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February 1, 2014
Supplemental Nutrition Assistance Program Manual - Volume V
Transmittal #14
This transmittal contains changes, clarifications and revisions of guidelines for the
Supplemental Nutrition Assistance Program (SNAP).
Federal regulations were issued in August 2013 that amended procedures for issuing
Electronic Benefits Card for SNAP benefits. These regulations require that replacement
cards must be available within two business days once a cardholder advises of the
need for a replacement card. These regulations also amend the trafficking definition to
include attempts to buy or sell EBT cards.
The provisions of this transmittal are effective March 1, 2014 for SNAP actions taken on
or after that date.
The certification manual and this transmittal are available at
https://jupiter.dss.state.va.us/FoodStampManual/mainpage.jsp.
Changes are noted for the following sections:
_____________________________________________________________________
Chapter
Significant Changes
_____________________________________________________________________
Definitions
Pages 3-5
The intentional program violation definition was expanded to
include the use of benefits to pay for food bought on credit.
The trafficking definition was expanded to include the attempt to
buy, sell, or steal SNAP EBT cards, personal identification
numbers, (PIN) or obtain benefits with a manual voucher and
signature.
Part I
Pages 1-2
The benefit issuance and use chapter was reformatted to address
items that must be reviewed with the household during the
801 East Main Street · Richmond VA · 23219-2901
http://www.dss.virginia.gov · 804-726-7000 · TDD 800-828-1120
-2_____________________________________________________________________
Chapter
Significant Changes
_____________________________________________________________________
certification interview or other agency contact.
Part II
Pages 7-8
Appendix II
Pages 1-4
Part VII
Appendix I
Pages 1-2
Part XV
Appendix I
Page 1
Part XVIII
Pages 1-4
Part XX
Pages 17-18
The section that requires contact with other states was revised.
Local agencies must refer instances of non-response to the
regional consultant for follow up with the Food and Nutrition
Service.
The benefit amounts for participants of the SNAP Combined
Application Project (VaCAP) were revised. The amounts show the
culmination of cost-of-living adjustments, reduction caused by the
ending of extra benefits provided under the American Recovery and
Reinvestment Act of 2009, and the project's cost neutrality
evaluation. The VaCAP application process was revised to require
screening of applicants for prior SNAP disqualifications and to
require a denial notice if applicants are disqualified. VaCAP
provisions were also revised to allow for a manual application after
automated applications have ended.
The amount of earnings needed to get a work credit through the
Social Security Administration was updated to $1,200 per quarter
for 2014.
The list of localities that are exempt from the work requirement was
revised. Residents in all Virginia localities are subject to the work
requirement and time-limited benefits.
Provisions for providing replacement EBT cards were revised.
Replacement cards must be available for the cardholder to pick up
at the local agency or be mailed within two business days of the
report by the household that another card is needed.
The income limits for determining eligibility for the disaster program
were revised. The maximum benefit amounts for the disaster
program were also revised to reflect current amounts.
VIRGINIA DEPARTMENT
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DEFINITIONS
VOLUME V, PAGE 3
c.
A temporary accommodation in the residence of another. (Temporary is defined here as
having been in the home for not more than 90 days as of the date of application); or
d.
A place not designed for, or ordinarily used as a regular sleeping accommodation for
human beings (e.g., as a park, bus station, hallway, lobby or similar places).
Initial or New Application - The first application for SNAP benefits filed in a locality by a household.
If the household subsequently moves to another locality, the first application taken in the new
locality is also a new application.
Intentional Program Violation (IPV) - An intentional program violation consists of any action by an
individual of having intentionally:
a.
Made a false or misleading statement to the local agency, orally or in writing, to obtain
benefits to which the household is not entitled. An IPV may exist for an individual even if
the agency denies the household's application;
b.
Concealed information or withheld facts to obtain benefits to which the household is not
entitled; or
c.
Committed any act that constitutes a violation of the Food and Nutrition Act, SNAP
regulations, or any State statutes relating to the use, presentation, transfer, acquisition,
receipt, or possession of SNAP access devices.
An IPV is also any action where an individual knowingly, willfully and with deceitful intent uses
SNAP benefits to buy nonfood items, such as alcohol or cigarettes, uses or possesses improperly
obtained access devices, trades or sells access devices, or uses benefits to repay food
purchased on credit..
Migrant Farm Worker - A farm worker who had to travel for farm work and who was unable to
return to the permanent residence within the same day. See also Seasonal Farm Worker.
PA Case - A public assistance (PA) SNAP case is any case in which all household members
receive or are authorized to receive income from the Temporary Assistance for Needy Families
(TANF), General Relief – Unattached Child (GR) or Supplemental Security Income (SSI) Program.
Any case that contains at least one member who does not receive TANF, GR - Unattached Child
or SSI is a nonassistance (NA) SNAP case. "Authorized to receive" income includes instances
when approved benefits are not accessed, are suspended or recouped, or are less than the
minimum amount for the agency to issue a payment.
Households that receive TANF Diversionary Assistance payments will be considered a PA case for
as long as the diversionary assistance is intended to cover. The month after the diversionary
assistance period of ineligibility expires will be when the PA status ends.
A PA case also includes a case in which any member receives or is authorized to receive a service
from a program funded by the TANF block grant. Service programs must derive more than 50
percent of their funding from the TANF block grant or from state funds intended to meet the
Maintenance of Effort (MOE) for TANF funding. (The VIEW Transitional Payment is state-funded
to meet the MOE obligation.) These programs must be for the purposes of:
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DEFINITIONS
VOLUME V, PAGE 4
a.
assisting needy families;
b.
promoting job preparation, work and marriage;
c.
preventing or reducing out-of-wedlock pregnancies, provided the program imposes a 200
percent of poverty income guideline; or
d.
promoting two-parent families, provided the program imposes a 200 percent of poverty
income guideline.
A child removed from the TANF grant because of noncompliance with school attendance
requirements continues to be a PA recipient, for SNAP purposes, as long as the TANF case status
remains active.
A case will be a PA unit as long as each household member derives some income from TANF, GR
- Unattached Child or SSI or at least one person receives a TANF service, which benefits the entire
household. A case will also be a PA case as long as the PA income counts toward SNAP eligibility
or benefit amount, such as in the case of the Noncompliance with Other Programs policy of Part
XII.D.
Reapplication -Processed as an initial or new application. a reapplication is:
a.
An application that is filed after an adverse or negative action. An adverse or negative
action is a denial of an application or termination of an ongoing case.
b.
An application filed when more than a calendar month has elapsed after the last
certification end date.
Recertification - The term recertification may refer to an application or the process of renewing
eligibility and entitlement to benefits. A recertification application is an application filed before the
certification end date or in the calendar month after the certification end date, provided the
application does not follow an action to close the case.
Seasonal Farm Worker - An individual employed by another in agricultural work of a seasonal or
other temporary nature. This includes employment on a farm or ranch performing fieldwork such
as planting, cultivating or harvesting, or employment in related activities such as canning, packing,
seed conditioning or related research, or processing operations.
Trafficking - Trafficking means:
a.
Directly or indirectly buying, selling, stealing, or otherwise obtaining SNAP benefits by an
Electronic Benefits Transfer (EBT) card and Personal Identification Number (PIN) or
manual voucher and signature for cash or consideration other than eligible food;
b.
Attempting to buy, sell, steal, or otherwise obtain SNAP benefits by an EBT card and
PIN or manual voucher and signature for cash or consideration other than eligible
food directly or indirectly;
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DEFINITIONS
VOLUME V, PAGE 5
c..
The exchange of firearms, ammunition, explosives, or controlled substances for SNAP
benefits; or
d.
Purchasing a product with SNAP benefits and intentionally:
discarding the contents in order to return the container for the return deposit
amount;
reselling the purchased product for cash; or
exchanging the purchased product for cash or for consideration other than
eligible food.
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A.
INTRODUCTION
VOLUME V, PART I, PAGE 1
PURPOSE OF THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
A goal of the Supplemental Nutrition Assistance Program (SNAP) is to reduce hunger and increase
food security. The Program permits low-income households to have a more nutritious diet through
normal channels of trade by increasing the food purchasing power for eligible households. The
Program also provides food when there is a disaster.
This manual provides SNAP certification procedures for Virginia. The Virginia Electronic Benefits
Transfer (EBT) Policy and Procedures Guide provides guidance for the issuance of EBT cards to
eligible households.
B.
HISTORY OF THE SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM
The Food Stamp Program started in four Virginia localities (Lee, Wise, Dickenson and the City of
Norton) during the pilot phase of its development before the establishment of the permanent
program on a national basis. Through requests to operate the Program from local governing
bodies, more than 70 localities in Virginia expanded the Program by June 1974. President Nixon
signed the Farm Bill into law in August 1973 that required nationwide implementation of the Food
Stamp Program effective July 1, 1974. Nationwide implementation of the Food Stamp Program
eliminated the Surplus Commodity Program which was an alternate food program available to
localities.
The Food Stamp Act of 1964 authorized the Food Stamp Program on a permanent basis. The
Food Stamp Act of 1977 and subsequent amendments amended the 1964 Act and is the basis of
the current Supplemental Nutrition Assistance Program. Provisions of the Food, Conservation and
Energy Act of 2008 renamed the Food Stamp Act of 1977, as amended, to the Food and Nutrition
Act of 2008 and renamed the Food Stamp Program as the Supplemental Nutrition Assistance
Program (SNAP).
The U.S. Department of Agriculture administers SNAP nationally through the Food and Nutrition
Service (FNS). In Virginia, local departments of social services operate the Program at the
county/city level under the supervision of the Virginia Department of Social Services.
C.
BENEFIT ISSUANCE AND USE
Eligible households receive SNAP benefits electronically. Households receive a plastic EBT card
with a magnetic stripe and must use a personal identification number (PIN) to access the benefits.
During the certification interview or other agency contact with eligible households, the agency must
advise or discuss with households of the following:
How to access benefits using the EBT card;
Case Name and authorized representative will each receive a card.
Cardholder should sign the EBT card upon receipt.
Selecting and protecting the PIN and EBT card;
When benefits will be available upon certification and for future months;
Use the EBT card at any retail store or other food vendor authorized by USDA to accept
SNAP benefits. Note that authorized retailers may display a sign indicating authorization
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VOLUME V, PART I, PAGE 2
that reads, "We accept SNAP Benefits" or similar language, or that displays the QUEST
logo. Other authorized facilities include:

Nonprofit meal delivery services, such as Meals-On-Wheels, or feeding sites for the
elderly;

Authorized drug addiction and alcoholic treatment and rehabilitation centers;

Certain group living arrangements;

Shelters for battered women and children; and

Authorized nonprofit establishments that feed homeless persons and restaurants
authorized to accept SNAP benefits.
Proper use of the benefits;
Purchase any food or food product for human consumption; or
Purchase seeds and plants for use in gardens to produce food for the household's
personal consumption.
Use of when making purchases:
Separate eligible items from ineligible ones at the checkout counter unless the store
is electronically programmed to identify eligible and ineligible items.
Advise the cashier beforehand of the intent to use SNAP benefits if electronic
programming is not available to denote SNAP benefits or when the household will
use EBT in conjunction with other payment methods.
Improper use of benefits. Households may not use SNAP benefits to purchase or pay for
the following:

Alcoholic beverages or tobacco;

Hot foods ready for immediate consumption or food to eat on the store’s premises;

Pet foods, soap products, paper products, or other non-food items usually available
in a grocery store;

To pay back grocery bills or tabs for food received on credit;

Firearms, ammunition, explosives, or controlled substances;

Purchasing a product with SNAP benefits and intentionally:
discarding the contents in order to return the container for the return deposit
amount;
reselling a purchased product for cash; or

exchanging a purchased product for cash or for consideration other than
eligible food.
