Page 535

COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

EXPEDITED SERVICE CHECKLIST

NAME: _____________________________________________

DATE: ______________________________________________

I. ( ) YES ( ) NO Has anyone for whom you are

applying received SNAP benefits this

month?

If YES, who: _____________________________________

where: _____________________________________

II. INCOME BEFORE DEDUCTIONS this month for everyone

in your household. Count money already received plus any

money expected to be received during this month.

Type of Income

________________________________ $____________

________________________________ $____________

III. RESOURCES for everyone in your household:

Cash on Hand

$_____________

Checking Accounts $_____________

Savings Accounts $_____________

IV. SHELTER EXPENSES this month.

Rent/Mortgage

$_____________

Utility expenses this month $_____________ Which utilities do you pay? (check all that apply)

 Heat  Lights  Telephone  Water  Electricity for Air Conditioning  Garbage  Sewer Other

V. ( ) YES ( ) NO Is anyone in your household a Migrant or

a Seasonal Farm worker?

AGENCY USE ONLY

1. ( ) YES ( ) NO Is income less than $150

AND resources $100 or less? IF YES, EXPEDITE

2. ( ) YES ( ) NO Is income plus resources less

than shelter?

Countable Income $_______________

Countable Resources $_______________

Total

$_______________

Shelter

$_______________

IF YES, EXPEDITE

NOTE: If the household is entitled to the Utility Standard,

apply the Standard to determine Shelter, unless

the household chooses to use actual shelter

costs.

FOR MIRGRANT & SEASONAL FARMWORKERS

3A. ( ) YES ( ) NO Are resources $100 or less

AND, in the next 10 days,

$25 or less is expected

from new income source?

IF YES, EXPEDITE

3B. ( ) YES ( ) NO Are resources $100 or less

AND no income is expected

from a terminated source

this month or next month?

IF YES, EXPEDITE

DETERMINATION

( ) EXPEDITED ( ) NOT EXPEDITED

Screened by:

032-03-0718-08-eng (02/2020)