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COMMONWEALTH OF VIRGINIA Case Number _________________

Date Received ________________

RENEWAL APPLICATION FOR AUXILIARY GRANT (AG), SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP), AND TEMPORARY ASSISTANCE FOR NEEDY FAMILIES (TANF)

This is an application to renew your eligibility for benefits. You may bring this application to the local Department of Social Services office or mail it to the local Department of Social Services office. You may also apply online for renewal for SNAP or TANF at https://commonhelp.virginia.gov/access/.

A. HOUSEHOLD INFORMATION 1. Your Contact Information

Your Name (last, first, middle initial)

Your Street Address (include apartment number)

City, State, ZIP

Your Mailing Address (if different from your street address)

City, State, ZIP

In what city or county do you live?

E-mail Address

Primary Telephone Number

Alternate Telephone Number Primary Method of Correspondence If you would like to receive either text or email messages notifying you that some notices about your benefits may be accessed electronically through CommonHelp (www.CommonHelp.Virginia.gov), select one of the choices below. List either a cell telephone number or an email address. Once you choose a preferred electronic method of correspondence, it will be used for all programs on the case for which you have applied. If you do not choose to be notified by text or email, you will receive all written correspondence through the U.S. mail. If you are completing this application on behalf of another individual as an authorized representative, all correspondence to you will be mailed. The applicant may contact the local department of social services to learn how to change the method of correspondence.  Text  Email Cell Phone Number ________________________ Email Address _____________________________________

2. Household Composition: This section includes information about everyone living in your home, even if you are not applying for that person. You may leave the Social Security Number blank if you are not applying for assistance for the person. 1

Self

Name (last, first, middle initial)

Relationship to You

Birth Date (mm-dd-yyyy)

Social Security Number:_________________________

City, State, Country of Birth:_____________________________ Gender:  Male  Female

Are you a U.S. citizen?  Yes  No Marital Status:  Married  Never Married

If No, immigration status: ____________________________  Separated  Divorced  Widowed

US Residency Date: __/____/____ Highest Grade Completed:____

Alien Registration Number:_________________________ School Name if a Student: _______________________

Are you disabled or pregnant?  Yes  No Are you a veteran or dependent?  Yes  No :

Are you temporarily living away from home?  Yes  No Program(s) Requested:

Date Left___/___/_____ Expected Return Date___/____/____  None  AG  SNAP  TANF

Reason for being away: Providing the following information is voluntary and will not affect eligibility. Please check all that apply. Ethnicity:  Hispanic/Latino  Not Hispanic/Latino Racial Heritage:  White  Black/African American  Asian  Asian & Black/African American  Asian & White

 American Indian/Alaskan Native  Black/African American & White  American Indian/Alaskan Native & White

 Native Hawaiian/Other Pacific Islander  American Indian/Alaskan Native & Black  Other/Unknown

032-03-729A-20-eng (09/2024)