At reapplication or recertification, determine if another EBT card is needed.
The agency must assist households who have difficulty in accessing their SNAP benefits, such as
households comprised of elderly or disabled members, homeless households or those without a
fixed mailing address. For example, the agency might assist an elderly person who is housebound
in finding an authorized representative who might access the household’s benefit account and shop
for groceries on behalf of the household. To ensure timely participation, the agency should issue a
vault card to Address Confidentiality Program participants who elect to use a substitute mailing
address. See Part VII.B.
Field offices for the USDA are responsible for authorizing retailers to accept SNAP benefits and are
responsible for ensuring compliance of SNAP regulations by retailers. The Richmond Field Office
(637) is responsible for Virginia localities. Contact information is:
Food and Nutrition Service, USDA
1606 Santa Rosa Road, Suite 129
Richmond, Virginia 23229
Telephone:
Fax:
(804) 287-1710
(804) 287-1726
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VOLUME V, PART II, APPENDIX II, PAGE 1
THE COMBINED APPLICATION PROJECT
The Virginia Combined Application Project (VaCAP) is a demonstration project that is designed to
increase SNAP participation among single, elderly Supplemental Security Income (SSI) recipients
who live alone and have no earned income. Participation in this group has historically been lower
than desired, often attributed to the cumbersome application process and low benefit level.
This project will:
Identify potentially eligible non-participating SSI recipients;
Produce a simplified, pre-filled, system-generated application;
Provide simplified processing procedures for local agencies; and
Provide a standardized benefit based on high or low shelter costs.
A.
The Pre-Application Process
1.
2.
3.
ADAPT will match against the State Data Exchange (SDX) monthly after cutoff to
identify potentially eligible clients who
a.
Receive SSI;
b.
Do not currently receive SNAP benefits;
c.
Live in Virginia;
d.
Are elderly (age 65 or older);
e.
Are single, divorced, widowed, or separated;
f.
Live alone or purchase and prepare alone; and
g.
Have no earned income.
ADAPT will generate an application and will pre-fill the application with the following
elements:
a.
Name
b.
Date of Birth
c.
Address
d.
SSI amount received
The Virginia Department of Social Services will mail the application to the household
with a postage-paid envelope and the address of the local social services
department.
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B.
APPLICATION PROCESSING
VOLUME V, PART II, APPENDIX II, PAGE 2
The Application Process
1.
2.
3.
Upon receipt of the simplified VaCAP application, the household must:
a.
Correct the preprinted information, if necessary;
b.
Specify the shelter amount to reflect rent or mortgage and utility expenses;
c.
Sign the application; and
d.
Return the application to the appropriate local agency.
If the application is complete, the local agency must:
a.
Screen the application in ADAPT for prior disqualifications;
b.
Complete an eDRS inquiry through SPIDeR;
c.
Process the application;
d..
Enter the case into ADAPT;
e..
Send the Notice of Action to approve the case;
f..
Issue an EBT card to the household, if necessary; and
g.
Send the Notice of Action to deny the application, if necessary, if the
household is ineligible based on a prior disqualification or eDRS
screening.
For incomplete applications, the local agency must take the following actions:
a.
No signature - The local agency must return the application to the household
for signature.
b.
Shelter expense information not provided – The local agency must process
the application with the lower shelter amount.
4.
If the household does not return the application, ADAPT will generate a second
application the following month. No additional applications will be mailed if the
second application is not returned. Individuals may apply for VaCAP if it is
determined they meet the VaCAP criteria but did not receive a systemgenerated application because they had already received two applications or
because they were participating in regular SNAP.
5.
The interview requirement has been waived.
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C.
APPLICATION PROCESSING
VOLUME V, PART II, APPENDIX II, PAGE 3
ADAPT
An application is determined to be VaCAP by fields on ASCASE, AECASE, and AERESI in
ADAPT.
ASCASE
The Interview Held field must be "V" for VaCAP.
AECASE
The Interim Reporting field must be "00."
AERESI
The FOR SNAP fields must be completed as follows:
Select one of the shelter expense entries;
Enter "N" in the Bypass VaCAP field; and
Enter "V" in the Interview Held field.
D.
Benefit Level
Benefits for participants in the VaCAP demonstration are not calculated using the process
outlined in Part XIII.C. Participants will receive:
High benefit - $86 - shelter expenses total $500 or above.
Low benefit - $61 - shelter expenses total $499 or less.
E.
Issuance of Benefits
VaCAP benefits will not be prorated. The household will receive a full month’s benefit
beginning the first of the month the application is received in the appropriate local agency.
F.
Certification periods
The certification period for all VaCAP applications will be three years.
G.
Recertification
VaCAP participants will receive a combined expiration notice and an application to recertify
for VaCAP. The Virginia Department of Social Services will mail the recertification
application to participants in the month before the certification period expires. Participants
must complete the application and return it to the local social services department for
processing. A report of VaCAP recertification applications mailed each month is available
through Option 18 in ADAPT.
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H.
APPLICATION PROCESSING
VOLUME V, PART II, APPENDIX II, PAGE 4
Change Reporting
a.
VaCAP households are not required to report changes to local departments of social
services. The Social Security Administration will report changes in SSI eligibility
through the monthly SDX file. Changes listed below will cause ADAPT to close the
VaCAP case and generate an Advance Notice of Action and an alert to the worker.
Death
Institutionalization
Marriage
Receipt of earned income
Discontinuation of SSI
A move to another state
A change in the Federal Living Arrangements
Certain SSI changes will only generate an alert for the worker to complete necessary
action. These changes are:
A move to another Virginia address
A change in the mailing address of an Authorized Representative
A change in the name of an Authorized Representative/payee
b.
I.
Although project participants are not required to report changes, the worker must
promptly act on changes reported by project participants that affect the household’s
VaCAP eligibility or the benefit amount
Conversion
There is no conversion to the VaCAP project.
1.
Move from the regular SNAP benefits - The household may request closure of the
regular SNAP case. The household may subsequently apply for VaCAP upon
receipt of the computer-generated application.
2.
Move to regular SNAP benefits - The household may request closure of the VaCAP
case in order to re-apply to the regular, ongoing program. The worker should
evaluate whether this would be beneficial to the household and provide the
household the information.
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APPLICATION PROCESSING
VOLUME V, PART II, PAGE 7
5 so that the household may receive the EBT card by mail by Saturday, August 13
or authorize the issuance of a vault card that the Case Name or authorized
representative could pick up before August 14. Additionally, the SNAP benefits
must be posted to the EBT account.
2.
Denying the Application (7 CFR 273.2(g)(3))
The agency must send a Notice of Action to deny an application if households are
ineligible for benefits. The agency must send the denial notice as soon as possible, but
not later than 30 days following the application date. Part XXIV contains a copy of the
Notice of Action and instructions.
3.
Processing Cases with Prior Participation in another Locality
When a household indicates on the application or during the interview that it had been
certified in another locality or State, for either the month of application or the prior month,
the EW must establish the household's current status with the prior agency. The EW must
establish and document the effective date of case closure with the prior agency.
The new locality may not issue duplicate benefits for any months covered by the
application if the agency can establish that the household or any of its members are still
active in the prior locality.
Contacts with Other States
For applications filed by persons who claim they have received SNAP benefits in another
state, the agency must confirm that the individual is no longer receiving benefits in that
state. If the agency is not able to verify this by the end of the processing period and all
other eligibility factors have been met, the agency must approve the application. The
agency must continue to seek verification from the other state to minimize the
overpayment period in case the individual continued to receive benefits in that state
however. If there is no response from the other state, the agency must contact the
regional consultant who will ensure the information is forwarded to FNS to follow
up with the other state.
If duplicate participation occurs, the Virginia agency must file a claim for any benefits the
household received while it also received benefits from the other state. The claim will be
household-caused if the household failed to report its connection to another state and the
receipt of benefits from the other state. An agency-caused claim will exist if the agency
failed to verify termination of benefits from another state.
For household members who are subject to the Work Requirement, the agency must also
address participation in another state towards the number of countable months if there is
an indication from the application or interview that the member may have received SNAP
benefits during the current 36-month period.
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VOLUME V, PART II, PAGE 8
F.
DELAYS IN PROCESSING
If the local agency does not determine a household's eligibility and provide an opportunity to
participate within 30 days following the date the application was filed, the local agency must take
the following action:
1.
Determining Cause (7 CFR 273.2(h)(1))
The local agency must determine who caused the delay using the following criteria:
a.
A delay must be considered the fault of the household if the household failed to complete
the application process even though the local agency took all required action to assist the
household. The local agency is required to take the following actions before a delay can be
considered the fault of the household:
1)
For households that failed to complete the application, the local agency must
have offered, or attempted to offer, assistance in its completion.
2)
If one or more members of the household failed to register for work, as
required in Part VIII.A, the local agency must have informed the household of
the need to register and given the household at least 10 days from the date of
notification to register these members.
3)
In cases where verification is incomplete, the local agency must have
provided the household with a statement of required verification and offered
to assist the household in obtaining required verification, and allowed the
household sufficient time to provide the missing verification. Sufficient time
will be at least 10 days from the date of the local agency's initial request for
the particular verification that was missing.
4)
For households that failed to appear for an interview, the local agency must
have scheduled an interview within 30 days following the date the household
filed the application. If the household failed to appear for the interview, and
the household does not request that the agency reschedule another interview
until after the 20th day but before the 30th day following the application filing
date, the household must appear for the interview, bring verification and
register members for work by the 30th day; otherwise, the delay will be the
fault of the household. If the agency must allow the household additional
time to provide information or verification, the delay will be the fault of the
household. If the household failed to appear for the interview and requests
another interview to occur after the 30th day following the date of application,
the delay will be the fault of the household. If the household missed the
scheduled interview and misses the one it requested, the household must
request another interview and any delay will be the fault of the household.
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NONFINANCIAL ELIGIBILITY CRITERIA
VOLUME V, PART VII, APPENDIX I, PAGE 1
SSA Quarters of Coverage Verification Procedures for Legal Immigrants
Individuals who are not citizens of the U.S. may be eligible for SNAP benefits depending on their
immigration status. (See Part VII.F.1.) One of the eligible classes requires that the immigrant
must be credited with 40 quarters of work. This appendix contains the process for determining the
number of qualifying quarters with which an individual can be credited.
To determine the number of quarters available to an eligible immigrant household member, the EW
must obtain answers to the following questions:
1.
How long has the applicant, the applicant’s spouse, or the applicant’s parents (before the
applicant turned 18) lived in the U.S.?
2.
How many years has the applicant, the applicant’s spouse, or the applicant’s parents
(before the applicant turned 18) commuted to work in the U.S. from another country before
coming to the U.S. to live, or worked abroad for a U.S. company or in self-employment
while a legal resident of the U.S.?
(If the total number of years to both questions is less than 10 years, the agency does not
need to ask question 3 because the 40-quarter standard cannot be met.)
3.
In how many of the years reported in answer to question 1, did the applicant, the
applicant’s spouse, or the applicant’s parent earn money through work?
(To determine whether the applicant’s earnings were sufficient to establish “quarters of
coverage” in those years, the agency should refer to the income chart included in this
appendix.)
If the answer to question 3 is 10 years or more, the EW must verify, from USCIS documents or
other documents, the date of entry into the country for the applicant, spouse and/or parent. If the
dates are consistent with having 10 or more years of work, an inquiry through SVES must be
made.
