills Information


Electricity $125.00
Natural Gas $70.00
Phone or Cell Phone Service $190.00
Sewer $35.00
Trash Removal $18.00
Water $30.00

Other Bills Questions

Person Medical Bills?
Mark Dental
Age: 48
Lisa Dental
Age: 49 Hospital Bills
Prescription Costs
Randall Hospital Bills
Age: 31

Dependent Care Bills


Child Support Details


School Enrollment Information

Person Graduation Status Enrollment Status
Earned high school equivalency or Not in school
Mark general equivalency diploma (GED)
Age: 48 Type Of School School Name Date of Graduation

Caring for a Caring for a Caring for a None of the In a federal or
child under 6 child 6 to 12 child 6 to 12 above state funded
years old? years old and years old and work-study
daycare not enrolled in program?
available? daycare?
No No No No No


Tenth Grade Not in school
Lisa Type Of School School Name Date of Graduation
Age: 49

available? daycare?
No No No No No
Earned high school equivalency or Not in school
Randall general equivalency diploma (GED)
Age: 31 Type Of School School Name Date of Graduation

available? daycare?
No No No No No


Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY THE
DEPARTMENT AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice is effective April 14, 2003. It is provided to you pursuant to provisions of the Health Insurance
Portability and Accountability Act of 1996 and related federal regulations. If you have questions about this
Notice, please contact the Legal Services Office at the address below.

The Department of Human Services is an agency of the State of Georgia responsible for numerous programs, which deal
with medical and other confidential information. Both federal and state laws establish strict requirements for most
programs regarding the disclosure of confidential information, and the Department must comply with those laws. For
situations where more stringent disclosure requirements do not apply, this Notice of Privacy Practices describes how the
Department may use and disclose your protected health information for treatment, payment, health care operations and
for certain other purposes. This notice relates only to health information. It describes your rights to access and control
your protected health information, and provides information about your right to make a complaint if you believe the
Department has improperly used or disclosed your "protected health information". Protected health information is
information that may personally identify you and relates to your past, present or future physical or mental health or
condition and related health care services. The Department is required to abide by the terms of this Notice of Privacy
Practices, and may change the terms of this notice, at any time. A new notice will be effective for all protected health
information that the Department maintains at the time of issuance. Upon request, the Department will provide you with a
revised Notice of Privacy Practices by posting copies at its facilities, publication on the Department's website, in response
to a telephone or facsimile request to the Privacy Coordinator, or in person at any facility where you receive services from
the Department.

1. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by the Department, its administrative and clinical staff and
others involved in your care and treatment for the purpose of providing health care services to you, and to assist in
obtaining payment of your health care bills.

Treatment: Your protected health information may be used to provide, coordinate, or manage your health care and any
related services, including coordination of your health care with a third party that has your permission to have access to
your protected health information, such as, for example, a health care professional who may be treating you, or to another
health care provider such as a specialist or laboratory.

Payment: Your protected health information may be used to obtain payment for your health care services. For example,
this may include activities that a health insurance plan requires before it approves or pays for health care services such
as; making a determination of eligibility or coverage, reviewing services provided to you for medical necessity, and
undertaking utilization review activities.

Health Care Operations: The Department may use or disclose your protected health information to support the business
activities of the Department, including, for example, but not limited to, quality assessment activities, employee review


activities, training, licensing, and other business activities. The Department may use a sign-in sheet at the registration
desk at any facility where services are provided. You may be asked to provide your name and other necessary
information, and you may be called by name in the waiting room when a staff member is ready to see you, and your
protected health information may be used to contact you about appointments or for other operational reasons. Your
protected health information may be shared with third party "business associates" who perform various activities that
assist us in the provision of your services.

Other Permitted or Required Uses and Disclosures with Your Authorization or Opportunity to Object

Other uses and disclosures of your protected health information will be made only with your written authorization, which
you may revoke in writing at any time, except as permitted or required by law as described below.

Other Permitted or Required Uses and Disclosures with Your Authorization or Opportunity to Object

The Department may use and disclose your protected health information in the following instances. You have the
opportunity to agree or object to the use or disclosure of all or part of your protected health information.

