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VIRGINIA DEPARTMENT OF SOCIAL SERVICES D-SNAP

10/24 VOLUME V, PART XX, APPENDIX I PAGE 9

Application For Disaster Supplemental Nutrition Assistance Program Benefits

Form Number – 032-03-1120

Purpose of Form – To record a household’s request for disaster benefit assistance and provide information about the household’s circumstances to determine eligibility. To serve as a paper back-up for the automated disaster system.

Number of Copies – One.

Disposition of Form – The application must be completed by the household or on behalf of the household by an authorized representative. An authorized representative must have written permission from an adult member of the household to file the application. The application must be filed in a disaster case record and retained for a minimum of three years.

Instructions For Preparation of The Form – The Disaster Benefit Period will be pre-printed on the form in four different places before reproduction of it. The BPS must complete the Agency Use Section on page 1, with identifying information. Note whether there are attachments (e.g., the household needed an additional sheet to list more than 5 household members) by circling Y or N in the Attachments block and show how many pages are attached.

The household or its authorized representative must complete and sign the application. If any information needs to be changed after it has been entered, the applicant or the authorized representative must initial and date the changes.

The Agency Worker must sign and date the application on page 3 underneath the client’s or authorized representative’s signature. The worker must complete page 4, with the eligibility documentation and determination of benefits if the automated system is not available.

TRANSMITTAL #35