Information received through SVES will not report earnings for the current year and possibly not
the last year’s earnings. The household must provide verification of earnings through pay stubs,
W-2 forms, tax records, employer records, or other documents, if the quarters of this period are
needed to qualify for assistance.
If the household believes the information from SSA is inaccurate or incomplete, beyond the current
two-year lag period, advise the household to provide verification to the SSA to correct the
inaccurate income records.
In evaluating the verification received directly from the household or through SVES, the EW must
exclude any quarter, beginning January 1997 in which the person who earned the quarter received
TANF, SSI, Medicaid or SNAP benefits. This evaluation also includes benefits from the Nutritional
Assistance Program from Puerto Rico, the Northern Mariana Islands, or American Samoa.
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VOLUME V, PART VII, APPENDIX I, PAGE 2
Establishing Quarters
The term “quarter” means the 3-calendar-month period that ends with March 31, June 30,
September 30 and December 31 of any year.
Social Security credits (formerly called “quarters of coverage”) are earned by working at a job or as
a self-employed individual. A maximum of 4 credits can be earned each year.
Credits are based solely on the total yearly amount of earnings. All types of earnings follow this
rule. The amount of earnings needed for each credit and the amount needed for a year in order to
receive four credits are listed below.
Year
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
Quarter
Minimum
$250
$260
$290
$310
$340
$370
$390
$410
$440
$460
$470
$500
$520
$540
$570
$590
$620
$630
Annual
Minimum
$1000
$1040
$1160
$1240
$1360
$1480
$1560
$1640
$1760
$1840
$1880
$2000
$2080
$2160
$2280
$2360
$2480
$2520
Year
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2011
2012
2013
2014
Quarter
Minimum
$640
$670
$700
$740
$780
$830
$870
$890
$900
$920
$970
$1000
$1050
$1090
$1120
$1130
$1160
$1200
Annual
Minimum
$2560
$2680
$2800
$2960
$3120
$3320
$3480
$3560
$3600
$3680
$3880
$4000
$4200
$4360
$4480
$4520
$4640
$4800
If a quarter for the current year is included in the computation, use the current year amount as the
divisor to determine the number of quarters available.
For quarters earned before 1978:
·
A credit was earned for each calendar quarter in which an individual was paid $50 or more
in wages (including agricultural wages for 1951-1955);
·
Four credits were earned for each taxable year in which an individual’s net earnings from
self-employment were $400 or more; and/or
·
A credit was earned for each $100 (limited to a total of 4) of agricultural wages paid during
the year for years 1955 through 1977.
TRANSMITTAL #14
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
WORK REQUIREMENT
3/14
VOLUME V, PART XV, APPENDIX I, PAGE 1
Localities Whose Residents Are Exempted from the Work Requirement*
April 2009September 2013
October 2013September 2014
All Virginia
Localities
None
TRANSMITTAL #14
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
REPLACEMENT OF EBT CARDS, BENEFITS AND FOOD
3/14
A.
VOLUME V, PART XVIII, PAGE 1
Replacement of EBT Cards
This chapter covers general guidance for replacing EBT cards, benefits in electronic benefit
accounts and food purchased with SNAP benefits destroyed in a household disaster. See Chapter
G of the Virginia EBT Policies and Procedures Guide for additional information.
Households need an EBT card to access SNAP benefits. The cardholder may call the Customer
Service Representative (CSR) for the EBT card vendor to request a replacement card or contact
the local agency. The CSR will validate the system address before issuing a replacement card if
the cardholder calls Customer Service for a replacement card. If the address is incorrect, the card
vendor will not mail a replacement card but will refer the cardholder to the local agency to have the
address updated.
Cardholders will generally receive a replacement EBT card through the mail. Depending on
individual household circumstances however, the local agency may provide a vault card as a
replacement card. The cardholder must call the CSR to request a change in the status of a card
before the local agency can issue a vault card if the original card is still active. The cardholder
does not need to call the CSR if the card already has an inactive status code.
The EW must authorize the issuance of a vault card for replacing an EBT card and notify the local
agency card issuance unit so that the card is available for pick up within two business days
of the report by the household. The EW must complete the Internal Action and Vault EBT Card
Authorization form to authorize the vault card and to document crediting the replacement fee to the
household's account. See Part XXIV for a copy of the Internal Action and Vault EBT Card
Authorization form.
A cardholder will need a replacement if the original EBT card is lost, damaged, destroyed in a
household disaster, or stolen. A cardholder will also need a replacement card if the original card is
undelivered through the mail.
In most instances, a request for a replacement card will result in the deduction of a $2.00 card
replacement fee from a household's EBT account. The vendor should not apply the card
replacement fee for reapplying households or for replacements for returned, undelivered cards.
The local agency must credit the fee back to the household's account if the replacement is due to a
household disaster, violence against the household or for improperly manufactured cards. See
Part XVIII.A.4 for information about assigning and crediting of the fee for replacement cards.
1.
Undelivered EBT Card
a.
Undeliverable, Returned Cards
The post office will not deliver EBT cards with inaccurate or incomplete addresses.
The post office will not forward EBT cards to a new or changed address if
households move but fail to report the change to the local agency.
If the card is undeliverable because of an incomplete or inaccurate address for the
primary cardholder or the authorized representative, the EW must update the
mailing address, as appropriate.
TRANSMITTAL #14
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
REPLACEMENT OF EBT CARDS, BENEFITS AND FOOD
3/14
VOLUME V, PART XVIII, PAGE 2
b.
Nonreceipt of the EBT Card
In instances when cardholders report the nonreceipt of a mailed EBT card to the
local agency, the agency must check the EBT account to determine the mailing date
and check if the status of the card has been changed. If more than six mail days
has passed and the status of the card is unchanged, the cardholder must call the
CSR to request a new card. If the local agency is to issue a vault card as the
replacement card, the cardholder must still also call the CSR to change the status of
the original card.
In some instances, the Department of Social Services may have already received
the undelivered card and may have changed the status of the card by the time the
cardholder reports the nonreceipt to the local agency or the CSR. In these
instances, either the vendor or the local agency may initiate the replacement so
that the card is available for pick up in the agency or is mailed within two
business days of the cardholder's report.
If the cardholder reports the nonreceipt of a mailed EBT card to Customer Service
after a sufficient mail period, the CSR will change the status of the card to cancel
the card. The vendor will mail another card to the household or, at the cardholder's
option, defer mailing another card to allow the cardholder to receive a vault card at
the local agency. in either case, the card must be available for pick up in the
agency or is mailed within two business days of the cardholder's report.
When a cardholder requests a vault card as replacement, the Issuance Worker
must determine if there has been a sufficient period for delivery of the mailed card
and determine the status of the original card before issuing a vault card. If the EBT
account shows that the card has an active or an inactive status, the cardholder must
call CSR to request a change in the status of the card. If there is an inactive status
when the Issuance Worker inquires or once there is an inactive status, the local
agency may issue a vault card to the cardholder.
Households will not have the $2.00 card replacement fee assessed against their
benefit accounts when they receive replacement of undelivered cards. Households
will generally have the card replacement fee automatically deducted from the
account except when there is a replacement card for a card in an inactive status
such as the initial card lost in the mail or one returned as undeliverable.
2.
Lost, Stolen, Damaged Cards
When a cardholder reports an inability to access the household’s benefits because the EBT
card is unavailable for use, the cardholder must call CSR to request deactivation of the
card. Deactivation will prevent the usage of the card should the cardholder or someone
else attempt to use the card.
The cardholder must request replacement of the card through the CSR or the local agency.
The cardholder must note the reason for the replacement to the local agency. A
replacement card must be available for pick up or mailed within two business days
of the cardholder's report.
TRANSMITTAL #14
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
REPLACEMENT OF EBT CARDS, BENEFITS AND FOOD
3/14
VOLUME V, PART XVIII, PAGE 3
The reason for the destruction or unavailability of the original card will determine whether
the local agency credits the replacement fee back to the household’s account. Reasons for
replacing an EBT card include:
Lost – The cardholder loses or misplaces the card.
Stolen – The cardholder loses the card through violence exerted upon a
household in an act of robbery or burglary committed by someone outside the
household.
Household Disaster – The cardholder loses or damages the card through a
household fire or natural disaster, such as a flood or tornado.
Card Damage (negligence) – The card is unusable because of the
cardholder’s neglect.
Card Damage (improperly manufactured) – The card is unusable because of
a manufacturing error.
3.
EBT Card Replacement Fee
Each cardholder will receive written and verbal instruction on how to protect the EBT card.
When an EBT card is or becomes unusable for any reason, the cardholder must obtain a
replacement card to access the household's EBT account. The EBT card vendor will deduct
$2.00 from each SNAP case benefit account for replacement EBT cards in nearly every
instance when a cardholder receives a replacement card.
The automatic fee deduction will not occur when the original card has an inactive status or
when a household reapplies for benefits. The chart below summarizes application of the
card replacement fee.
No Fee
Reapplication
Inactive card, such as lost
in the mail
Fee Deducted
Lost
Stolen/robbery
Household disaster
Improperly manufactured
Cardholder name change
Card damaged/destroyed
Fee Credited
x (if applied)
x (if applied)
x
x (verify if questionable)
x
x
x Agency-caused error,
such as misspelled name
4.
EBT Card Replacement Fee Credit
The EBT vendor will automatically deduct a $2.00 fee from a household's SNAP EBT
account in most instances when a cardholder requests a replacement card. There are
instances however, when, despite proper care of the card by the cardholder, the household
experiences loss or destruction of the EBT card. In these instances, the local agency must
credit the $2.00 replacement fee back to the household's account.
TRANSMITTAL #14
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
10/13
REPLACEMENT OF EBT CARDS, BENEFITS AND FOOD
VOLUME V, PART XVIII, PAGE 4
An eligibility or administrative unit supervisor must authorize the fee credit on the Internal
Action and Vault EBT Card Authorization form.
The local agency must credit the card replacement fee when a household experiences an
individual household disaster or there is a natural disaster. An EBT card destroyed by fire or
a flood, tornado, hurricane or earthquake would allow the agency to credit the replacement
fee back to the household. The agency must verify the impact of the disaster upon the
household if the report is questionable, otherwise, the household's statement is acceptable.
The local agency must also credit the replacement fee when a cardholder loses the card
through violence inflicted upon the household or cardholder by someone outside the
household. The agency may verify the existence of the police report if the information is
questionable, otherwise, the household's statement is acceptable.
In addition to crediting the replacement fee for instances of a household disaster or violence
against the household, the local agency must credit the replacement fee if the agency
discovers an improperly manufactured card after a cardholder receives the card. The
agency must also credit the replacement fee if the vendor fails to identify a replacement card
at reapplication or a replacement for an inactive card. The local agency may also credit the
fee back to the household's account, if requested, when the household identifies another
Case Name or authorized representative.
The chart above summarizes instances when the local agency must credit the card
replacement fee to the household. As indicated above, an eligibility or administrative
supervisor must authorize the credit. The Issuance Supervisor must provide the credit.
B.
BENEFIT REPLACEMENT
Households will not receive a replacement for benefits lost due to loss of the EBT card and/or PIN
up to the time that the cardholder reports the loss to CSR or the local agency. Households will
have benefits replaced if someone accesses the benefits after the household reported to CSR that
the card was lost or stolen. Households will also receive replacement for benefits lost due to a
system error.
C.
REPLACEMENT OF FOOD DESTROYED IN A DISASTER
Households may request a replacement for food purchased with SNAP benefits and that was
subsequently destroyed in a household disaster. This policy may apply to an individual household
disaster or a disaster that affects more than one household.
