(Applicant/Representative) Must sign the screening page of the Request for Cash Assistance - Medical Assistance - SNAP (Form 2378C). This form is also known as the Combined Application Form (CAF).

(FCRC) Print the interview CAF for the applicant's review and signature at the completion of the eligibility interview.

Document any changes in the applicant's statements between the interview and final CAF in the write-up section (CAF Screen 32B) before revised textsaving the final CAF.

When changes are made to the screener or final CAF, reprint the changed page and insert the new page in place of the original in the proper sequence of the printed CAF. new textWhen changes are made to the final CAF, save a new copy to Content Management.

(Applicant/Representative) Must sign the rights and responsibilities page before the application can be approved.

(FCRC) revised textInclude the rights and responsibilities and signature pages of the interview CAF in the paper record.  Keep the screening CAF, the rights and responsibilities and signature pages of the interview CAF.revised textIf applicable, properly dispose of the rest of the interview CAF.

Do not dispose of any manual applications (e.g., Form 2378B, Form 2378BS, or Form 2378H) or attachments to applications (e.g., Form 2781 or Form 3162).

For a denial action, do not require a signature on the rights and responsibilities page. deleted text

DHS Web Applications

(Applicant/Representative) For cash and medical applications, must sign the rights and responsibilities page before the application can be approved.

(FCRC) Can print and send the Web signature page to the customer with a 267 (The Web Application Signature Page for SNAP, Medical or Cash is available in English and Spanish in Smart Forms).

(Applicant/Representative/Outreach Partner) To satisfy the cash and medical signature requirements, a customer may sign, date and submit the signature page (currently page 11) of Form 2378B instead of the Web Application Signature Page.

 (FCRC) Accepts the signed and dated 2378B signature page in lieu of the Web Application Signature Page. Files the signature page in the application section of the case record.

(Applicant/Representative) For SNAP, will use the electronic signature. Do not deny SNAP applications for failure to provide a SNAP signature page when they filed a web application, except for the following:

In those instances when a web application is received from one applicant but others in the applicant household are entitled to receive SNAP on their own case under a different payee, request a SNAP signature page for the household with the different payee. Register a separate 08 case using the web application date. If they fail to provide then deny using the TAR E3.

Example: 65 year old Mr. Z applies for medical and SNAP for himself, his 35 year old daughter, and his 16 year old grand daughter. At the SNAP interview you learn that Mr. Z does not buy and prepare food with his daughter and grand daughter. Register a separate 08 case for Mr. Z's daughter and grand daughter using the web application date. Schedule a SNAP interview with Mr. Z's daughter and request a signed SNAP signature page.

(FCRC) File the rights and responsibilities and signature pages in the application section of the case record.  Do not print the web application for inclusion in the paper case record. The record of the application is available electronically in Caseworker Tools.

HFS All Kids and FamilyCare Online Application

The applicant must sign and send the Read and Sign page to the All Kids Unit before the application can be approved. The online application and the signed signature page may arrive on different days.

The online application creates a Request for Additional Information (Form 267EW) that includes a request for the signature page. The due date is 10 calendar days from the date the application is submitted. If the 10th day falls on a non-work day, the due date is the first workday following the 10th calendar day. 

The applicant has the choice to print Form 267EW and the signature page or have these forms mailed to them. If the applicant chooses to print the forms and confirms that the forms have printed, no additional Form 267EW is sent.

If a signed signature page is not received by the due date, deny the application using TAR E3 (Applicant failed to provide signature page).

revised textThe final CAF is saved to Content Management. revised textThe signature page is kept in the case record in place of the actual application. A copy of the electronically submitted application is available if needed for appeal and QC review purposes.

To receive a TAP payment, AKAAs are required to fax the signature page as well as all needed proofs within 24 hours of submitting the application electronically.

FCRC Responsibilities

FCRCs do not receive the All Kids and FamilyCare Online Application electronically. However, the applicant may choose to print it and submit the paper application to the FCRC rather than submitting it electronically. These applications can be identified by the 14-digit household ID number printed in the upper right-hand corner of each page.

If an FCRC receives a paper copy of this application (Form 2378KC) with a signature, treat the application as any other mail-in application. Do not register the application if a signed signature page is not included or the application is pending with the All Kids Unit. See WAG 02-05-03 for procedures about registration of mail-in applications.