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TRANSMITTAL #1 Appendix III

City/County of DEPARTMENT OF HUMAN SERVICES

APPLICATION FOR DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (Date)

1. Type of Disaster and Date of On-set: EX: Hurricane, September 18, 2003. Include a statement that a Presidential declaration has been granted.

2. Description of the geographical area: EX: The entire county was affected by the hurricane. EX: Only the southern part of the county was affected by the flood, primarily residences in zip code 22407.

3. Status of Food Distribution: (USDA requires commercial trade networks to be operational again before approving a disaster SNAP program or an estimate given when they will be restored.) EX: Retail food outlets were closed for two days and all major grocery stores are now in operation. Point-of-sale (POS) devices are operational.

4. Needs Assessment Part A: (Statement explaining why the food needs cannot be met by the regular program and that the volume of affected households cannot be adequately served). EX: There are many citizens who have been unable to work due to the business closures from flooding. In addition, there was widespread property damage along the tributaries of the river where flash floods wiped out the community around the courthouse.

5. Needs Assessment Part B: (Provide separate estimates of the number of ongoing and new households involved in the disaster. Depending on the nature of the disaster, there may be other options available for consideration in the plan, such as automatic replacements for ongoing households.) EX: Our current participation is xxx number of households. We anticipate XXX new households needing disaster services.

6. Needs Assessment Part C: If disaster resulted in loss of food only, the plan must include: a Statement of outage duration b. Geographical limits c. Percentage of customers affected d. Indication of whether food loss alone allows household eligibility

7. Description of Residency Requirement (Does the applicant need to reside in the locality? Is a household working but not living in the affected area eligible?)

8. Application Processing Estimate: (Indicate the time frame for taking applications for the D-SNAP, including the beginning date normally not to exceed 7 days.) EX: If approval is received by October 9, we will initiate operations on October 10 and take

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