The agency must use prudent judgement when households request a food replacement. Eligibility
for a replacement must be based on the benefit amount for the month, the amount of the food loss
reported, and time of the month when the loss occurred on a case-by-case basis. The agency may
deny replacement requests, such as for unsupported explanations or unacceptable collateral
contacts. See Part III.A.3 for a discussion of collateral contacts. Households may appeal the denial
of a replacement request or the authorized amount.
TRANSMITTAL #13
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
D-SNAP
4/13
VOLUME V, PART XX, PAGE 17
HOUSEHOLD
SIZE
INCOME LIMIT
BENEFIT
AMOUNT
FULL MONTH
$189
$347
$497
$632
$750
$900
$995
$1,137
BENEFIT
AMOUNT
HALF MONTH*
$ 95
$174
$249
$316
$375
$450
$498
$569
$2,320
1
$3.028
2
$3,486
3
$4,114
4
$4,539
5
$5,075
6
$5,464
7
$5,854
8
Each additional
person
$390
+$142
+$71
*
The half-month benefit amount is calculated by dividing the full month
amount by two and rounding up to the nearest whole dollar amount.
d.
For eligible households, the worker must complete the Internal Action Form for
Disaster Benefits to authorize the issuance of the EBT card. See the Forms
Section of this Chapter for a copy of the form.
M.
DISASTER PROGRAM BENEFIT PERIOD
1.
The benefit period for the D-SNAP is not based on a calendar month as it is for the regular
program. The benefit period is determined by the disaster benefit period authorized by
FNS. The period will be either a half-month (15 days) or a full month (30 days).
2.
The full amount of accessible liquid resources must be counted regardless whether the
length of the disaster benefit period is a half month or a full month.
3.
If the disaster benefit period is a half-month, income over the 15 day period must be
counted. If the disaster benefit period is a full month, then income during the 30-day
period must be counted. The maximum income limit for the appropriate household size
must not exceed the disaster income eligibility limit as shown in the table in Chapter K.
N.
VAULT CARD ISSUANCE PROCEDURES
For the D-SNAP, eligible households must receive a new EBT card and EBT account. There
must be a new card and account even if households are already known to the EBT system.
Procedures for setting up EBT accounts are in Appendix IV of this chapter.
To issue EBT cards in the D-SNAP, the local agency must issue vault cards in the same manner
they are issued for regular program operations. The eligibility worker must authorize issuance of a
vault card in ADAPT and prepare the Internal Action Form. Refer to the EBT Policy and
Procedures Guide.
TRANSMITTAL #14
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
D-SNAP
1/13
VOLUME V, PART XX, PAGE 18
The agency must provide an overview of the issuance process and use of benefits to the applicant.
The overview must also advise the applicant of the approximate time when the EBT card will be
available for use and when to select the Personal Identification Number (PIN). Households must
select or change the PIN to access benefits through the Automated Response Unit.
O.
FAIR HEARINGS AND CONFERENCES
Households denied Disaster Program benefits may request a fair hearing in accordance with Part
XIX. If the household decides to withdraw its request for a fair hearing, the request must be in
writing.
Households may also request a local agency conference in accordance with Part XIX. A requested
conference must be provided within three working days because of the short processing time for
disaster applications. The conference is not a replacement for the fair hearing process.
P.
TRANSITION TO THE REGULAR PROGRAM
Households that are issued D-SNAP benefits may follow up and file applications for the regular
program. In such situations, benefits for the regular program must be prorated from the day
following the end of the disaster benefit period, or the day of application for the regular program,
whichever is later.
Example
The D-SNAP benefit period is August 18 through September 17. The household filed
for and got disaster benefits on September 1. The household files an application for
the regular program on September 15. If eligible, benefits are prorated from
September 18, the day following the end of the disaster benefit period.
Q.
DISASTER REPORTS
The VDSS must report daily to FNS the number of households and persons approved for disaster
benefits. The report must distinguish between households and persons participating in the normal,
ongoing program and new, nonparticipating households and persons. This information will be
gathered at the end of each business day from the web-based system or the Master Issuance File
or EBT files if a paper application is used. Daily reports will also capture the value of benefits
issued and the number of households denied benefits.
The VDSS must submit additional reports at the end of the disaster period. These reports include:
FNS - 292B
Report of Supplemental Nutrition Assistance Program Benefit
Issuance for Disaster Relief
FNS – 388
Monthly Issuance Report
FNS – 209
Status of Claims Against Households Report
Appendix VII contains guidance for the completion of these reports.
TRANSMITTAL #10
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
TABLE OF CONTENTS
3/14
VOLUME V, PART XXIV, PAGE i
PART XXIV
FORMS
FORM NUMBER
NAME
PAGES
032-03-0824-29-eng
APPLICATION FOR BENEFITS
1-17
032-03-729A-12-eng
ELIGIBILITY REVIEW - Part A
20-21
032-03-729B-13-eng
ELIGIBILITY REVIEW - Part B
22-26
032-03-0823-11-eng
EVALUATION OF ELIGIBILITY
27-31
032-03-823B-03-eng
PARTIAL REVIEWS AND CHANGES
32-34
032-03-0819-12-eng
SNAP - HOTLINE INFORMATION
35-37
032-03-0821-05-eng
KNOW YOUR RIGHTS WHEN APPLYING FOR SNAP
BENEFITS
38-39
032-03-0718-07-eng
EXPEDITED SERVICES CHECKLIST
40-41
032-03-0814-10-eng
CHECKLIST OF NEEDED VERIFICATIONS
42-43
032-03-0117-19-eng
NOTICE OF ACTION
44-47
032-03-0018-33-eng
ADVANCE NOTICE OF PROPOSED ACTION
48-51
032-12-0157-19-eng
NOTICE OF EXPIRATION
52-53
032-03-0051-29-eng
CHANGE REPORT
54-56
032-03-0153-14-eng
ENTITLEMENT TO RESTORATION OF LOST BENEFITS
57-59
032-03-0148-02-eng
REQUEST FOR CONTACT
60-61
032-03-0875-15-eng
REQUEST FOR ASSISTANCE – ADAPT
62-66
032-03-0649-07-eng
INTERIM REPORT FORM – REQUEST FOR ACTION
67-69
032-03-823A-04-eng
PERMANENT VERIFICATION LOG
70-72
032-03-0388-05-eng
FOOD REPLACEMENT REQUEST
73-74
032-03-0387-06-eng
INTERNAL ACTION AND VAULT EBT CARD
AUTHORIZATION
75-77
TRANSMITTAL #14
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
TABLE OF CONTENTS
8/13
VOLUME V, PART XXIV, PAGE ii
PART XXIV
FORMS (continued)
FORM NUMBER
NAME
032-02-0072-12-eng
PAGES
EMPLOYMENT SERVICES PROGRAMS
COMMUNICATION FORM
78-80
SNAP SANCTION NOTICE FOR NON-COMPLIANCE
WITH A WORK REQUIREMENT
81-83
032-03-0721-10-eng
NOTICE OF INTENTIONAL PROGRAM VIOLATION
84-86
032-03-0722-04-eng
WAIVER OF ADMINISTRATIVE DISQUALIFICATION
HEARING
87-89
REFERRAL FOR ADMINISTRATIVE DISQUALIFICATION
HEARING
90-91
ADVANCE NOTICE OF ADMINISTRATIVE
DISQUALIFICATION HEARING
92-94
ADMINISTRATIVE DISQUALIFICATION HEARING
DECISION
95-96
NOTICE OF DISQUALIFICATION FOR INTENTIONAL
PROGRAM VIOLATION
97-98
032-03-0419-02-eng
MISSED INTERVIEW NOTICE
99-100
032-03-0460-04-eng
NOTICE OF ACTION AND EXPIRATION
101-103
032-03-0366-05-eng
ADAPT VERIFICATION FORM
104-110
032-03-0658-02-eng
NOTICE OF TRANSFER
111-113
032-03-0227-10-eng
CASE RECORD TRANSFER FORM
114-115
032-03-0440-00-eng
RIGHTS AND RESPONSIBILITIES
116-117
032-03-0572-00-eng
COMPROMISING CLAIMS WORKSHEET
118-119
032-03-0174-08-eng
032-03-0725-04-eng
032-03-0724-07-eng
032-03-0723-09-eng
032-03-0052-12-eng
TRANSMITTAL #12
Commonwealth of Virginia
Department of Social Services
APPLICATION FOR BENEFITS
GENERAL INFORMATION
With this application, you may apply for one or more of the following assistance programs.
Refer to the fold-out page for instructions.
Supplemental Nutrition Assistance Program (SNAP), (formerly food stamps)
Temporary Assistance for Needy Families (TANF)
TANF Emergency Assistance
General Relief – Unattached Child
Auxiliary Grants
Refugee Cash Assistance
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 8 people are living in your home and you need more space to list everyone, tell
the agency you need extra pages.
SPECIAL INFORMATION FOR SNAP APPLICANTS
You may apply for SNAP benefits by leaving a completed Application for Benefits at
the agency or by leaving a partially completed Application with at least your name,
address, and signature, or by tearing off and leaving this half-sheet with your name,
address, and signature. You must complete the rest of this Application before
your eligibility can be determined.
You must also be interviewed in the office or by telephone. You may turn in your
application before you are interviewed. This is important because if you are eligible
for the month in which you apply, your SNAP amount will be based on the date you
actually turn in your application.
EXPEDITED SERVICE FOR SNAP BENEFITS
Your household may qualify for Expedited Service and receive SNAP benefits within
7 days if you are eligible and if your gross monthly income is less than $150 and
liquid resources are $100 or less; or your monthly shelter bills are higher than your
household’s gross monthly income plus your liquid resources; or if someone in your
household is a migrant or seasonal farm worker with little or no income and
resources. GIVE THE INFORMATION BELOW SO YOUR ELIGIBILITY FOR
EXPEDITED SERVICE CAN BE DETERMINED.
Total income received/expected this month before deductions $______________
Individuals who have a disability or who have difficulty with English may receive extra help to
make sure they get assistance or services they are eligible to receive.
COMPLETE AND ACCURATE INFORMATION
You must give complete, accurate, and truthful information. If you do not give needed
information, we may not be able to determine your eligibility for assistance. Information
regarding your race is not required. However, if you decide not to give this information,
your worker will complete that section. If you knowingly give false, incorrect or incomplete
information, or fail to report changes, you could lose your benefits and be arrested,
prosecuted, fined and/or imprisoned. If you knowingly give false, incorrect, or incomplete
information in order to help someone else receive benefits, you could be arrested and
prosecuted for fraud.
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. For
some programs, 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.
032-03-0824-29-eng (09/13)
Total cash, money in checking/savings accounts, CDs
$______________
Total rent or mortgage for this month
$______________
Utility expenses for this month
$______________
Which utilities do you pay? (check all that apply)
 Heat
 Lights
 Telephone  Electricity for Air Conditioning
 Water
 Sewer
 Garbage
 Other
Is anyone in your household a migrant or seasonal farm worker?
NO ( )
NAME
DATE OF BIRTH
ADDRESS
SOCIAL SECURITY NUMBER
TELEPHONE NUMBER
SIGNATURE
DATE
YES (
)
VERIFICATION AND USE OF INFORMATION
AGENCY USE ONLY
Information you give on this application, including Social Security numbers (SSN), may be
matched against federal, state, and local records. These records include:
Virginia Employment Commission (VEC)
Internal Revenue Service (IRS)
Department of Motor Vehicles (DMV)
US Citizenship and Immigration Services (USCIS)
Social Security Administration (SSA)
CASE NAME
CASE NUMBER
LOCALITY
SCREENER
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.
