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State Plan Checklist - FOOD DELIVERY 8/14/2026 Page 4

[ ] Other 4. Participants who receive home food delivery: [ ] Are notified in writing of the types and quantities of food they will receive [ ] Indicate by authorized signature on FI, receipt, or signature device that supplemental foods were received [ ] Are delivered only a one-month supply of supplemental foods per delivery [ ] Other

5. Supplemental foods may be delivered: [ ] Only to the participant [ ] To the proxy [ ] To any adult at home during time of delivery [ ] To anyone at home during time of delivery [ ] Other

6. Documentation:

a. The forms verifying delivery are reconciled against vendor invoices:

Weekly Monthly Other

b. Signatures of participants who sign the receipt are compared to signatures on file: Yes No

7. Please attach a list of the names of contractors/providers that the State agency works with to provide Home Delivery services: This is not applicable for my state agency

ADDITIONAL DETAIL Food Delivery Appendix and/or Procedure Manual (citation): This is not applicable for my state agency