Unless you object, the Department may disclose protected health information for a facility directory or to a family member,
relative, or any other person you identify, information related to that person's involvement in your health care and may use
or disclose protected health information to notify or assist in notifying a family member, personal representative or other
person responsible for your care of your location, general condition or death. The Department may use or disclose your
protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate
uses and disclosures to family or other individuals involved in your health care. Objections may be made orally or in
writing.

Permitted or Required Uses and Disclosures without Your Authorization or Opportunity to Object

The Department may use or disclose your protected health information without your authorization when required to do so
by law; for public health purposes; to a person who may be at risk of contracting a communicable disease; to a health
oversight agency; to an authority authorized to receive reports of abuse or neglect; in certain legal proceedings; and for
certain law enforcement purposes. Protected health information may also be disclosed without your authorization to a
coroner, medical examiner or funeral director; for certain approved research purposes; to prevent or lessen a threat to
health or safety; and to law enforcement authorities for identification or apprehension of an individual.

Required Uses and Disclosures: Under the law, the Department must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate or determine the Department's compliance with
the requirements of the Privacy Rule at 45 CFR Sections 164.500 et. seq.

2. Your Rights under the federal Privacy Rule

If you would like to create an account so you can come back to your application later, click the Create Account button.


You have the right to inspect and copy your protected health information. Upon written request, you may inspect and
obtain a copy of protected health information about you for as long as the Department maintains the protected health
information. This information includes medical and billing records and other records the Department uses for making
medical and other decisions about you. A reasonable, cost-based fee for copying, postage and labor expense may apply.
Under federal law you may not inspect or copy information compiled in anticipation of, or for use in, a civil, criminal, or
administrative proceeding, or protected health information that is subject to a federal or state law prohibiting access to
such information.

You have the right to request restriction of your protected health information. You may ask in writing that the Department
not use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare
operations, and not to disclose protected health information to family members or friends who may be involved in your
care. Such a request must state the specific restriction requested and to whom you want the restriction to apply. The
Department is not required to agree to a restriction you request, and if the Department believes it is in your best interest to
permit use and disclosure of your protected health information, your protected health information will not be restricted,
except as required by law. If the Department does agree to the requested restriction, the Department may not use or
disclose your protected health information in violation of that restriction unless it is needed to provide emergency
treatment.

You have the right to request to receive confidential communications from us by alternative means or at an alternative
location. Upon written request, the Department will accommodate reasonable requests for alternative means for the
communication of confidential information, but may condition this accommodation upon your provision of an alternative
address or other method of contact. The Department will not request an explanation from you as to the basis for the
request.

You may have the right to request amendment of your protected health information. If the Department created your
protected health information, you may request in writing an amendment of that information for as long as it is maintained
by the Department. The Department may deny your request for an amendment, and if it does so will provide information
as to any further rights you may have with respect to such denial.

You have the right to receive an accounting of certain disclosures the Department has made of your protected health
information. This right applies only to disclosures for purposes other than treatment, payment or healthcare operations,
excluding any disclosures the Department made to you, to family members or friends involved in your care, or for national
security, intelligence or notification purposes. Upon written request, you have the right to receive legally specified
information regarding disclosures occurring after April 14, 2003, subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from the Department, upon request. All written requests regarding
your rights as set forth above should be sent to the Privacy Coordinator for the DHS Division, Office or facility which
maintains your PHI.

3. Complaints related to use or disclosure of your protected health information


You may file a complaint if you believe your health information and privacy rights have been violated. You may file a
complaint with the DHS, Division of Family and Children Services by calling 404-463-7291 or by mailing your complaint to:
DFCS HIPAA Privacy Coordinator, 2 Peachtree Street, N.W. Suite 19-244, Atlanta, Georgia 30303-3142.

*Please DO NOT send your application for services to this address*

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature.

I have read and understand this Notice of Privacy Practices.

Mark A Ostrander

June 20, 2012 at 05:19 P.M.