DATE
EXPEDITED SERVICE DETERMINATION
Income < $150 + resources ≤ $100
YES ( )
NO ( )
NONDISCRIMINATION STATEMENT
This institution is prohibited from discriminating on the basis of race, color, national origin,
disability, age, sex and in some cases religion and political beliefs.
Income + resources < shelter bills
YES ( )
NO ( )
For migrant or seasonal farm workers:
Resources ≤ $100 and ≤ $25 is expected in next 10 days
from new income;
YES ( ) NO ( )
OR
Resources ≤ $100 and $0 income is expected from a terminated
source for the rest of this month or next month.
YES ( ) NO ( )
The U.S. Department of Agriculture (USDA) also prohibits discrimination against its customers,
employees, and applicants for employment on the basis of race, color, national origin, age,
disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital
status, familial or parental status, sexual orientation, or all or part of an individual's income is
derived from any public assistance program, or protected genetic information in employment or
in any program or activity conducted or funded by Department. Not all prohibited based will
apply to all program and/or employment activities.
If you wish to file a Civil Rights program complaint of discrimination with USDA, complete the
USDA Program Discrimination Complaint Form found online at
http://www.ascr.usda.gov/complaint_filing_cust.html or at any USDA office, or call (866) 6329992 to request the form. You may also write a letter containing all of the information
requested in the form. Send your completed complaint form or letter to us by mail at U.S.
Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected].
Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8338, or (800) 845-6136 (Spanish).
EXPEDITE IF YES TO ANY OF THE ABOVE.
For any other information dealing with SNAP issues, persons should either contact the USDA
SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information
Hotline Numbers (click the link for a listing of hotline numbers by State); found online at
http://www.fns.usda.gov/snap/contact_info/hotline.htm.
To file a complaint of discrimination regarding a program receiving Federal financial assistance
through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for
Civil Rights, Room 515-F, 200 Independence Avenue, S. W , Washington, D.C. 20201 or call (202)
619-0403 (voice) or (800) 537-7697 (TTY).
USDA and HHS are equal opportunity providers and employers.
.
Page 1
INSTRUCTIONS
1.
Do not write in shaded areas. These areas are for agency use only.
2.
Read and complete the VOTER REGISTRATION section on this page.
3.
Complete SECTION A: GENERAL INFORMATION. Answer the questions in SECTION A for everyone who lives in your home, even if you are not applying
for that person. You may leave questions about citizenship, immigration and Social Security Number blank for anyone for whom you are NOT requesting
assistance.
4.
Answer the questions in SECTION B: INCOME for everyone for whom you are applying. In addition, if applying for TANF, also provide income information for
children age 18 or under, even if you are not applying for that child, and the stepparent of the children for whom you are applying.
5.
Answer the questions in SECTION C: RESOURCES for everyone for whom you are applying unless you are applying for TANF.
6.
After completing Sections A, B, and C, answer the questions in the sections indicated below, depending on the type of assistance you are requesting.
SNAP (Food Stamps)
Financial Assistance
Section D, page 8
Section E, page 9
TANF Emergency Assistance
Auxiliary Grants
Section F, page 10
Section G, page 10
7. Read CHANGE REPORTING AND PENALTIES on page 13.
8. Read and complete the last page of this application. Be sure to sign and date the application.
Commonwealth of Virginia Voter Registration Agency Certification
If you are not registered to vote where you live now, would you like to apply to register to vote here today? (Please check only one)
 I am already registered to vote at my current address, or I am not eligible to register to vote and do not need an application to register to vote.
 Yes, I would like to apply to register to vote. (please fill out the voter registration application form)
 No, I do not want to register to vote.
If you do not check any box, you will be considered to have decided not to register to vote at this time. Applying to register to vote or declining to register to vote
will not affect the assistance or services that you will be provided by this agency. If you decline to register to vote, this fact will remain confidential. If you do
register to vote, the office where your application was submitted will be kept confidential, and it will be used only for voter registration purposes. If you would like
help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in
private if you desire.
If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to
register or in applying to register to vote, you may file a complaint with: Secretary of the Virginia State Board of Elections, Washington Building, 1100
Bank Street, Richmond, VA 23219-3497, Telephone (804) 864-8901.
______________________________________ ______________________________________ ___________________________
Applicant Name
Voter Registration form completed:
 Yes  No
______________________________________________
Agency Staff Signature
Signature
Date
Voter Registration form given to applicant for later mailing (at applicant’s request)
_______________________________________________
Date:

Page 1a
Commonwealth of Virginia
Department of Social Services
Case Name
APPLICATION FOR BENEFITS
Locality
AGENCY USE ONLY
Program
Case Number
Worker
Date Received
Caseload
Date of Service Referral
Date of Interview
 In
office
Applicant’s Name
Social Security Number
Phone Number
 Telephone
(Home/Messages)
(Work/Other)
Residence Address (Include City, State and Zip Code)
Directions to Home
Mailing Address (If Different)
E-Mail Address
Language: (Enter Code) _______________
1 - English
2 - Spanish
A - Somali
1.
3 - Cambodian
B - Kurdish
C – Arabic
5 - Farsi
F - French
6 - Haitian-Creole
G - German
7 - Laotian
J - Japanese
8 - Chinese
9 - Korean
O - Other
YES ( ) NO ( ) Have you or anyone for whom you are applying ever applied for, or received, or are currently receiving any benefits from a social services agency, including SNAP
(Food Stamps), AFDC, TANF, Medicaid, General Relief, Auxiliary Grants, Foster Care, Adoption Assistance, or Refugee Cash Assistance?
Applicant’s Name
Social Security Number
When
From What County, City, or State
2.
4 - Vietnamese
Type of Benefits Received
YES ( ) NO ( ) 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 TANF, SNAP, or
Medicaid in two or more states at the same time? If YES, give date and place of conviction _____________________________________________________________
3.
YES ( ) NO ( ) 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______________________________________________________________________________________________________________________ ____
4.
YES ( ) NO ( ) Do you or anyone in your home have a felony conviction for drugs after August 22, 1996 for ( ) Use? ( ) Possession? ( ) Distribution of drugs? (check all that apply)
If YES, who?______________________________________ Did the court assign ( ) Periodic Testing? ( ) Drug Treatment? ( ) Other Action? YES ( ) NO ( ) If
YES, have you finished the plan or are you cooperating? YES ( ) NO ( )
032-03-0824-29-eng (09/13)
A. GENERAL INFORMATION (ALL APPLICANTS MUST COMPLETE THIS SECTION)
Page 2
__________________________________________
LAST NAME, FIRST, MI, AND MAIDEN
(DO NOT make any entry in the ID# space)
1
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date_________
Reason
2
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date_________
Reason
3
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date________
Reason
4
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date_________
Reason
5
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date_________
Reason
6
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date_________
Reaon
7
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date_________
Reason
8
ID#
YES ( ) NO ( )
Date Left____________
Expected Return Date_________
Reason
NONE
__________________________________________
REFUGEE CASH ASSISTANCE
If YES, give the date the person left and
expected return date If more than 60
days, give the reason for the absence.
AUXILIARY GRANTS
Check ( ) YES ( ) NO ( ) Do you expect any
change in who lives in your home, either this month
or next month? If YES, explain:
__________________________________________
Give the
relationship of
each person to the
person listed on
Line #1.
TANF EMERGENCY
ASSISTANCE
Check ( ) YES or NO
UNATTACHED CHILD
LIST YOURSELF ON LINE #1.
GENERAL RELIEF
Is this person temporarily away from
home?
4. TYPE OF ASSISTANCE REQUESTED (Check ( ) type of assistance
requested for each person. If no assistance is requested, check NONE for that
person. Note that an application for TANF will also be an application for SNAP.
Check TANF - No SNAP if you do not want to apply for SNAP benefits.
TANF – NO SNAP
LIST EVERYONE LIVING IN YOUR HOME, even if
you are not applying for assistance for that person.
3. RELATIONSHIP
TO PERSON
ON LINE #1
TANF
2. TEMPORARILY AWAY FROM HOME
SNAP (FOOD STAMPS)
1. EVERYONE IN YOUR HOME
Page 3
COMPLETE THIS SECTION FOR EACH PERSON AS LISTED ON PAGE 2
5. U.S. CITIZEN*
6. ANSWER ONLY IF AN
ALIEN
7. PLACE OF BIRTH
9a. RACE
(not required)
9b. ETHNICITY
(not required)
10. SEX
Check ( )
YES or NO
Give the Alien Number and
Date of Entry for anyone for
whom you are requesting
assistance.
Give the State if born in
the U.S. or the Country if
born outside of the U.S.
Select all that
apply
1. White
2. Black/African
American
3. American
Indian/Alaska
Native
4. Asian
5. Native
Hawaiian/
Pacific Islander
Give the code
to show
ethnicity.
Give the
code to
show Sex.
1 - Hispanic or
Latino
2 - Not Hispanic
or Latino
M - Male
F - Female
If YES, do not answer
Question 6.
1
2
3
4
5
6
7
8
You may leave this
blank for anyone not
in the assistance
request
You may leave this blank for
anyone not in the assistance
request.
8. DATE OF BIRTH
YES ( ) NO ( )
Alien Number
Place of Birth
Date of Entry
Date of Birth
Alien Number
Place of Birth
Date of Entry
Date of Birth
Alien Number
Place of Birth
Date of Entry
Date of Birth
Alien Number
Place of Birth
Date of Entry
Date of Birth
Alien Number
Place of Birth
Date of Entry
Date of Birth
Alien Number
Place of Birth
Date of Entry
Date of Birth
Alien Number
Place of Birth
Date of Entry
Date of Birth
Alien Number
Place of Birth
Date of Entry
Date of Birth
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
11. SOCIAL
SECURITY
NUMBER
Give the number for
anyone for whom
you are requesting
assistance.
12. MARITAL
STATUS
Give the
code to show
Marital
status.
1 - Married
2 - Never
Married
3 - Divorced
4 - Widowed
5 - Separated
Page 4
COMPLETE THIS SECTION FOR EACH PERSON AS LISTED ON PAGE 2
14. EDUCATION
13. VETERAN/
DEPENDENT
OF A
VETERAN A.
Check ( )
YES or NO
15. DISABILITY
STATUS
Give the Last Grade Completed in school.
B.
Check ( ) YES or NO Is the person a High School (HS) or GED graduate?
C.
D.
Check ( ) YES or NO Is the person Currently Enrolled in school? If YES,
give the school name and use one of the codes to show enrollment.
FT - Enrolled full time
HT - Enrolled half time
LT - Enrolled less than half time
Give the code to
show
Disability/Pregnant
Status
ND - Not disabled
DS - Disabled
BL - Blind
CD - Needed to care
for disabled
person
16. ANSWER ONLY IF DISABLED
A. Check ( ) if the disability reduces or
prevents the ability to work or to obtain
work.
B. Check ( ) if the disability reduces or
prevents the ability to care for a child in
the home.
C. Check ( ) if the disability requires
someone to be in the home to provide
care.
ENROLLMENT
SCHOOL NAME
1
2
3
4
5
6
7
8
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
CODE
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
A. Last Grade Completed: ___________
A. ( ) Ability to work is reduced
B. ( ) YES ( ) NO HS or GED Graduate
B. ( ) Ability to care for child is reduced
C. ( ) YES ( ) NO Currently Enrolled
C. ( ) Someone is needed in the home
Page 5
B.
INCOME (ALL APPLICANTS MUST COMPLETE THIS SECTION)
Answer the income questions for everyone for whom you are applying. If applying for TANF or TANF Emergency Assistance, , also provide income information for the additional persons
indicated on the INSTRUCTIONS page and also provide income information for the child’s parent or stepparent living in the home; or any person living with the parent as husband or wife.
