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E. SNAP BENEFITS 1. List the name of the person who is the head of your household: ____________________________________________________ 2. An authorized representative may apply for SNAP benefits on your behalf, receive and use your SNAP benefits on your behalf, or receive copies of your program notices. If you want to name an authorized representative, please give the information below about the representative and what you want the representative to do on your behalf. Name, Address and Telephone Number of the Authorized Representative Check () each duty authorized for that person
Apply for SNAP benefits Receive correspondence Receive or use SNAP benefits
YES NO 3. Is anyone living in your home NOT included in your SNAP application? If YES, do you and everyone for whom you are applying usually purchase and prepare meals apart from these people? Or, do you intend to do so if your application for SNAP benefits is approved? Check () YES NO YES NO 4. Is anyone living in your home a roomer or boarder? If YES, list names: _____________________________ ______________________________________________________________________________________ YES NO 5. Is anyone age 60 or older OR approved to receive Medicaid because of a disability OR receiving any type of disability payment? If YES, list all current medical expenses for these people. Household Member with Medical Expense Type of Expense Amount Name of Doctor, Hospital, Pharmacy
YES NO 6. Do you have any of the following shelter expenses? If YES, list your current expenses. Check () here if these expenses are for a house you do not live in. Expense Amount Billed How Often Billed? Who is Responsible for the Bill? Rent/Mortgage
Taxes
Insurance
Electricity
Gas/Oil/Kerosene
Coal/Wood
Water/Sewage/Garbage
Telephone
Installation
6a How do you heat your home? ______________________________________________________________ YES NO 6b Do you have air conditioning in your home? YES NO 6c Did you receive energy/fuel assistance during this past year while living in your current home? YES NO 6d Are you staying temporarily in someone else’s home, an emergency shelter, welfare hotel, other halfway house, or a place not usually used for sleeping? If YES, how much does it cost to stay there during the month? _______________________________________________________________________________________ If you are staying temporarily in someone else’s home, when did you move there? ______________________
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