Electronic Signature
I have agreed to submit this application for myself and/or my family. By signing this application electronically, I certify
under penalty of perjury and false swearing that my answers are true and accurate to the best of my knowledge, including
information provided about the citizenship or immigration status for each household member applying for benefits. I also
certify that:

• I understand the questions and statements on this application.
• I have read and understand my Rights & Responsibilities.
• I understand the penalties for giving false information or breaking the rules.
• I understand that the agency may contact other persons or organizations to obtain needed proof of my eligibility and
level of benefits.
• I understand that I am not required to report reduction or loss of income, that that I may be able to get a higher Food
Stamps benefit if I do. I understand that as long as I do not report this reduction or loss in income, my Food Stamps
benefit will not increase.
• I understand that failure to report or verify any listed expenses will be seen as a statement by me that I do not want to
receive a deduction for the unreported or unverified expenses.
• I understand I can be punished by law if I do not tell the complete truth.
• I certify that all of the information provided on this application is true and correct to the best of my knowledge.

I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written
signature.
By checking this box and typing my name below, I am electronically signing my application.

Mark A Ostrander

June 20, 2012 at 05:19 P.M.


Food Stamp Rights and Responsibilities
Please read the following information carefully.

YOU HAVE THE RIGHT TO
• receive an application on the day you ask for it.
• have your application accepted when you file it.
• have an adult apply for your household if you are unable to.
• a telephone interview.
• have your EBT card and PIN within 30 days of the date you file your application, if eligible, or
• have your EBT card and PIN within 7 days of the date you file your application, if eligible for expedited services.
• receive fair treatment without regard to age, sex, race, color, handicap, religious creed, national origin, or political
beliefs.
• have a fair hearing if you disagree with any action on your case.
• examine your case file and the rules of the program.
• be notified in advance if your benefits are reduced or stopped due to a change that is not reported in writing.

YOUR RESPONSIBILITIES:
• you must answer all questions completely.
• you must sign your name to certify, under penalty of perjury, that all answers are true.
• you must provide proof that you are eligible.
• Reporting when your households total gross monthly income is more than 130% of the Federal Poverty Level for the
households size within 10 days of the end of the month that the change occurred.
• do not sell, trade, or give away your food stamp benefits.
• use food stamp benefits to buy only eligible items.
• For more information about Community Outreach Services, please visit our website
at:http://www.dfcs.dhr.georgia.gov or call 1-877-423-4746 or 404-657-3426.

In all programs, you have the right to:

• request a fair hearing in writing or in person. You have the right to be represented by a household member, legal
counsel, a relative, a friend or other spokesperson. If you are not satisfied with the action we have taken on your
case, you can request a hearing by contacting the county office where you applied for benefits or by calling 1-877-
423-4746.
• review some of the material and information in your case file. However, you may not be able to see all of the
information in the case file, such as names of people who have given us information about you or your household
members or information about any criminal prosecutions involving you or any of your household members.
• decide if you want to provide a Social Security Number (SSN), citizenship, or immigration status. Only the people
who give information to us about their SSN, citizenship, or immigration status will be eligible to receive benefits. This
information will be used to check the "Income and Eligibility Verification System" (IEVS) and other computer matches
with other agencies to verify your income and other points of eligibility. We may also give this information to other
Federal and State agencies to review and to law enforcement officials for them to use in catching people who are
running from the law. If your household has a Food Stamp or SNAP claim, the information on this application,
including the SSN, may be given to Federal and State agencies and private claims collection agencies for them to


use in collecting the claim. We will not share your information with the United States Citizenship and Immigration
Services (USCIS); however, if alien status information has been submitted on your application, this information may
be subject to verification through USCIS and may affect your household's eligibility and benefit level. We will not
deny help to people asking for help because other household members do not provide their SSN, citizenship, or
immigration status. The following federal laws and regulations: 7 U.S.C. § 2011-2036, 45 C.F.R. § 205.52, 42 C.F.R.
§ 435.910, 42 C.F.R. § 435.920, authorize DFCS to request your and your household members social security
number(s).
• decide if you want to provide information about your race and ethnicity. We collect data on race, color, and national
origin to ensure we are in compliance with Federal civil rights laws. By providing this information, you will assist us in
administering our programs in a non-discriminatory manner. Your household is not required to give us this information
and it will not affect your eligibility or benefit level.

