title: "Tennessee Benefits Access - LSC-Grade Legal Packet"

state: "TN"

category: "Benefits Access"

date: "2026-03-20"

price: "$37"

lsc_grade: true

Tennessee Benefits Access Packet

Jurisdiction-correct document templates. Not legal advice.

ELIGIBILITY CHECKLIST

Families First (TANF):

• [ ] You have a child under 18 (or 18 and in school full-time)
• [ ] Monthly income at or below: 1 person $545 / 2 people $733 / 3 people $920 / 4 people $1,108
• [ ] You are a U.S. citizen or qualified non-citizen and a Tennessee resident
• [ ] You meet work requirements (exempt if pregnant, parent of child <12 months, disabled, or DV victim)
• [ ] You have not exceeded the 60-month (5-year) lifetime maximum

SNAP (Food Assistance):

• [ ] Gross monthly income at or below 130% FPL: 1 person $1,580 / 2 people $2,137 / 3 people $2,694 / 4 people $3,250
• [ ] Assets under $2,750 (or $4,250 if 60+ or disabled)
• [ ] You are a U.S. citizen or qualified non-citizen
• [ ] You meet work requirements if age 16–59 and able-bodied

TennCare (Medicaid):

• [ ] You are a child under 19, pregnant woman, parent/caretaker with dependent children, age 65+, person with disability, or woman with breast/cervical cancer
• [ ] Income within category limits — verify at tn.gov/tenncare or call 1-855-259-0701

FORM 1: APPLICATION FOR BENEFITS (HS-0010) — BLANK TEMPLATE

INSTRUCTIONS: Complete this form to apply for SNAP, Families First (TANF), or both programs through Tennessee DHS.

`

TENNESSEE DEPARTMENT OF HUMAN SERVICES

APPLICATION FOR BENEFITS

Date: _______________

I. APPLICANT INFORMATION

1. Your Full Legal Name: ________________________________________________

1. Other Names Used (including maiden name): ________________________________________________

1. Mailing Address:

Street: ________________________________________________

City: _______________________ State: TN Zip: __________

1. Physical Address (if different from mailing):

Street: ________________________________________________

City: _______________________ State: TN Zip: __________

1. Phone Number: (_____________) Area Code - ___________

1. Email Address: ________________________________________________

1. Date of Birth: _______________

1. Social Security Number: ___-___-_____

1. Sex: [ ] Male [ ] Female [ ] Non-Binary

1. Race/Ethnicity (optional): [ ] White [ ] Black/African American [ ] Hispanic [ ] Asian [ ] American Indian [ ] Native Hawaiian [ ] Other: __________

1. Are you a U.S. citizen? [ ] Yes [ ] No

If no, what is your immigration status? ________________________________________________

1. Are any of the following true for you? (Check all that apply)

[ ] Pregnant [ ] Disabled [ ] Age 65 or older [ ] Veteran

[ ] Currently employed [ ] Self-employed [ ] Unemployed

[ ] Student [ ] Retired

II. HOUSEHOLD MEMBERS

List ALL people living with you (even if not related):

1. Household Member 1:

Name: ________________________________________________

Relationship: _____________________ DOB: _______________

SSN: ___-___-_____

[ ] Spouse [ ] Child [ ] Parent [ ] Other: __________

1. Household Member 2:

Name: ________________________________________________

Relationship: _____________________ DOB: _______________

SSN: ___-___-_____

[ ] Spouse [ ] Child [ ] Parent [ ] Other: __________

1. Household Member 3:

Name: ________________________________________________

Relationship: _____________________ DOB: _______________

SSN: ___-___-_____

[ ] Spouse [ ] Child [ ] Parent [ ] Other: __________

1. Add additional household members on separate sheet if needed.

III. BENEFITS REQUESTED

Check ALL benefits you want to apply for:

1. [ ] SNAP (Food Stamps) - Helps buy food
2. [ ] Families First (TANF) - Cash assistance for families with children
3. [ ] TennCare (Medicaid) - Health insurance
4. [ ] CoverKids - Health insurance for children
5. [ ] Other: ________________________________________________

IV. INCOME

List ALL income for your household:

