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Fill Out Your Ga 508 Form

The GA 508 form is a renewal application used by the Georgia Department of Human Services for various support programs such as Food Stamps, Medicaid, and TANF. Completing this form is essential for individuals looking to reapply or renew their benefits, enabling them to provide necessary information efficiently. Click the button below to begin the process of filling out the form!

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The GA 508 form is a critical document for Georgia residents seeking assistance through various state programs such as Food Stamps, Medicaid, and Temporary Assistance for Needy Families (TANF). Designed for renewals or new applications, this form streamlines the process by allowing individuals to submit their requests with only essential information, including their name, address, and signature. However, completing the entire form along with any requested verification can accelerate the processing of the application. Importantly, submitters should note that an application for one program will not jeopardize their Food Stamp renewal, ensuring that applicants can receive the necessary support regardless of the outcomes of other programs. The form also accommodates various communication preferences and offers assistance for individuals with disabilities, emphasizing the commitment to inclusivity. To ensure accuracy and compliance, applicants must provide information about their citizenship status, Social Security numbers, and household income, while being fully aware of the consequences of incorrect filings. The integrity of the application hinges on truthful disclosures, as any misrepresentation can lead to penalties or disqualification from benefits. Furthermore, provisions are included for authorized representatives to assist with the application process, fostering accessibility for those who may need additional support.

Ga 508 Example

Georgia Department of Human Services

FOOD STAMP/MEDICAID/TANF Renewal Form

If you need help reading or completing this document or need help communicating with us, ask us or

call 1-877-423-4746. Our services, including interpreters, are free. If you are deaf, hard-of-hearing, deaf-blind or have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay).

For Office Use only: Date Received Load #		Client ID # _____________Date Initiated_________________
Programs Initiated:  TANF  Food Stamps  Medicaid

If 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/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.

Please PRINT the name and address of the person who is reapplying for benefits in the space below:

Client Name:		Date of Birth:	Social Security Number:

Street Address:


Mailing Address:


Main Phone Number:		Other Contact Number:	Email Address:
			(Optional)

E-mail Communication Yes___ or No___	(optional)	Texting: Yes__ or No__(optional)

What is your Preferred Language?		If an interview is required, will you
		need an interpreter?	Yes ____ or No ____

Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):

Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes__ No ___

(If yes, please describe the reasonable modification or Communication Assistance that you are requesting):

Sign Language interpreter ___; TTY ____; Large Print ____; Electronic communication (email) ____; Braille ____; Video

Relay ___; Cued Speech Interpreter___ ; Oral Interpreter ___; Tactile Interpreter ___; Telephone call reminder of program deadlines ___; Telephonic signature (if applicable) ___; Face-to-face interview (home visit) ___; Other:_______

Do you need this Reasonable Modification or Communication Assistance one-time ___ or ongoing ___? If possible, briefly explain when and how long you need this modification or assistance?

__________________________________________________________________________________________

Form 508 (Rev. 09/20)

- 1 -

I declare under penalty of perjury to the best of my knowledge and belief that the person(s) for whom I am applying for benefits is/are U.S. citizen(s) or are noncitizen(s) lawfully present in the United States. I further certify that all of the information provided on this application is true and correct to the best of my knowledge. I understand and agree that DHS-DFCS, DCH and authorized Federal Agencies may verify the information I give on this application. Information may be obtained from past or present employers. I understand that my information will be used to track wage information and my participation in work activities.

I will report any change in my situation according to Food Stamp/Medicaid and/or TANF program requirements. I will also report If anyone in my household receives lottery or gambling winnings, gross amount of $3500 or more (before taxes or other amounts are withheld). I will report these winnings within 10 days from the end of the month in which my household receives the winnings. I understand if any information is incorrect, my benefits may be reduced or denied, and I may be subject to criminal prosecution or disqualified from DHS-DFCS 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-DFCS about some of my expenses at my application or renewal interview and/or fail to verify them that DHS-DFCS will not budget that expense in calculating the amount of my Food Stamp benefits.

Signature:

Date

Witness Signature if signed by ‘X’

Date

Form 508 (Rev. 09/20)

- 2 -

Authorized Representative:

Complete 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.


Name 1: ____________________________________________		Phone:	_________________________
Address: ____________________________________________		Apt:	_____________
City:	____________________________________________	State:	______________ Zip: ___________

Preferred Language: __________________________________		Is an interpreter needed? Yes ____ or		No ____
Name 2: ____________________________________________		Phone:	_________________________
Address: ____________________________________________		Apt:	_____________
City:	____________________________________________	State:	______________ Zip: ___________

Preferred Language: __________________________________		Is an interpreter needed? Yes ____ or		No ____
For Medicaid, do you want this individual to have a copy of your Medicaid card? ❑ Yes ❑ No

Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance for Authorized Representatives (if applicable):

Does the authorized representative have a disability that will require a Reasonable Modification or Communication Assistance? Yes__ No ___ (If yes, please describe the reasonable modification or Communication Assistance that you are requesting):

Sign Language interpreter ___; TTY ____; Large Print ____; Electronic communication (email) ____; Braille ____;

Video Relay ___; Cued Speech Interpreter___ ; Oral Interpreter ___; Tactile Interpreter ___; Telephone call reminder of program deadlines ___; Telephonic signature (if applicable) ___; Face-to-face interview (home visit) ___; Other:_______

Does the authorized representative need this Reasonable Modification or Communication Assistance one-time ___ or ongoing ___? If possible, briefly explain when and how long you need this modification or assistance? __________________________________________________________________________________

FOR MEDICAID ONLY:

Do 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.)