In all programs, you are responsible for:

• giving your worker correct information and providing proof of statements needed to receive benefits. When you sign
this form, you are giving your worker permission to get information from your employer, bank, neighbor or others so
we can make sure you are receiving the correct amount of benefits.
• telling the truth at all times. If you or someone who is applying for you provides incorrect information, you may be
committing a crime, and you may go to jail.
• providing proof that you or anyone in your household applying for benefits is a U.S. citizen or eligible immigrant.
Note: Your worker will give you a list of the ways you can prove your citizenship or immigration status.
• reporting certain changes in your household situation. Each program has different reporting requirements. See the
responsibilities section for each program for things you need to report.

What Other Responsibilities Do I Have in the Food Stamp Program?
In the Food Stamp Program, you are also responsible for:

• cooperating with state and federal personnel who work for Fraud Prevention or the Office of Investigative Services
and who are doing special case reviews. If you do not cooperate and we cannot determine that you are still eligible
for Food Stamps, your case may be denied or closed.
• cooperating with Quality Control reviewers when they call or come to your home to interview you about the
information you have given your case manager. If you do not cooperate with them, your case may be denied or
closed.
• repaying benefits you should not have received.
• reporting when your household's total gross monthly income is more than 130% of the Federal Poverty Level for your
household's size. You will be given a form 339, Simplified Reporting Requirement Notice, which explains more about
this.

If you are an able-bodied adult without dependents (ABAWD), you must report when your work hours fall below 20 hours
per week or 80 hours per month.


What Are My Rights and Responsibilities for Reporting Household Expenses in the Food Stamp
Program?

In the Food Stamp Program, certain household expenses such as shelter costs, medical bills, dependant care costs, and
child support paid outside the home may affect the amount of benefits you receive. If you have heating or cooling
expenses, you may be eligible to receive the standard utility allowance. If you have only one utility expense and it is NOT
a heating or cooling expense, you may be eligible to receive a deduction for the actual expense incurred. If you want us to
consider these expenses, you are responsible for reporting and verifying them. If you fail to report or verify these
expenses, we will not use them to determine your benefit amount.

What Are the Penalties in the Food Stamp Program?

In the Food Stamp Program, there are penalties:

If you ... You will lose food benefits ...
• hide information or don't tell the truth. • for 12 months for the first offense,
• use EBT cards that belong to someone else. 24 months for the second offense,
• use food benefits to buy alcohol or tobacco. and permanently for the third
• trade or sell benefits or EBT cards. offense.
• trade or sell food benefits for drugs and were convicted prior to 8/22/96. • for 12 months for the first offense
and permanently for the second
offense.
• trade or sell food benefits for drugs and were • for 24 months for the first offense
convicted of less than $500 on or after 8/22/96. and permanently for the second
offense.
• trade or sell food benefits for drugs and were • permanently.
convicted of $500 or more on or after 8/22/96.
• trade food benefits for firearms, • permanently.
ammunition or explosives.
• give false information about where you • for 10 years.
live so you can get food stamp benefits in
more than one state.
• commit and are convicted of a felony related to • permanently.
possession, use or distribution of drugs, on or
after 8/22/96.
• flee to avoid prosecution, custody or confinement for a felony. • until you are no longer fleeing.
• violate a condition of your probation or parole. • until you are no longer a probation
or
parole violator.
Non-Discrimination Statement


In accordance with Federal law and U. S. Department of Agriculture (USDA) and U.S. Department of Health and Human
Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age,
or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or
political beliefs.

To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, S.W., Washington D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). Write
HHS, Director, Office for Civil Rights, Room 509-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call
(202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.

Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national origin,
or political or religious beliefs. To report Medicaid eligibility or provider discrimination, call the
Georgia Department of Community Health's Office of Constituent Services at (404)656-4496.

You may also file a complaint of Discrimination by contacting the DFCS Civil Rights Program, Two Peachtree Street,
N.W., Suite 19-248, Atlanta, GA 30303, or call (404) 657-3735 or fax (404) 463-3978.


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