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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

032-03-1120-06 eng (02/23) APPLICATION FOR DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM BENEFITS

Disaster Benefit Period

AGENCY USE ONLY

CASE NAME

FIPS CASE NUMBER ATTACHMENTS: Y or N

# ____ WORKER NAME WORKER NUMBER DATE RECEIVED

___________________ TO ___________________

INSTRUCTIONS: Complete this application honestly and to the best of your knowledge. If you give false or misleading information or withhold information to receive benefits, you may be prosecuted or referred for an Administrative Disqualification Hearing. You may also be required to repay any benefits you erroneously received. If your household knows and refuses to give the needed information, you will not be eligible to receive Disaster Supplemental Nutrition Assistance Program benefits. The information you give, including Social Security numbers, may be matched against federal, state, and local records to determine if it is accurate. In addition, this information will be used to prevent duplicate receipt of benefits from more than one social service agency at the same time, and to inquire the Department of Human Resources state employee database. At your interview, you must provide proof of your identity. You may also be required to provide proof of residence, income, and resources. Tell your worker if you want someone who is not in your household to apply for and/or pick up and/or use your Disaster SNAP benefits on your behalf.

HEAD OF HOUSEHOLD (LAST NAME, FIRST, MIDDLE/ MAIDEN, SUFFIX):

PERMANENT ADDRESS (STREET, CITY, ZIP): TEMPORARY ADDRESS (IF DIFFERENT): Telephone: AUTHORIZED REPRESENTATIVE: Written permission from the household to apply for benefits? __YES __NO Written permission from the household to access the account? ___YES NO

PART I: HOUSEHOLD SITUATION

CIRCLE ONE

YES NO 1. Were you residing in the disaster area at the time of the disaster? YES NO 2. Has your home property or self-employment property in the disaster area been damaged or destroyed by the disaster? YES NO 3. Will you be purchasing food during the Disaster Benefit Period indicated above? YES NO 4. Did your household lose food because of the disaster? YES NO 5. Has your income been delayed, reduced, or stopped because of the disaster? YES NO 6. Does your household have any cash or money in bank or other financial institution accounts that are not accessible to your household to use because of the disaster? YES NO 7. Do you or anyone in your household currently receive SNAP benefits? Name of person:____________________ From where:___________________ Amount: $__________