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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) REQUEST FOR DISASTER SNAP ASSISTANCE General Information This request for assistance is the first part of the application process for the Disaster SNAP Program. You must also complete the second part of the application process by: 1. Having an interview and 2. Signing an Application for Disaster SNAP Program Benefits Complete and Accurate Information You must give complete, accurate, and truthful information. If you give false or misleading 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 SNAP Benefits. Verification and Use of Information The information that you give, including Social Security Numbers, may be matched against Federal, State and local records to determine if it is accurate. In addition, the information will be used to prevent 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. Completing the Request for Assistance If you are applying for your own household, please enter your name and other information requested in the space provided.

You may complete this request for assistance for someone else, if you have been authorized by that person to represent them. You will need a signed and dated statement from the person for whom you are applying before you can complete the application process. If you are applying for someone else, please enter the name and information of the person for whom you are applying. In addition, please enter your name and other information in the space provided.

032-03-0663-02-eng (05/2024) Applicant Name

Date of Birth

Address Social Security Number

Telephone

Signature or Mark

Date

Authorized Representative Name Relationship to Applicant

Address Telephone

Signature or Mark

Date Your SNAP Rights The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, or marital or family status. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD).

To file a complaint of discrimination, write USDA, Director, Office of credible, Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410, or call (202) 720-5964 (voice and TDD). USDA is an equal employment provider and employer.