Attachment A- Example Client Disaster Supplemental Nutrition Assistance Application

Attachment A

Example Client Disaster Supplemental Nutrition Assistance Application

APPLICATION FOR DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE In accordance with Federal law and U.S. Department of Agriculture policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, religion, political beliefs, or disability. To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250–9410 or call (202) 720–5964 (voice and TDD). USDA is an equal opportunity provider and employer. DO NOT WRITE IN SHADED AREAS.

Disaster Benefit Period Begin:__________ End:__________ Number:______________________

Application Date:________________

INSTRUCTIONS: Complete this application honestly and to the best of your knowledge. If your household knows but refuses on purpose to give any required information, it will not be eligible to receive Disaster Supplemental Nutrition Assistance benefits. When you are interviewed, you must show identification. You must show proof that your household lived {inset “worked” if applicable to disaster} in the disaster area at the time of the disaster. You may have to verify any questionable expenses. You can authorize someone outside your household to apply for, receive, or use your Disaster Supplemental Nutrition Assistance benefits.

Head of Household

Verified

Authorized Representative

Permanent Home Address with zip code

Verified

Temporary Address and Telephone Number (if different)

Phone Number:

Mailing Address (if different) with zip code

County:

PART A – HOUSEHOLD SITUATION

1. Was your household living {inset “working” if applicable to disaster} in the disaster area at the time of the disaster? If yes, please answer the following questions:

YES

NO

Did the disaster damage or destroy your home or self-employment property?

Does your household have any additional expenses as a result of the disaster?

Does your household plan to buy food before {insert end date of disaster period}?

Did the disaster delay, reduce or stop any of your household’s income?

Does your household have any cash or money in checking or savings accounts which you cannot get to because the bank is closed due to the disaster?

2. Are you a current Supplemental Nutrition Assistance (Food Stamp Program) participant? If so, State: _____________________ County: _____________________

List the members of your household, including yourself, who were affected by the disaster who are living and eating with you. List each household member’s social security number (SSN) if available. However, applicants are not required to have or give their Social Security on this application in order to qualify for Disaster Supplemental Nutrition Assistance. Also list each household member’s date of birth, sex, race and source and amount of take-home pay. List any other income your household members have received or expect to receive while the Disaster Supplemental Nutrition Assistance Program is operating. DO NOT INCLUDE PEOPLE WHO WERE NOT PART OF YOUR HOUSEHOLD WHEN THE DISASTER HAPPENED. IF YOU ARE TEMPORARILY STAYING WITH ANOTHER HOUSEHOLD BECAUSE OF THE DISASTER, DO NOT LIST MEMBERS OF THAT HOUSEHOLD.

PART B – HOUSEHOLD MEMBERS (Attach paper for more space)

PART C – INCOME

First Name / Last Name

Social Security No.

Birth Date

Sex

Race

Source/Type

Amount

PART D – RESOURCES List all cash your household will be able to get to during the disaster

PART E – EXPENSES List disaster-caused expenses that your household paid or expects to pay during this disaster. DO NOT INCLUDE EXPENSES THAT WERE PAID OR WILL BE PAID BY SOMEONE OUTSIDE YOUR HOUSEHOLD.

AMOUNT

AMOUNT

Checking accounts

Dependent care due to disaster

Saving accounts

Funeral/medical expenses due to disaster

Cash on hand

Moving and storage costs due to disaster

Temporary shelter expenses

Cost to protect property during disaster

Cost to repair or replace items for home or self-employment property

Other disaster-related expenses

Food destroyed in disaster

PART F – CERTIFICATION AND SIGNATURE

I understand the questions on this application and the penalties for hiding or giving false information. My household is in need of immediate food assistance as a result of the disaster. I certify, under penalty of perjury, that the information I have given is correct and complete to the best of my knowledge. I also authorize the release of any information necessary to determine the correctness of my certification. I understand that if I disagree with any action taken on my case, I have the right to request a fair hearing orally or in writing. APPLICANT, AUTHORIZED REPRESENTATIVE, OR WITNESS (if signed with an X) __________________________________________________________________ DATE: __________________

PART G – PENALTY WARNING

If your household gets Supplemental Nutrition Assistance benefits, it must follow the rules listed below. We may choose your household for a Federal or State review sometime after you receive your Supplemental Nutrition Assistance benefits to make sure you were eligible for disaster aid.

DO NOT give false information or hide information to get or to continue to get Supplemental Nutrition Assistance benefits.

DO NOT give or sell Supplemental Nutrition Assistance benefits or authorization documents to anyone not authorized to use them.

DO NOT alter any Supplemental Nutrition Assistance authorization documents to get benefits you are not entitled to.

DO NOT use Supplemental Nutrition Assistance benefits to buy unauthorized items such as alcohol or tobacco.

DO NOT use another household’s Supplemental Nutrition Assistance benefits or authorization documents for your household.