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GENERAL INFORMATION With this application, you may apply for food assistance if: • Everyone in the household is 60 years of age or older; or • All household members aged 60 or older purchase and prepare food separately from other household members; and • No member receives earnings from work.

COMPLETING THE APPLICATION If you need help completing this application, a friend or relative or your eligibility worker can help you. If you are completing this application for someone else, answer each question as if you were that person. If you need to change an answer or make a correction, write the correct information nearby and put your initials and date next to the change. If there are more than 2 people living in your home and you need more space to list everyone, tell the agency you need extra pages. If you have a disability or have difficulty with English, you may receive extra help to make sure you get the assistance or services you are eligible to receive.

FILING THE APPLICATION You may turn in a partially completed application which contains at least your name, address, and signature (or the signature of your authorized representative), but you must complete the rest of this application before your eligibility can be determined. You must also be interviewed, but you may turn in your application before your interview. You may turn in your application any time during office hours the same day as you contact your local agency. You have the right to turn in your application even if it looks like you may not be eligible for benefits.

VERIFICATION AND USE OF INFORMATION Information you give on this application, including Social Security numbers, 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) • Virginia Lottery

Any difference between the information you give and these records will be investigated. Information from these records may affect your eligibility and benefit amount. Information may be used to: • determine the correctness, accuracy, and truthfulness of the application; • verify your identity and citizenship; verify wages and salary, unemployment benefits, and unearned income, such as Social Security and Supplemental Security Income (SSI) benefits; verify quarters of coverage under Social Security for an alien, or to verify the status of aliens; • prevent receipt of benefits from more than one social service agency at the same time; • make required program changes; • allow disclosure for official examination and to law enforcement officials to assist in apprehending persons fleeing to avoid the law; or • assist in SNAP claims collection actions.

Your information may also be used or disclosed to study public benefit programs, such as SNAP.

Information regarding your race and ethnicity is not required and will not affect your eligibility or benefit amount. This information is requested to be sure that program benefits are provided without regard to race, color, or national origin.

EXPEDITED SERVICE FOR SNAP BENEFITS Your household may qualify for Expedited Service and receive SNAP benefits within 7 days if you are eligible. To qualify for Expedited Service: 1) your gross monthly income must be less than $150 and liquid resources $100 or less; 2) your monthly shelter bills must be higher than your household’s gross monthly income plus your liquid resources; or 3) someone in your household must be a migrant or seasonal farm worker with little or no income and resources.

REPORTING REQUIREMENTS You must report changes within 10 days, but no later than the 10th day of the month after the change occurs. Report these changes: • If you have lottery or gambling winnings of $4,500 or more; • If you have changes in the number of people in your household; or • If you or a member of your household start to receive money from working.

032-03-824A-01-eng (09/2024) Commonwealth of Virginia Department of Social Services Supplemental Nutrition Assistance Program (SNAP) APPLICATION FOR THE ELDERLY SIMPLIFIED APPLICATION PROJECT (ESAP) Return your completed application to: _________________ County/City DSS __________________________________ __________________________________