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COMMONWEALTH OF VIRGINIA Case Number _________________ DEPARTMENT OF SOCIAL SERVICES Date Received ________________

ELDERLY SIMPLIFIED APPLICATION PROJECT (ESAP) RECERTIFICATION APPLICATION

This is an application to renew your eligibility for benefits. You may bring this application to the local Department of Social Services office or mail it to the local Department of Social Services office. You may also apply online for renewal for SNAP at https://commonhelp.virginia.gov/access/.

A. HOUSEHOLD 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

In what city or county do you live?

E-mail Address

Primary Telephone Number

Alternate Telephone Number 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 _____________________________________

B. Household/Unit Members. List everyone who lives with you who. Name Date of Birth Relationship to you

List information for any new people who moved into your home after you last applied for SNAP benefits. Name: Name: Date of Birth:

Sex: Date of Birth:

Sex: Relationship: Relationship: *Social Security Number: *Social Security Number: *Social Security Numbers are used to check computer systems before new members may be added to the case: C. Resources. List the balances of any bank accounts, cash, individual retirement accounts, 401K, 403B, money market funds, or similar accounts, etc. What? Where? Amounts

D. Lottery/Gambling Winnings Has anyone received or expect to receive winnings of $4,500 or more from lottery or gambling?  Yes  No If YES, please explain and send proof. E. Unearned Income. List any income received from Social Security, unemployment, pensions, disability, support or similar sources. Source Amount Source Amount

Is there a new source of income from Social Security, unemployment, pensions, disability, support or a similar source?  Yes  No If YES, please send proof. What is the new source and amount?

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Official source

COMMONWEALTH OF VIRGINIA Case Number _________________ DEPARTMENT OF SOCIAL SERVICES Date Received ________________

ELDERLY SIMPLIFIED APPLICATION PROJECT (ESAP) RECERTIFICATION APPLICATION

A. HOUSEHOLD 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

In what city or county do you live?

E-mail Address

Primary Telephone Number

B. Household/Unit Members. List everyone who lives with you who. Name Date of Birth Relationship to you

List information for any new people who moved into your home after you last applied for SNAP benefits. Name: Name: Date of Birth:

Sex: Date of Birth:

Is there a new source of income from Social Security, unemployment, pensions, disability, support or a similar source?  Yes  No If YES, please send proof. What is the new source and amount?