If the parent is a minor under age 18 (for TANF), also provide income information for the parent of the minor parent.
1.
Does anyone receive any of the following types of money from working? Check ( ) YES or NO for each type. If YES, give the information requested.
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
Wages/salary
Contract income
Commissions, bonuses, tips
Person Receiving Money
From Working
2.
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
Employer’s Name, Address
Phone Number
Vacation Pay
Earned sick pay
Babysitting/day care
Employment
Begin Date
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
Hours Worked
Per Month
Rate of Pay
Farming/fishing
Domestic work
Odd jobs
How Often Paid
YES ( ) NO ( )
YES ( ) NO ( )
Day of The
Week Paid
Other self- employment
Any other money from working
Gross Monthly Pay Before Deductions
$
PER
$
$
PER
$
$
PER
$
Does anyone receive any other type of money? Check ( ) YES OR NO for each type. If YES, give the information requested.
YES (
YES (
YES (
YES (
YES (
YES (
)
)
)
)
)
)
NO (
NO (
NO (
NO (
NO (
NO (
)
)
)
)
)
)
Social Security
YES (
SSI
YES (
VA benefits
YES (
Black Lung benefits YES (
Railroad retirement YES (
Other retirement
YES (
Person Receiving Money
)
)
)
)
)
)
NO (
NO (
NO (
NO (
NO (
NO (
)
)
)
)
)
)
Child support, alimony
Military Allotment
Unemployment benefits
Worker compensation
Strike benefits
Interest, dividends YES ( )
Type of Money Received
YES (
YES (
YES (
YES (
YES (
NO ( )
)
)
)
)
)
NO ( )
Cash gifts or contributions
NO ( )
Public Assistance
NO ( )
Room/board income
NO ( )
Rental Income
NO ( )
Prize winnings
Insurance settlement
How Often Received
YES (
YES (
YES (
YES (
YES (
)
)
)
)
)
NO (
NO (
NO (
NO (
NO (
)
)
)
)
)
Loans
Training allowances, including WIA
Inheritance
All food, clothing, utilities, or rent
Any other type of money
When Received
Gross Monthly Amount Before Deductions
$
$
$
$
YES ( ) NO ( )
3. Does anyone besides the people for whom you are applying pay directly for you, help you pay, or lend you money to pay rent, utilities, medical bills or any other bills? Or,
does anyone totally supply food or clothing for you or someone else on a regular basis?
Person Receiving Help
Person Providing Help
Type of Help
Received
Amount
$
Does Money Come
Directly to You?
Is This a Loan?
Is Repayment Expected
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
YES ( ) NO ( )
PER
$
PER
Page 6
YES ( ) NO ( )
4. Has anyone been fired, laid off, gone on sick or maternity leave, gone on strike, quit a job or reduced hours worked in the last 60 days?
Employer’s Name, Address,
Phone
Name of Person
Employed
From/To
Hrs./Wk.
Worked
Rate of
Pay
How Often
Paid
Date Last Pay
Received
Reason For Leaving,
Reducing Hours
$
PER
YES ( ) NO ( )
5. Does anyone expect any change in the type of money received, employment, or hours worked, either this month or next month?
If YES, explain and give date: ________________________________________________________________________________________________________________
YES ( ) NO ( )
6. Does anyone have a day care expense for a child, an elderly person, or an adult with a disability?
Person Paying For Care
YES ( ) NO ( )
Person Receiving Care
Check ( ) If Disabled
Provider’s Name, Address, Phone Number
Amount Paid
(
) Disabled
$
PER
(
) Disabled
$
PER
7. Does anyone pay legally obligated child support to someone not in the household? If YES, person paying: ___________________________________________________
Person supported: ________________________________________________ Amount paid and how often: _________________________________________________
YES ( ) NO ( )
8. ANSWER ONLY IF SOMEONE IS APPLYING FOR AUXILIARY GRANTS AND IS BLIND OR DISABLED: Does this person have a work related expense?
If YES, give amount and explain: ______________________________________________________________________________________________________________
C.
RESOURCES
Do not complete this section if you are applying only for TANF, TANF Emergency Assistance or General Relief-Unattached Child. For all other programs, answer the
resource questions for everyone for whom you are applying. Include any resources jointly owned with someone else, even if that person does not live with you. List the names of all
joint owners. After each joint owner’s name, list the percentage (%) of the resource
owned by that person. TALK TO YOUR ELIGIBILITY WORKER IF YOU NEED HELP
ANSWERING THESE QUESTIONS, INCLUDING THE PERCENTAGE OWNED.
YES ( ) NO ( )
YES ( ) NO ( )
1. Cash on hand and not in a bank? If YES, list owner(s)__________________________________________________________________ Amount_________________________
2. Checking account, savings or investment account, credit union account, Christmas Club account, CDs or money market account, individual development account, patient
funds for people in a nursing facility or Assisted Living Facility, or special welfare fund account? List all accounts, even if there is no money in the account. If Yes to
savings or investment account, has the savings account been set up to pay for school expenses, to make a down payment on a house, or to start a business? Check ( )
YES ( ) NO ( ) If the savings account is to pay for school expenses, list the person(s) whose expenses will be paid ____________________________. If the savings
or investment account is for another purpose, explain _____________________________________________________________________________________________
Owner(s)
Type of Account
Where
Owner(s)
Account #
Type of Account
Where
Owner(s)
Account #
Type of Account
Where
Account #
YES ( ) NO ( ) Is this
resource used in your
business, trade, or farming?
YES ( ) NO ( ) Is this
resource used in your
business, trade, or farming?
YES ( ) NO ( ) Is this
resource used in your
business, trade, or farming?
Amount
Date Acquired
$
Amount
Date Acquired
$
Amount
Date Acquired
$
Page 7
YES ( ) NO ( )
Owner(s)
Owner(s)
3. Stocks or bonds, trust funds, pension plans, retirement accounts, promissory notes, deeds of trust, mutual funds, IRAs, or annuities?
Type of Account
Where
Amount
$
Account #
Type of Account
Where
Amount
$
Account #
Date Acquired
Date Acquired
YES ( ) NO ( ) 4. Has anyone sold, transferred, or given away any resources in the last 3 months if applying for SNAP benefits or he last 3 years, if applying for Auxiliary Grants?
Property Transferred
Value at Transfer
Amount Received
Explain Reason for Transfer
From Whom?
To Whom?
$
Date Acquired
$
Date Transferred
Answer the questions below this point (5-10B) only if this is an application for Auxiliary Grants.
YES ( ) NO ( )
Owner(s)
5. Burial plots, burial arrangement or trust funds for burial?
Number of Plots,
Type of Arrangement
Where
Value $
Date Acquired
Amount Owed $
YES ( ) NO ( )
Owner(s)
6. Personal property, such as campers/trailers, non-motorized boats, utility trailers, tools, equipment, supplies, or livestock?
Type
YES ( ) NO ( ) Is this property
Value $
necessary to your business, trade, or
farming?
Amount Owed $
YES ( ) NO ( )
Owner(s)
7. Real property, including life estates, land, buildings, or mobile homes? If YES, do you live there? Check ( ) YES ( ) NO ( )
Type (Include number of acres)
YES ( ) NO ( ) Currently rented
Value $
YES ( ) NO ( ) Income producing
YES ( ) NO ( ) Currently for sale
Amount Owed $
YES ( ) NO ( )
Owner(s)
8. Licensed or unlicensed vehicles, such as cars, trucks, vans, motorboats, motor homes, mobile homes, recreational vehicles, or motorcycles/mopeds?
Type of Vehicle: Year--Make--Model
Currently Licensed?
License #
Value $
Explain How Vehicle Is Used
Date Acquired
Amount Owed $
Vehicle Id#
YES ( ) NO ( )
Type Of Vehicle: Year-Make-Model
CURRENTLY
License #
Value
Explain How Vehicle Is Used
Date Acquired
LICENSED?
$
Vehicle Id#
Amount Owed
YES ( ) NO ( )
$
Owner(s)
YES ( ) NO ( )
PERSON(S) INSURED
COMPANY NAME, ADDRESS, PHONE
TYPE OF POLICY
POLICY NUMBER
OWNER(S)
PERSON(S) INSURED
COMPANY NAME, ADDRESS, PHONE
TYPE OF POLICY
POLICY NUMBER
EXPLAIN
Date Acquired
9. Life insurance policies?
OWNER(S)
YES ( ) NO ( )
YES ( ) NO ( )
Date Acquired
FACE VALUE
$
FACE VALUE
$
CASH VALUE
$
CASH VALUE
$
10A. Does anyone expect to receive any money because of a legal suit involving personal injury or property damage? If YES, explain.
10B. Does anyone expect a change in resources this month or next month? If YES, explain and give date change is expected.
DATE ACQUIRED
DATE ACQUIRED
Page 8
D.
SNAP (formerly FOOD STAMPS)
1. List the name of the person who is the head of your household for SNAP purposes ______________________________________________________________.
YES ( ) NO ( )
2. Would you like to name a representative who could apply for SNAP benefits for you, access your SNAP benefit account to buy food for you, or receive SNAP correspondence
and notices for you? You may have only one representative who can access your benefits. You may fill in the name of your representative here or you may write a letter to
identify a representative.
Name, Address, Phone Number of Authorized Representative(s)
Check ( ) Each Duty Authorized for the Representative
1
( ) Apply for SNAP benefits
( ) Receive correspondence
( ) Receive SNAP benefits
2
( ) Apply for SNAP benefits
( ) Receive correspondence
( ) Receive SNAP benefits
YES ( ) NO ( )
3. Is there anyone else living with you that you have NOT included on your SNAP application? If YES, do you and everyone for whom you are applying usually purchase
and prepare meals apart from these people? Or, do you intend to do so if your application for SNAP benefits is approved? Check ( ) YES (
IF YES, list names: __________________________________________________________________________________________
)
NO (
).
YES ( ) NO ( )
4. Is anyone living in your home a roomer or a boarder? If YES, list names: ______________________________________________________________________
YES ( ) NO ( )
5. Is anyone age 60 or older, OR approved to receive Medicaid because of a disability, OR receiving any type of disability check? If YES, list all current medical expenses for
these people. Include Medicare and other medical insurance premiums, medical and dental bills, psychotherapy, prescription drugs, eye glasses, dentures, hearing aids,
transportation for medical services, nursing services, and any other medical bills. .
Person with Expense
Type of Expense
AMOUNT
Name, Address, Phone Number of Doctor, Hospital, Pharmacy
$
$
YES ( ) NO ( )
6. Does anyone have any of the shelter expenses listed below? Check () here  if these expenses are for a house you do not live in.
Reason for not living there__________________________________ Is someone else living there? YES ( ) NO ( )
If someone else lives there, does that person pay rent? YES ( ) NO ( )
Expenses
Rent/mortgage
Taxes
Insurance
Electricity
Gas/ oil/Kerosene
Coal/wood
Water/sewer/
garbage
Telephone
Installation
Amount billed
$
$
$
$
$
$
$
$
$
How often
Who pays bill
a. YES ( )
b. YES ( )
c. YES ( )
NO ( ) Do you have a heating or cooling expense for your home? If YES, what is the average amount for heating or cooling your home?______________.
NO ( ) Did you receive energy/fuel assistance during this past year?
NO ( ) Are you staying temporarily in someone else’s home, an emergency shelter, welfare hotel, other halfway house, or a place not usually used for
sleeping? If YES, how much does it cost to stay there during the month?___________________________________
If you are staying temporarily in someone else’s home, tell us the date you moved there:_______________________________
Page 9
E.