 YES If Yes, Please answer questions a, b, and c		 NO If No, Please answer question c.
a. Will you file jointly with a spouse? Yes No If yes, name of spouse:
b. Will you claim any dependents on your tax return? Yes		No
If yes, list name(s) of dependents: _

c. Will you be claimed as a dependent on someone's tax return? Yes No If yes, list the name of the tax filer: ________________________________

Form 508 (Rev. 09/20)

- 3 -

If you need help reading or completing this document or need help communicating with us, ask us or call 1-877-423-4746. Our services, including interpreters, are free. If you are deaf, hard-of-hearing, deaf-blind or have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay).

COMMUNITY OUTREACH SERVICES:

For more information about other DHS services, please visit our website at www.dfcs.georgia.gov or call 1-877-423- 4746.

Please answer all questions and provide proof of all income and any expenses as requested.

CITIZENSHIP IMMIGRATION STATUS AND SOCIAL SECURITY NUMBERS:

Please fill out the chart below about the applicant and all household members. The following federal laws and regulations: The Food and Nutrition Act of 2008, 7 U.S.C. § 2011-2036, 7. C.F.R. § 273.2, 45 C.F.R.

§205.52, 42 C.F.R. § 435.910, and 42 C.F.R. § 435.920, authorize DFCS to request you and your household members social security number(s). Anyone who is living in your household and is not applying for benefits may be treated as a non-applicant. Non-applicants do not have to give us information about their social security number, citizenship, or immigration status and are not eligible for benefits. Other household members may still be able to receive benefits, if they are otherwise eligible. If you want us to decide whether any household members are

eligible for benefits, you will still need to tell us about their citizenship or immigration status and give us their social

security number (SSN). You will still need to tell us about their income and resources to determine the eligibility and

benefit level of the household. We will not report any non-applicant household members to the United States

Citizenship and Immigration Services (USCIS) Systematic Alien Verification for Entitlements (SAVE) system if they

do not give us their citizenship or immigration status. However, if immigration status information has been submitted

on your application, this information may be subject to verification through the SAVE system and may affect the

household’s eligibility and benefit level. We will match your information with other Federal, state, and local agencies

to verify your income and eligibility. This information may also be given to law enforcement officials to use to catch

people who are running from the law. If your household has a Food Stamp claim, the information on this application,

including 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 deny benefits to

applicant household members because other household members

fail to provide their SSN, citizenship, or immigration status. If you are applying for emergency medical services only,

you do not have to provide your SSN or information about your immigration status.

Ethnicity

youArea U.S citizen, immigrantqualified or in satisfactorya immigrationstatus? (Applicantsonly) (Y/N)

theDoesmother of this livechildin the home? (Y/N)

theDoesfather of this livechildin the home? (Y/N)

wantyouDo Medicaid? (Y/N)

Hispanic

Social

Security

Latino?

Race

Sex

Date

Relationship

Number

First Name

Last Name

(Optional)

M/F

Of Birth

To You

(Applicants only)

Y/N

SELF

Y/N

Race Codes (Choose all that apply):
AI – American Indian or Alaska Native	AS – Asian	BL – Black or African American
HP – Native Hawaiian or Other Pacific Islander	WH – White

By providing Race/Ethnicity 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. However, if you do not provide this information, visual identification of race and ethnicity will be made during the first face-to-face interview.

Form 508 (Rev. 09/20)

- 4 -

For Medicaid only:

Was anyone in your household in Foster Care at age 18? ☐Yes ☐No


If you have tax dependents that do not live in the home with you, please list below.
Name:		Social Security Number_			Sex: M F (please circle
Name:		Social Security Number_
one)	Date of Birth:			Citizenship:

Relationship to you:			(Please add additional pages as needed)

For Food Stamp Program only - DISQUALIFICATIONS:

(1)Have you or any household member been convicted of giving false information about where they live and who they

are to get multiple FS benefits in more than one area after 8/22/96?		Yes  No 
If yes, Who:	Where:		When:

(2)Do you or any household member have a felony conviction because of behavior related to the possession, use or distribution of a controlled substance after 8/22/96? Yes  No 


If yes, Who:		When:
Date of offense:	Date of Conviction:
Does this person have 1st Offender Status?	Yes  No 

a)Are you in compliance with any terms of probation related to any sentence received as a result of a drug felony conviction? (For Food Stamps only) ❑Yes ❑ No

b)Are you in compliance with the terms of parole related to any sentence received as a result of a drug felony conviction? (For Food Stamps only) ❑Yes ❑ No

c)Have you successfully completed all the terms of probation or parole related to any drug related conviction? (For Food Stamps only) ❑Yes ❑ No

(3) Is anyone trying to avoid prosecution or jail for a felony?Yes		No
If yes, who
(4) Is anyone violating conditions of probation or parole?		Yes  No 
If yes, who

(5)Have you or any household member been convicted of trading SNAP benefits for drugs after 8/22/96? Yes  No 

If yes, who;

when:

(6)Have you or any household member been convicted of buying or selling SNAP benefits over $500 after 8/22/96?

