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VERIFICATION AND USE OF INFORMATION

Information you give on this application, including Social Security numbers (SSN), may be matched against federal, state, and local records. These records include: • Virginia Employment Commission (VEC) • Department of Motor Vehicles (DMV) • Internal Revenue Service (IRS) • US Citizenship and Immigration Services (USCIS) • Social Security Administration (SSA) • Income and Eligibility Verification System IEVS)

SNAP CHANGE REPORTING

You must report changes that occur for SNAP but, what you must report is tied to how long you are determined eligible for benefits, the certification period. You must report changes that occur during the certification period within 10 days, but no later than the 10th day of the month after the change occurs.

Changes that need to be reported during the certification period for SNAP depend on the length of the certification period. “Simplified Reporting” applies to households that are eligible for SNAP benefits for five (5) months or longer. “Change Reporting” applies to households that are eligible for one (1) month to four (4) months.

INTERIM REPORT FILING

In addition to reporting changes when they occur during the SNAP certification period, Simplified Reporting households may be required to submit an Interim Report in the sixth or twelfth month. The Interim Report is used to determine the amount of SNAP benefits households will receive for the second half of the certification period. The Interim Report provides a snapshot of household circumstances that were presented at the time of application. We will ask for proof of income changes and changes in legal obligations to pay child support. If households fail to return the completed Interim Report by the fifth of the month, SNAP benefits for the seventh or thirteenth month may be delayed or closed. Assistance for filing the Interim Report is available by calling the telephone number printed on the form.

DOMESTIC VIOLENCE INFORMATION

Domestic violence information and services are available to anyone experiencing violence or abuse from their partner. If you are in immediate danger, call 911. If you would like to speak with, text or chat with someone who understands these issues or to learn about services and safety options, contact the Virginia Statewide Hotline. • Call and speak with an advocate toll-free at 1-800-838-8238. (Note: Interpreters are available for more than 200 languages via the Language Line.) • Text with an advocate at 804-793-9999. • Chat with an advocate at https://www.vadata.org/chat/. (Chat feature works best on a computer or tablet.) • Call and speak with an advocate - LGBTQ Helpline: 1-866-356-6998

BY MY SIGNATURE BELOW, I DECLARE, UNDER PENALTY OF PERJURY, THAT THE INFORMATION PRESENTED HERE IS CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I understand: • All of my responsibilities, including my responsibility to report required changes on time. • If I give false, incorrect, or incomplete information, or do not report required changes on time, I may be breaking the law and could be prosecuted. • If I helped someone complete this form so as to get benefits he or she is not entitled to, I may be breaking the law and could be prosecuted. • If I refuse to cooperate with any review of my eligibility, including reviews by Quality Assurance, my benefits may be denied until I cooperate. • If my application is for SNAP, failure to report or verify of my expenses will be seen as a statement by my household that I do not want to receive a deduction for unreported expenses.

My signature authorizes the release to this agency of all information necessary to both determine and review my eligibility. This authorization is valid for one year from the date of my signature below. I understand that this time limit does not apply to investigations regarding possible fraud.

I filled in this application myself:  Yes  No If NO, it was read back to me when complete:  Yes  No

___________________________________________

________________________________ Your Signature or Authorized Representative's Signature or Mark

Date

____________________________________________

________________________________ Witness to Mark or Interpreter

Date

Complete this section if this application was completed for the applicant by someone else.

___________________________________________ ____________________ __________________ Name of person completing application Date Relationship to applicant

Primary Telephone Number _____________________ Alternate Telephone Number _____________________

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