FINANCIAL ASSISTANCE
(ASK FOR AN EXTRA PAGE IF YOU NEED MORE SPACE)
2. PARENT’S STATUS
(Not needed for Medicaid)
1. CHILD/PARENT INFORMATION
List each child for whom you are applying. Then, list the
names of both parents.
3. IMMUNIZATION
(Not needed for Medicaid)
(Answer only if applying for TANF and the child is not in
school.)
Check if either PARENT is:
YOU MUST IDENTIFY BOTH PARENTS IN ORDER TO
RECEIVE TANF. IF YOU INTENTIONALLY
MISIDENTIFY A PARENT, YOU SHALL BE
PROSECUTED
Has the child received ALL of the immunizations required
according to the child’s age?
Check ( ) YES or NO or UNKNOWN
UNEMPLOYED
DISABLED
DEAD
ABSENT
CHILD’S NAME
YES ( )
NO ( )
UNKNOWN ( )
YES ( )
NO ( )
UNKNOWN ( )
YES ( )
NO ( )
UNKNOWN ( )
YES ( )
NO ( )
UNKNOWN ( )
MOTHER
FATHER
CHILD’S NAME
MOTHER
FATHER
CHILD’S NAME
MOTHER
FATHER
CHILD’S NAME
MOTHER
FATHER
TANF APPLICANTS:
The diversionary assistance program was explained to me.
The family cap provision was explained to me.
YES ( )
YES ( )
NO ( )
NO ( )
Page 10
F.
TANF EMERGENCY ASSISTANCE
YES ( ) NO ( )
1. Have you or your family experienced a natural disaster or fire in the past 30 days? If YES, give date and explain _____________________
________________________________________________________________________________________________________________
YES ( ) NO ( )
2. Does anyone have any emergency needs, such as clothing, repair or replacement of household equipment and supplies which were
destroyed?
Description and cause of emergency
G.
AUXILIARY GRANTS
YES ( ) NO ( )
YES ( ) NO ( )
1. Is the applicant living in an Assisted Living Facility, an Adult Foster Care Home, a Nursing Facility, or other institution?
If YES, Date Applicant Entered_______________________ City\County and State Applicant lived before entering ____________________-_
If outside Virginia, was placement made by a government agency? YES ( ) NO ( )
2. Do you have a spouse who does not live in the home? If YES, enter the Spouse’s Name and address _______________________________
_______________________________________________________________________________________________________________
YES ( ) NO ( )
3. Have you lived in Virginia for the past 90 days?
YES ( ) NO ( )
4. Do you owe or did you pay any bills you had in the month of entry into an assisted living facility or adult foster care?
Description of Bills
YES ( ) NO ( )
Dates of Bills
Dates Bills Paid
5. Do you own any household goods or personal effects worth more than $500, such as silver, fine china, furs, artwork, jewelry, or other items
held for their value or as an investment?
Description and Value of Items
Page 11
CHANGE REPORTING AND PENALTIES (READ THIS SECTION CAREFULLY BEFORE SIGNING THIS APPLICATION)
REPORTING CHANGES
You must report changes that occur. What you need to
report and when you need to report it varies by each
program as listed below.
.
SNAP: Report within 10 days, but no later than the 10th
day of the month after the change occurs. Report these
changes:
Your household income goes over 130% of the
Federal poverty level. See the Change Report or
the Notice of Action for the amount.
The number of work hours in a week goes under 20
for anyone who is 18-49 if there are no children in
your household.
TANF/Refugee Cash Assistance: Report within 10
days, but no later than the 10th day of the month after
changes occur. Report these changes:.
Your household income goes over 130% of the
Federal poverty level. See the Change Report or
the Notice of Action for amount.
Your address changes.
An eligible individual leaves or enters the home.
Changes that may affect your participation in VIEW
such as, changes in income, employment,
education, training, transpotation, and child care.
General Relief-Unattached Child: Report the day the
change occurs or the first day that the agency is open
after the change occurs. Report these changes:
Your address changes.
The amount of your monthly income changes.
There are other changes that may affect eligibility.
Auxiliary Grants: Report changes within 10 days.
Report these changes:
Your address changes.
The amount of your monthly income changes.
There are changes in your resources, including
transferring assets/property or in any motor
vehicles owned
:
PENALTIES FOR SNAP VIOLATIONS
You must not give false information or hide
information to get SNAP benefits. You must not
trade or sell EBT cards. You must not use SNAP
benefits to buy non-food items, such as alcohol,
tobacco or paper products. You must not use
someone else’s, EBT card for your household.
If you intentionally break any of these rules you
could be barred from getting SNAP benefits for 12
months (1st violation), 24 months (2nd violation), or
permanently (3rd violation); subject to $250,000 fine,
imprisoned up to 20 years, or both; and suspended
for an additional 18 months and further prosecuted
under other Federal and State laws.
If you intentionally give false information or hide
information about identity or residence to get SNAP
benefits in more than one locality at the same time,
you could be barred for 10 years.
PENALTIES FOR TANF AND REFUGEE CASH
ASSISTANCE (RCA) VIOLATIONS
You must not knowingly give false information, hide
information, or fail to report changes on time in order to
receive TANF/RCA or to receive supportive or
transitional services such as child care or assistance
with transportation.
If you are found guilty of intentionally breaking these
rules, you will be ineligible to receive TANF/RCA for
yourself for 6 months (1st violation), 12 months (2nd
violation), or permanently (3rd violation). In addition, you
may be prosecuted under Federal or State law.
Anyone convicted of misrepresenting his or her
residence to get TANF, Medicaid, SNAP benefits or SSI
in two or more states is ineligible for TANF for 10 years.
Anyone convicted of a drug-related felony for
actions that occurred after August 22, 1996, could
be barred permanently.
If you are convicted in court of trading or selling
SNAP benefits of $500.00 or more, you could be
barred permanently.
If you are convicted in court of trading SNAP
benefits for a controlled substance, you could be
barred for 24 months for the 1st violation,
permanently for the 2nd violation.
If you are convicted in court of trading SNAP
benefits for firearms, ammunition, or explosives, you
could be barred permanently for the first violation.
INFORMATION ABOUT THE DIVISION OF
CHILD SUPPORT ENFORCEMENT (DCSE)
In order to receive TANF, you are required to assign all
of your rights to financial support paid to you and to
everyone else for whom you are receiving TANF. After
your case is approved, you must give any support
payments you receive to DCSE.
.
Page 12
BY MY SIGNATURE BELOW, I DECLARE:
I read the information in the GENERAL INFORMATION and the YOUR RESPONSIBILITIES sections of this application.
I understand that if I refuse to cooperate with any review of my eligibility including review by Quality Assurance, my benefits may be denied
until I cooperate.
I understand that if my application is for SNAP benefits, failure to report or verify any of my expenses will be seen as a statement by my
household that I do not want to receive a deduction for these expenses.
I have given true and correct information on this application to the best of my knowledge and belief. I understand that if I give false information,
withhold information, or fail to report a change promptly or on purpose, I may be breaking the law and could be prosecuted for perjury, larceny,
and/or welfare fraud. I understand that if I help someone complete this form so as to get benefits he or she is not entitled to receive, I may be
breaking the law and could be prosecuted.
I authorize the Department of Social Services and refugee service contractors to obtain any verification necessary to both determine and
review financial assistance eligibility. This authorization is valid for one year from the date of my signature below. I understand that this time
limit does not apply as long as my medical assistance case is open or to investigations regarding possible fraud.
I understand that different state agencies provide different services and benefits. Each agency must have specific information to determine
eligibility services and benefits.
 I allow  I do not allow the Department of Social Services to disclose certain information about me to other state agencies, including
information in electronic databases, for the purpose of determining my eligibility for benefits/services provided by that agency. This disclosure
will make it easier for agencies to work together efficiently to provide or coordinate services and benefits. Agencies include, but are not limited
to, the Department of Health, the Department for the Aging, the Department of Rehabilitative Services and the Department of Vocational
Rehabilitation. I can withdraw this authorization at any time by notifying my eligibility worker.
I filled in this application myself. YES ( )
NO ( )
Applicant’s or Authorized Representative’s Signature or
Mark
Date
Witness To Mark Or Interpreter
Date
If NO, it was read back to me when completed. YES ( )
Spouse’s or Authorized Representative’s Signature or Mark (Not
Needed for Snap))
Complete the box below if this application was completed for the applicant by someone else.
Name of Person Completing Application
Date
Address
Phone Number
(Home)
(Other)
NO ( )
Realationship to Applicant
Date
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
APPLICATION FOR BENEFITS
3/14
VOLUME V, PART XXIV, PAGE 17
APPLICATION FOR BENEFITS
FORM NUMBER - 032-03-0824
PURPOSE OF FORM - To record a household's request for assistance and to provide information
about the current situation needed to determine eligibility.
NUMBER OF COPIES - One.
DISPOSITION OF FORM - The application is to be completed by or on behalf of the applying
household. The completed application may be mailed to the agency or completed at the agency
prior to or during an interview. The completed application is to be filed in the eligibility case record.
The application must be retained for a minimum of three years.
The application may be used to apply for benefits of other programs if assistance is requested
within three months of the original filing date. The date of the application in this instance is the
date of the secondary request.
INSTRUCTIONS FOR PREPARATION OF FORM - General instructions appear of the form for
completion.
If changes need to be made after the application is completed, the applicant should write the
revised information near the original entry. The applicant must initial and date the changes. Except
for agency-use sections, eligibility workers may not add to or write on a completed application.
TRANSMITTAL #14
DEPARTMENT OF SOCIAL SERVICES
Supplemental Nutrition Assistance Program (SNAP)
KNOW YOUR RIGHTS WHEN APPLYING FOR SNAP Benefits
If you are interested in applying for SNAP benefits, here is information you need to know:
Persons applying for SNAP benefits must file an application by submitting the application form to the
Department of Social Services in the county or city where they live. Submit the application either in
person, through an authorized representative, online at https://commonhelp.virginia.gov/access/, by fax,
or by mail.
You have the right to file an application on the same day you contact the Department of Social Services in
your locality. The address and hours of the office are shown at the bottom of this notice. Your application
may be submitted any time during office hours.
You may come to the office to pick up an application any time during office hours, or the agency can mail
you an application on the same day you request it.
If your resources and income are very low ($100 in resources and $150 in income), or you are a migrant
or seasonal farm worker, or your combines gross monthly income and resources are less than your
family’s shelter expenses, you may be eligible for expedited service. This means that if you are eligible,
you are entitled to receive benefits within 7 days following the date your application is filed at the local
social services department.
Your Application will be reviewed on the day it is received for possible eligibility for expedited service.
You have the right to file an application even if you appear to be ineligible for the program.
You or a designated authorized representative may file an incomplete application as long as it contains a
name, address, and signature of a responsible household member or properly designated authorized
representative. The agency has 30 days to process your application (7days, if expedited). The 30-day
(or 7-day, if expedited) processing time begins the day after the application is received at the office.
Additionally, your SNAP benefits for the month of application will be prorated from the date of application
if you are found eligible.
If your case is approved, you must receive your benefits within 30 days following the date of application
(or 7 days, if expedited)
As part of the SNAP application process, you must have an interview before you are certified. The
interview is not necessary before you file the application. The interview may be held in the office or by
telephone.
SNAP has separate rules and processes from other programs. You should apply for SNAP benefits even
if there are limitations on receiving benefits for other programs.
YOU ARE ENCOURAGED TO APPLY FOR SNAP BENEFITS THE SAME DAY YOU CONTACT THE
AGENCY FOR ASSISTANCE.
