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COMMONWEALTH OF VIRGINIA VDSS DISASTER SYSTEM ACCESS REQUEST FORM DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM

The following information will be used to grant access to the Disaster System. This document must be retained at the locality for a period of five years. Note: This access will be removed after the disaster period ends.

Existing VA EBT User ID

Existing User Profile #

User’s Full Name:

Position/Title:

Phone # with area code

Agency/Division

FIPS:

Additional FIPS required:

Acknowledgment:

Inappropriate access to or use of Disaster Food Stamp System and or computer application/systems is a violation of the Department’s Security Policy and may result in the Department initiating administrative and/or criminal action against the responsible party. By signing I acknowledge that the password and other access devices are my responsibility to safeguard.

User Signature

Date:

Approval:

Supervisor’s Signature

Date:

Director/Designee’s Signature

Date:

(Agency Security Officer Use Only)

Additional FIPS

Agency Security Officer Signature / Date:

Form retained by Agency Security Officer for a period of 5 years Created 08/08/05