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A. APPLICANT INFORMATION. Enter your Contact Information.

Your Name (last, first, middle initial)

Your Street Address (include apartment number)

City, State, ZIP

Your Mailing Address (if different from your street address)

City, State, ZIP

Email Address

Primary Telephone Number Alternate Telephone Number

What is the primary language spoken in your household? Primary Method of Correspondence You may receive either text or email messages notifying you that some notices about your benefits may be accessed electronically through CommonHelp (www.CommonHelp.Virginia.gov). List either a cell telephone number or an email address. If you do not choose to be notified by text or email, you will receive all written correspondence through the U.S. mail.  Text  Email Cell Phone Number ________________________ Email Address __________________________________  YES  NO 1. Have you or anyone for whom you are applying ever applied for, or received, or are currently receiving SNAP benefits from a social services agency? If YES, enter the information below. When? __________________________ From What County, City, or State? ______________________________  YES  NO 2. Have you or anyone for whom you are applying ever been convicted of making false or misleading statements about your identity or address to receive SNAP benefits in two or more states at the same time? If YES, give date and place of conviction.________________________________________________________________________

 YES  NO 3. Have you or anyone for whom you are applying ever been disqualified from participating in SNAP? If YES, give date and place of all disqualifications._____________________________________________________________

 YES  NO 4. Are you or anyone for whom you are applying in violation of parole or probation or fleeing capture to avoid prosecution or punishment of a felony? If YES, explain _____________________________________________

 YES  NO 5. Have you or anyone for whom you are applying ever been convicted as an adult on or after February 8, 2014 for the following: i. Aggravated sexual abuse under Title 18 United States Code (USC), Section 2241 or a similar state offense?  YES  NO j. Murder under Title 18 USC, Section 1111 or a similar state offense?  YES  NO k. An offense under Title 18 USC, Chapter 110 (sexual exploitation and other abuse of children) or a similar state offense?  YES  NO l. A federal or state offense involving sexual assault, as defined in Section 40002(a) of the Violence Against Women Act of 1994 (42 USC 13925(a)) ?  YES  NO If YES to any of the above, are you in compliance with the terms of the sentence?  YES  NO

6. You may appoint someone to 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 a representative, please give the information below

Name, Address and Telephone Number of the Authorized Representative Check () each duty authorized for that person

 Apply for SNAP benefits  Receive correspondence  Access or use SNAP benefits

032-03-824A-01-eng (09/2024) Commonwealth of Virginia Department of Social Services Supplemental Nutrition Assistance Program (SNAP)

APPLICATION FOR THE ELDERLY Return your completed application to: _________________ County/City DSS __________________________________ __________________________________