AGENCY NAME:
ADDRESS:
PHONE NUMBER:
OFFICE HOURS:
SNAP is administered without regard to age, race, color, sex, disability, religion, national origin, or political
beliefs. The Virginia Department of Social Services is an equal opportunity provider.
032-03-0821-05-eng (9/13)
VIRGINIA DEPARTMENT
OF SOCIAL SERVICES
10/09
APPLICANT RIGHTS FLYER
VOLUME V, PART XXIV, PAGE 39
KNOW YOUR RIGHTS WHEN APPLYING FOR SNAP BENEFITS
FORM NUMBER - 032-03-0821
PURPOSE OF FORM - To consolidate information the local agency must share with an
applicant for SNAP benefits. The form is optional.
USE OF FORM - May be given to applicants requesting SNAP information instead of a verbal
explanation of applicants' rights. The agency must advise applicants that the form is a listing of
program rights. The agency must also ensure that the applicant is able to read the form in
English and comprehend it.
NUMBER OF COPIES - One.
DISPOSITION OF FORM - The flyer may be given to applicants inquiring about SNAP benefits.
INSTRUCTIONS FOR PREPARATION OF FORM - Complete the identifying information at the
bottom of the form, supplying the local agency's name, address, telephone number, and office
hours.
TRANSMITTAL #1
Commonwealth of Virginia
Department of Social Services
REQUEST FOR ASSISTANCE
--- ADAPT ---
COMPLETING THE REQUEST FOR ASSISTANCE
If you need help completing this Request for Assistance, a friend or relative or your
eligibility worker may help you. If you are completing this Request 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 more than 6 people are living in your home and you need
more space to list everyone, tell the agency you need extra pages.
GENERAL INFORMATION
EXPEDITED SERVICE FOR SNAP BENEFITS
This Request for Assistance is the first part of the application process and protects
your application date. You must also complete the second part of the application
process by (1) having an interview, or (2) completing an Application for Benefits
form, or another appropriate application.
Your household may qualify for Expedited Service and receive SNAP benefits within
7 days if you are eligible and your gross monthly income is less than $150 and liquid
resources are $100 or less; or your monthly shelter bills are higher than your
household’s gross monthly income plus your liquid resources; or your household is a
migrant or seasonal farm worker household with little or no income and resources.
GIVE THE INFORMATION REQUESTED IN THE BOXES BELOW SO YOUR
ELIGIBILITY FOR EXPEDITED SERVICE MAY BE DETERMINED.
With this Request for Assistance, you may begin the application process for one or
more of the following assistance programs.
Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF)
TANF Emergency Assistance
Refugee Cash Assistance
General Relief – Unattached Child
COMPLETE AND ACCURATE INFORMATION
You must give complete, accurate, and truthful information. If you refuse to give
needed information, we may not be able to determine your eligibility for assistance.
Information regarding your race is not required. However, if you decide not to give
this information, your worker will complete that section. If you knowingly give false,
incorrect or incomplete information, or fail to report changes, you could lose your
benefits and be arrested, prosecuted, fined and/or imprisoned. If you knowingly
give false, incorrect, or incomplete information in order to help someone else
receive benefits, you could be arrested and prosecuted for fraud.. You must also
provide required verifications.
$_____________
Total cash, money in checking/savings accounts, CDs
$_____________
Total rent or mortgage for this month
$_____________
Utility expenses for this month
Which utilities do you pay? (check all that apply)
$_____________
 Heat
 Water
 Lights
 Sewer
 Telephone
 Garbage
 Electricity for Air Conditioning
 Other
Is anyone in your household a migrant or seasonal farm worker? YES ( ) NO ( )
FILING A REQUEST FOR ASSISTANCE
You may turn in a partially completed Request for Assistance which contains at
least your name, address, and signature (or the signature of your authorized
representative), but you must complete the rest of the application process before
your eligibility can be determined. For some programs, you must also be
interviewed, but you may turn in your Request for Assistance before your interview.
NAME
DATE OF BIRTH
ADDRESS
SOCIAL SECURITY NUMBER
TELEPHONE NUMBER
You may return your Request for Assistance by mail, fax, or in person. If you return
the form in person, you may turn it in any time during office hours the same day you
contact your local social services agency. You have the right to file your Request for
Assistance, even if it looks like you may not be eligible for benefits.
032-03-0875-15-eng (9/13)
Total income received/expected this month before deductions
SIGNATURE
1
DATE
VERIFICATION AND USE OF INFORMATION
NONDISCRIMINATION STATEMENT (continued)
Information you give on this application, including Social Security numbers (SSN),
may be matched against federal, state, and local records. These records include:
Virginia Employment Commission
Internal Revenue Service
Department of Motor Vehicles
U.S. Citizenship and Immigration Services
Social Security Administration
Individuals who are deaf, hard of hearing or have speech disabilities may
contact USDA through the Federal Relay Service at (800) 877-8338, or
(800) 845-6136 (Spanish).
For any other information dealing with SNAP issues, persons should either
contact the USDA SNAP Hotline Number at (800) 221-5689, which is also
in Spanish or call the State Information Hotline Numbers (click the link for a
listing
of
hotline
numbers
by
State);
found
online
at
http://www.fns.usda.gov/snap/ contact_info/hotline.htm.
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 or TANF claims collection actions.
To file a complaint of discrimination regarding a program receiving Federal
financial assistance through the U.S. Department of Health and Human
Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F,
200 Independence Avenue, S. W , Washington, D.C. 20201 or call (202)
619-0403 (voice) or (800) 537-7697 (TTY).
USDA and HHS are equal opportunity providers and employers.
AGENCY USE ONLY
EXPEDITED SERVICE DETERMINATION
NONDISCRIMINATION STATEMENT
This institution is prohibited from discriminating on the basis of race, color, national
origin, disability, age, sex and in some cases religion and political beliefs.
Screener: _______________________
The U.S. Department of Agriculture (USDA) also prohibits discrimination against its
customers, employees, and applicants for employment on the basis of race, color,
national origin, age, disability, sex, gender identity, religion, reprisal, and where
applicable, political beliefs, marital status, familial or parental status, sexual
orientation, or all or part of an individual's income is derived from any public
assistance program, or protected genetic information in employment or in any
program or activity conducted or funded by Department. Not all prohibited based
will apply to all program and/or employment activities.
Date: ____________
Income < $150 + resources ≤ $100
YES (
)
NO (
)
Income + resources < shelter bills
YES (
)
NO (
)
For migrants or seasonal farm workers:
•
If you wish to file a Civil Rights program complaint of discrimination with USDA,
complete the USDA Program Discrimination Complaint Form found online at
http://www.ascr.usda.gov/complaint_filing_cust.html or at any USDA office, or call
(866) 632-9992 to request the form. You may also write a letter containing all of the
information requested in the form. Send your completed complaint form or letter to
us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442
or email at [email protected].
•
Resources ≤ $100 and ≤ $25 is expected in next 10 days from
new income:
YES ( ) NO ( )
OR
Resources ≤ $100 and $0 income is expected from a terminated
source for the rest of this month or next month
YES ( ) NO ( )
EXPEDITE IF YES TO ANY OF THE ABOVE
2
Commonwealth of Virginia
Department of Social Services
REQUEST FOR ASSISTANCE
--- ADAPT ---
Case Name
AGENCY USE ONLY
Date Received
Program(s)
Registration Number
Application Type
Locality
Caseload Number
Worker
Case Number(s)
DATE OF INTERVIEW
 In office
 Telephone
1.
Applicant’s Name
Phone Number
(Home/Messages)
E-mail Address (if you would like to receive electronic messages)
(Work/Other)
Residence Address (Include City, State and Zip)
Mailing Address (If Different)
2.
Check () your household’s primary language:
3.
LIST EVERYONE LIVING IN YOUR HOME even if you are not requesting assistance for that person. List yourself on the first line. If you are married, list your spouse on the second
line. Then list everyone else. Provide the information requested for each person listed. Check () type of assistance requested for each person. If no assistance is requested, check
NONE for that person. You do not have to provide the Social Security Number and Alien Registration Number for any individual unless you are applying for assistance for that person.
Please note that an application for TANF will also be an application for SNAP (food stamps). Check TANF - No SNAP if you do not want to apply for SNAP benefits.
Social
Security
Number
) Vietnamese ( ) French
( ) Farsi
) German
( ) Chinese
( ) Haitian-Creole
) Other_____________________________________
Alien
Registration
Number
1 Hispanic/
Latino
2 Not
Hispanic/
Latino
(Your Name)
(Your Spouse’s Name, if married)
3
This
Person’s
Relationshi
p To You
None
Date
of
Birth
(
(
(
Refugee Cash Assistance
1- White
2- Black/African
American
3- American
Indian/
Alaska Native
4- Asian
5- Native
Hawaiian/
Pacific
Islander
Ethnicity
(Not
required)
) Cambodian
) Japanese
) Laotian
TANF Emergency Assistance
Race
(Not required)
Select all that
apply
(
(
(
General Relief – Unattached Child
Sex
M/F
) Spanish
) Arabic
) Korean
TANF - No SNAP
Name
Last Suffix (Jr., Sr.)
(
(
(
TANF
Mi
) English
) Kurdish
) Somali
SNAP (food stamps)
First
(
(
(
Agency
Use Only
Client Id
4.
YES ( )
NO ( ) Have you or anyone for whom you are applying ever applied for or received or are currently receiving any benefits from a social services agency,
including SNAP (food stamps), TANF, Medicaid, General Relief, Auxiliary Grants, Foster Care, Adoption Assistance, Refugee Cash or Medical
Assistance?
Person Who Applied for or Received Benefits
Under What Case Name
Type of Benefits Received
When
From What County or City or State
5.
YES ( )
NO ( ) Does anyone have any of the following emergencies? If YES, check () the type of emergency and explain the cause.
( ) Food
( ) Shelter
( ) Clothing
( ) Other Emergency_____________________________________________________
Cause: ___________________________________________________________________________________________________________
6.
YES ( )
NO ( ) Is there anything you would like to talk about with a service worker? This could include concerns about your children, school problems,
child care needs, family planning, family violence, referrals to other community organizations, or other problems or concerns. If YES, explain.
Explain:
BY MY SIGNATURE BELOW I DECLARE, UNDER PENALTY OF PERJURY, THAT THE INFORMATION PRESENTED HERE IS CORRECT AND COMPLETE
TO THE BEST OF MY KNOWLEDGE AND BELIEF. I understand:



All of the information in the GENERAL INFORMATION Section on pages 1 and 2.
If I give false, incorrect, or incomplete information, I may be breaking the law and could be prosecuted for perjury, larceny, or welfare fraud.
If I helped someone else complete this form so as to get benefits he or she is not entitled to receive, I may be breaking the law and could be prosecuted.
I understand that different state agencies provide different services and benefits. Each agency must have specific information to determine eligibility services and
benefits.
 I allow  I do not allow the Department of Social Services to disclose certain information about me to other state agencies, including information in electronic
databases, for the purpose of determining my eligibility for benefits/services provided by that agency. This disclosure will make it easier for agencies to work together
efficiently to provide or coordinate services and benefits. Agencies include, but are not limited to, the Department of Health, the Department for the Aging, the
Department of Rehabilitative Services and the Department of Vocational Rehabilitation. I can withdraw this authorization at any time by notifying my eligibility worker.
I filled in this Request for Assistance myself.
YES ( ) NO ( )
Applicant or authorized representative’s signature or mark
If NO, it was read back to me when completed.
Date
Witness to mark or interpreter
Complete the box below if this request for assistance was completed for the applicant by someone else:
Name of person completing the application
Date
Address
Phone number
(Home)
(Work)
Relationship to applicant
YES ( ) NO ( )
Date