Yes  No 
If yes, who;	when:

(7)Have you or any household member been convicted of trading SNAP benefits for guns, ammunition or explosives after 8/22/96? Yes  No 

If yes, who;		when:
(8) Have you or any household member received lottery or gambling winnings?				❑ Yes ❑ No

If yes, who: _____________________________________when: ___________________________________

Amount received: ________________________________

For the TANF Program only - DISQUALIFICATIONS

(1) Has anyone been convicted of a violent felony?		Yes  No 
If yes, who:

(2)Has anyone been convicted on or after January 1997 of misrepresenting their residency in order to receive TANF

benefits in multiple states?		Yes  No 
If yes, who:
Form 508 (Rev. 09/20)		- 5 -

(3)Has anyone been convicted of using the TANF cash assistance or TANF debit MasterCard at prohibited places listed below: liquor stores, casinos, poker rooms, adult entertainment business, bail bonds, night clubs/salons/taverns, bingo halls, race tracks, gun/ammunition stores, cruise ships, psychic readers, smoking shops, tattoo/piercing shops, and

spa/massage salons.			Yes  No 
If yes, who:		when:

Food Stamps and TANF only:

STUDENTS IN HIGHER EDUCATION: Is anyone in your household enrolled at least half-time in a college, university, vocational or technical school? Yes  No  If yes, who:

School Name:		Grade/Status	_Graduation date:

Is the student employed? Yes  No  Enrolled in work study?			Yes  No 
If yes, hours worked per week	(Please complete the employment section below as well.)

For Medicaid and TANF Only:

Is anyone in your household pregnant?

Yes  No  Number of expected births:Name of pregnant woman: __________________________________

Baby’s Due Date: _____________ Unborn baby’s father’s Name: _____________________________________________

Father’s address: ___________________________________________________________________________________

_________________________________________________________________________________________________

MEDICAL:

For Medicaid Only:

Does anyone in the household have any unpaid medical bills? Yes  No 

If yes, please send the unpaid bills if you have a Medicaid case.

For Food Stamps Only:

Does anyone age 60 or older or disabled have medical expenses? Yes  No 

Did your medical expenses such as Medicare premiums, prescription drug cost, or hospital bills change? Yes  No 

If yes, list expenses on chart below. Attach bills, prescription drugs for most recent month(s).

	Type of Expense	Amou		Will
Household Member Billed	Type of Expense	Amou	Date of Bill	Insurance
Household Member Billed	(Doctor, Hospital,	nt	Date of Bill	Insurance
	(Doctor, Hospital,	nt		Pay?
	Prescription)	Owed		Pay?
	Prescription)	Owed		Yes/No
				Yes/No

Does anyone 60 years of age or older or disabled have medical expenses for transportation? Yes  No 

If yes, please provide the information below. If you are receiving Medicaid, provide proof:

Purpose of the trip (doctor or hospital visit; pharmacy pick- up)

Total miles driven:

Cost of taxi, bus, parking or lodging:

Does someone else pay any of these medical expenses for you? Yes  No 

If yes, please provide information below:

Which expense is paid?		Who pays the expense?

To whom does this person pay the bills?		Address:

Form 508 (Rev. 09/20)	- 6 -

For Medicaid only

OTHER HEALTH COVERAGE

Is anyone enrolled in health insurance now from the following?

 Georgia Department of Human Services Medicaid

 PeachCare for Kids

 Medicare

VA Healthcare Programs  TRICARE (Don’t check if you have direct care or Line of Duty)

 Employer Insurance: Name of Insurance_					Policy Number
 Other: Name of Insurance			Policy Number

Do you have any health insurance other than Medicaid? Yes  No  If yes, send us a copy of your insurance card.

RESOURCES:

(Not needed for MAGI Medicaid): Does any person in your household have any of the following resources? Yes  No (If yes provide the information below. If you are receiving Aged, Blind or Disabled Medicaid (other than Medicare Savings Plans such as QMB, SLMB or QI-1 only) provide proof.

		Account/Policy #
		(Do not complete
Resource Type	Owner	If your	Value	Name of Bank, Insurance Company etc.
Resource Type	Owner	account/policy #	Value	Name of Bank, Insurance Company etc.
		account/policy #
		is the same as
		your SSN)
Cash

Checking/Savings

Credit Union

Annuities

Stocks or Bonds

Safe Deposit Box

Retirement Account