Signature page
 
  I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury and false swearing that my answers are correct and complete to the best of my knowledge, including information provided about the citizenship or alien 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 the legal information.
  • 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.
  • For Food Assistance, I understand that I am not required to report a reduction or loss of income, but that I may be able to get more benefits if I do. I understand that as long as I do not report a reduction or loss of income, my benefits 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 that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
  •  
     Step 1. Check the box below
     Step 2. Type in your name
     First name  Middle initial  Last name  Suffix
     
     I have signed this application as an authorized representative on behalf of the applicant.
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