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MS 3830

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Volume 2 - Supplemental Nutrition Assistance Program(SNAP) MS 3830 – R. 8/1/10 – OMTL – 368 Emergency Representatives

The household can designate an emergency Authorized Representative (AR) as the need arises. The emergency AR can obtain benefits on the occasions when neither a household member nor the AR is able, due to an emergency. A separate written designation is needed each time an emergency AR is used.

When notified by the household that an emergency AR is needed, instruct the head of household or spouse to complete a statement similar to the one below. The head of household or spouse and the emergency AR sign the statement. The emergency AR brings the completed statement, plus a form of personal ID, along with the household's Electronic Benefit Transfer (EBT) card and Personal Identification Number (PIN).

I authorize ___________________________________________________

(Emergency Representative)

to use my EBT card and PIN to buy food for me.

____________________________________________________ (Signature of Head of Household or Spouse) (Date)

____________________________________________________] (Signature of Emergency Representative)