1. Employment Income:

Employer: ________________________________________________

Address: ________________________________________________

Phone: (_____________) Pay Rate: $_______ per [ ] hour [ ] week [ ] month

How often paid: [ ] Weekly [ ] Biweekly [ ] Monthly [ ] Other: __________

1. Self-Employment Income:

Type of Business: ________________________________________________

Monthly Income: $______________

1. Other Income:

[ ] Unemployment Benefits: $_______ per month

[ ] Workers Comp: $______________ per month

[ ] Social Security/SSI: $_________ per month

[ ] Child Support Received: $_______ per month

[ ] Pension/Retirement: $__________ per month

[ ] Other Income: $______________ per month

TOTAL MONTHLY INCOME: $______________

V. EXPENSES

List your household's monthly expenses:

1. Rent/Mortgage: $______________
2. Utilities (electric, gas, water, phone): $______________
3. Child Care: $______________
4. Medical Expenses (not covered by insurance): $______________
5. Child Support Paid: $______________
6. Other Expenses: $______________

TOTAL MONTHLY EXPENSES: $______________

VI. ASSETS

1. Cash on Hand: $______________
2. Bank Accounts (checking, savings): $______________
3. Vehicles (year, make, model): ________________________________________________
4. Real Estate/Property: ________________________________________________
5. Other Assets: ________________________________________________

TOTAL ASSETS: $______________

VII. CERTIFICATION

I certify under penalty of perjury that:

• All information on this application is true and correct
• I will notify TDHS within 10 days of any changes in my circumstances
• I understand that providing false information may result in denial of benefits, repayment of benefits, or criminal charges
• I authorize TDHS to verify the information provided

Signature: ________________________________________________

Date: _______________

TELEPHONE INTERVIEW

TDHS will contact you for a phone interview within 10 days.

Best time to reach you: ________________

Phone number where we can reach you: (_____________) ___-___-____

`

--- PAGE BREAK ---

FORM 2: REQUEST FOR FAIR HEARING — BLANK TEMPLATE

INSTRUCTIONS: Use this form to appeal if your benefits are denied, reduced, or terminated. You must request within 90 days of the notice date.

`

TENNESSEE DEPARTMENT OF HUMAN SERVICES

REQUEST FOR FAIR HEARING

Date: _______________

TO: Tennessee Department of Human Services

Administrative Hearing Section

[YOUR COUNTY] COUNTY DHS OFFICE

FROM:

Name: ________________________________________________

Address: ________________________________________________

City, State, Zip: _______________________ TN __________

Phone: (_____________) ___-___-_____

Case Number (from notice): _______________

Program: [ ] SNAP [ ] Families First [ ] TennCare [ ] Other: __________

I REQUEST A FAIR HEARING regarding the following action:

[ ] Denial of application

[ ] Reduction of benefits

[ ] Termination of benefits

[ ] Failure to act on my application

[ ] Other: ________________________________________________

Date of notice: _______________

REASONS FOR REQUEST

I disagree with the agency's action because:

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

[ ] I request an expedited hearing because:

[ ] My SNAP benefits were terminated and I need continued benefits within the month

[ ] Other reason: ________________________________

EVIDENCE I WILL PRESENT

1. _____________________________________________________________________
2. _____________________________________________________________________
3. _____________________________________________________________________

[ ] I will need an interpreter. Language needed: ________________________________

[ ] I will need a reasonable accommodation due to disability: ________________________________

[ ] I cannot attend in person. I request: [ ] Phone hearing [ ] Video conference

WITNESSES (if any):

Name: ________________________________________________

Relationship: _____________________

Phone: (_____________) ___-___-____

CERTIFICATION

I certify under penalty of perjury that the information provided is true and correct to the best of my knowledge.

Signature: ________________________________________________

Date: _______________

`

--- PAGE BREAK ---

FORM 3: CHANGE REPORT FORM — BLANK TEMPLATE

INSTRUCTIONS: Use this form to report changes in your household circumstances within 10 days of the change.

