Summary of e-Form # R402229455
Department of Social Services Signature Page
XUAN H NGUYEN
1819 6th Street, Brookings, SOUTH DAKOTA 570061606
Application Submitted Language
You are applying Benefits for the following Individuals:
Rights and Responsibilities Summary Statement and Certification of Citizenship or Alien Status
- I have agreed to submit an application by electronic means.
- I understand the questions on this application and the penalty for giving false or misleading information or breaking any
of the rules listed in the penalty warning below. I understand that I can be prosecuted if I provide false or misleading
information or documentation or hide or omit information or documentation.
- I understand and agree to provide information and documentation to prove what I have said as a condition of program
- I understand and agree that DSS may contact other persons, employers, financial institutions or organizations to obtain
the necessary proof of my eligibility and to determine my level of benefits.
- I certify, under penalty of perjury, that all my answers are true, correct and complete to the best of my knowledge,
including information about the citizenship or alien status of each household member applying for benefits.
- I understand that an electronic signature has the same legal effect and enforceability as a written signature on an
Signature of applicant or person applying for applicant