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It collects client identity details, contact information, household size data, and authorization for an authorized representative. The form includes accessibility communication assistance options and a Medicaid-only section about expected federal income tax filing next year and related tax questions. 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If you are deaf or hard of hearing, please call GA Relay at 1-800-255- 0135. Our services are free.  \nFor Office Use only: Date Received   Load \\#   Client ID \\#    \nDate Initiated:   Programs Initiated: 􀂅 TANF 􀂅 Food Stamps 􀂅 Medicaid  \nDoes the applicant or person renewing/applying on behalf of the applicant need assistance when communicating with us? If so check all that apply.  \n( ) TTY ( ) Braille ( ) Large Print ( ) E-mail ( ) Video Relay) ( ) Sign Language Interpreter    \n( ) Foreign Language Interpreter (specify language)   ( ) Other    \nIf you are reapplying for Food Stamps or renewing your TANF or Medicaid benefits, you can file this renewal/application form with only your name, address and signature. However, it will help us to process your application, recertification and/or renewal more quickly if you complete the entire form and provide verification of information, if it is requested. You may use this form to file a joint renewal/application for the Food Stamp/Medicaid and/or TANF program or for the Food Stamp Program (FS) only. Your Food Stamp renewal will not be terminated solely on the basis that your renewal/application for another program has been denied/terminated. We will make a separate eligibility determination for your Food Stamp renewal.  \n\n| Client Name: |  | Date of Birth: | Social Security Number: |  |\n| --- | --- | --- | --- | --- |\n| Street Address: |  |  |  |  |\n|  |  |  |  |  |\n| Mailing Address: |  |  |  |  |\n|  |  |  |  |  |\n| Main Phone Number: | Other Contact Number: |  |  | E-mail Address (optional) |\n\nPlease PRINT the name and address of the person who is reapplying for benefits in the space below:  \nI declare under penalty of perjury to the best of my knowledge and belief that the person(s) for whom I am applying/renewing benefits for is/are U.S. citizen(s) or are lawfully present in the United States. I further certify that all of the information provided on this form is true and correct to the best of my knowledge. I understand and agree that DHS and authorized Federal Agencies may verify the information I give on this form. Information may be obtained from past or present employers. I will report any change in my situation according to Food Stamp/Medicaid and/or TANF program requirements. If any information is incorrect, benefits may be reduced or denied and I may be subject to criminal prosecution or disqualified from DHS programs for knowingly providing incorrect information. I understand that I can be prosecuted if I provide false information or hide information. I understand that if I fail to tell DHS about some of my expenses at my application or renewal interview that DHS will not budget that expense in calculating the amount of my food stamp benefits.  \nSignature Date  \nWitness Signature if signed by ‘X’  \nDate  \nForm 508 (Rev. 07/14)  \n-1-  \nAuthorized Representative:  \nComplete this section only if you want someone to fill out your application/renewal, complete your interview for Food Stamps or TANF, and/or use your Food Stamp EBT card to buy food when you cannot go to the store. If you are applying for Medicaid, you can choose more than one person to apply for medical assistance on your behalf.  \nName:   Phone:    \nAddress:   Apt:   City:   State:   Zip:    \nName:   Phone:    \nAddress:   Apt:    \nCity:   State:   Zip:    \nFor Medicaid, do you want this individual to have a copy of your Medicaid card? 􀂉 Yes 􀂉 No  \nFOR MEDICAID ONLY  \nDo you expect to file a federal income tax return NEXT YEAR? (You can still apply for health insurance even if you don’t file a federal income tax return. )  \n􀂅 YES If Yes, Please answer questions a, b, and c 􀂅 NO If No, Please answer question c.  \na. Will you file jointly with a spouse? 􀂅Yes 􀂅No If yes, name of spouse:    \nb. Will you clai","cbCaipw16xKMMMQd","https://ap.wps.com/l/cbCaipw16xKMMMQd","pdf",300777,"English","# Applicant and Assistance Options\n## Programs Initiated and Communication Assistance\n## Declarations, Signature, and Witness\n# Client Identification and Contact Information\n# Authorized Representative (Optional)\n# Medicaid-Only Tax Filing Questions\n# Household Size and Verification Instructions","[{\"question\":\"What information is required to renew or apply for benefits using this form?\",\"answer\":\"The form requests the applicant’s name and address, client identity details, contact information, and household size information. It also asks for proof of income and expenses when requested.\"},{\"question\":\"Can someone else complete the application or renewal interview for me?\",\"answer\":\"Yes. The form includes an Authorized Representative section where you can enter a person’s name, phone, and address details, and specify options for Medicaid card copies where applicable.\"},{\"question\":\"What declarations and consent does the applicant provide when signing?\",\"answer\":\"By signing, the applicant declares under penalty of perjury that the information is true and correct and agrees that DHS and authorized federal agencies may verify the information. The form warns that incorrect or hidden information may lead to reduced or denied benefits and possible prosecution.\"}]","FOOD STAMP/MEDICAID/TANF Renewal Form - Form 508 (Rev. 07/14) | PDF",1789835990]