`

TENNESSEE DEPARTMENT OF HUMAN SERVICES

CHANGE REPORT FORM

Date: _______________

Case Number: _______________

County: _______________

YOUR INFORMATION

Name: ________________________________________________

Address: ________________________________________________

Phone: (_____________) ___-___-____

CHANGES TO REPORT

HOUSEHOLD COMPOSITION

[ ] Someone moved into my household

Name: ________________________________________________

Relationship: _____________________ Date moved in: _______________

[ ] Someone moved out of my household

Name: ________________________________________________

Relationship: _____________________ Date moved out: _______________

[ ] New baby born or adopted

Name: ________________________________________________ Date of birth: _______________

INCOME CHANGES

[ ] Someone started a new job

Name: ________________________________________________

New employer: ________________________________________________

Pay rate: $_______ per [ ] hour [ ] month Date started: _______________

[ ] Someone's income changed

Name: ________________________________________________

New pay rate: $_______ per [ ] hour [ ] month Date of change: _______________

[ ] Someone lost their job

Name: ________________________________________________ Last day of work: _______________

[ ] Other income change: ________________________________

EXPENSE CHANGES

[ ] Rent or mortgage changed: Previous $______________ New $______________ Date: _______________

[ ] Child care changed: Previous $______________ New $______________ Date: _______________

ADDRESS CHANGES

[ ] I moved to a new address

New Address: ________________________________________________

City, State, Zip: _______________________ TN __________ Date moved: _______________

OTHER CHANGES

[ ] Someone in household became pregnant

Name: ________________________________________________ Due date: _______________

[ ] Other: ________________________________

SUPPORTING DOCUMENTS (check items attached):

[ ] Proof of new income [ ] Proof of job loss [ ] Proof of address change

[ ] Proof of new household member [ ] Proof of expense change

CERTIFICATION

I certify under penalty of perjury that I am reporting all changes within 10 days of when they occurred and that all information provided is true and correct.

Signature: ________________________________________________

Date: _______________

`

--- PAGE BREAK ---

FILING STEPS

1. Apply online at tdhs.service-now.com (fastest) — click "Apply for Benefits," complete all sections, upload documents, and record your confirmation number.
2. Apply in person at your county TDHS office — bring completed application and all supporting documents, request a receipt showing you applied.
3. Apply by mail or fax — download and print HS-0010, complete it, make copies of all documents, mail or fax to your county office, and keep confirmation.
4. After submitting, TDHS will call you for a phone interview within 10 days — answer the call or attend the appointment.
5. Submit any additional verification documents TDHS requests within their deadline.
6. Receive decision notice within 30 days (SNAP) or 45 days (Families First).
7. If approved, your EBT card will be mailed (SNAP) or direct deposit will be set up (Families First).
8. If denied or reduced, file FORM 2 (Request for Fair Hearing) within 90 days of the notice date.
9. Report any changes in income, address, or household composition within 10 days using FORM 3.

COURT INFORMATION

Find your county office: tn.gov/humanservices/office-locations.html — There is no fee to apply for benefits.

FILING CHECKLIST

For everyone in household:

• [ ] Social Security cards (or numbers)
• [ ] Birth certificates
• [ ] Photo ID for adults
• [ ] Proof of citizenship or immigration status

For income:

• [ ] Last 4 weeks of pay stubs
• [ ] Unemployment benefit letter
• [ ] Social Security/SSI award letter
• [ ] Child support records
• [ ] Self-employment records

For expenses:

• [ ] Rent or mortgage statement
• [ ] Utility bills (electric, gas, water)
• [ ] Child care receipts
• [ ] Medical bills (if elderly or disabled)

For resources:

• [ ] Bank statements (last 2 months)
• [ ] Vehicle registration

For fair hearing (if appealing):

• [ ] Copy of denial notice
• [ ] Request for Fair Hearing form
• [ ] Evidence supporting your appeal

STATUTE REFERENCES

Tennessee Benefits Law

Federal Law

DISCLAIMER

Jurisdiction-correct document templates. Not legal advice.

• Jurist-Diction is not a law firm and cannot provide legal advice.
• Benefits laws are complex and case-specific.
• These documents may not be appropriate for your specific situation.
• Laws change frequently. Verify current law before applying.
• Providing false information on benefit applications can result in denial, repayment, or criminal charges.

Need help? Find free legal aid at lawhelp.org or call 211.