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.
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Disaster Benefit Period
Begin:__________
End:__________
Number:______________________
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Application
Date:________________
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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.
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Head of Household
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Verified
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Authorized Representative
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Permanent Home Address with
zip code
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Verified
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Temporary Address and
Telephone Number (if different)
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Phone Number:
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Mailing Address (if
different) with zip code
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County:
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PART A – HOUSEHOLD
SITUATION
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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:
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YES
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NO
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Did the disaster damage or
destroy your home or self-employment property?
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Does your household have
any additional expenses as a result of the disaster?
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Does your household plan
to buy food before {insert
end date of disaster period}?
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Did the disaster delay,
reduce or stop any of your household’s income?
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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?
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2. Are you a current
Supplemental Nutrition Assistance (Food Stamp Program)
participant? If so, State: _____________________ County:
_____________________
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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.
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PART B – HOUSEHOLD
MEMBERS (Attach paper for more space)
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PART C – INCOME
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First Name / Last Name
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Social Security No.
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Birth Date
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Sex
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Race
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Source/Type
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Amount
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PART D – RESOURCES
List
all cash your household will be able to get to during the
disaster
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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.
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AMOUNT
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AMOUNT
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Checking accounts
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Dependent care due to
disaster
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Saving accounts
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Funeral/medical expenses
due to disaster
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Cash on hand
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Moving and storage costs
due to disaster
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Temporary shelter expenses
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Cost to protect property
during disaster
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Cost to repair or replace
items for home or self-employment property
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Other disaster-related
expenses
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Food destroyed in disaster
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PART F –
CERTIFICATION AND SIGNATURE
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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: __________________
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