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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) ENTITLEMENT TO RESTORATION OF LOST BENEFITS

CASE NUMBER

DATE

LOCALITY

WORKER

 YOU ARE ENTITLED TO A RESTORATION OF BENEFITS BECAUSE YOUR PRIOR BENEFIT AMOUNT WAS INCORRECTLY CALCULATED OR YOU WERE DENIED IMPROPERLY.

TOTAL AMOUNT OWED $_____________________________ MONTH(S) RESTORATION COVERS______________________

REASON_______________________________________________________________________________________________

_______________________________________________________________________________________________________

 IF THIS BLOCK IS CHECKED, YOU WERE OVERISSUED SNAP BENEFITS, YOUR RESTORATION WAS REDUCED BY

THE AMOUNT YOU WERE OVERISSUED.

AMOUNT YOU WERE OVERISSUED $________________ AMOUNT YOU ARE ENTITLED TO RECEIVE $____________

 YOUR REQUEST FOR RESTORATION OF BENEFITS, DATED ________________________________, WAS DENIED DUE TO

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

IF YOU DO NOT AGREE WITH THIS DECISION, YOU MAY REQUEST A FAIR HEARING.

IF YOU WANT TO REQUEST A FAIR HEARING, YOU MUST DO SO WITHIN 90 DAYS FROM THE DATE OF THIS NOTICE.

FOR ADDITIONAL INFORMATION ABOUT APPEALS AND FAIR HEARINGS, PLEASE SEE THE BACK OF THIS NOTICE.

BENEFIT PROGRAM SPECIALIST TELEPHONE NUMBER FOR FREE LEGAL ADVICE CALL 1-866-534-5243

032-03-0153-15-eng (09/2024)