Report of Disaster Food Stamp Benefits Issuance

FORM APPROVED OMB. NO. 0584-0037
U.S DEPARTMENT OF AGRICULTURE - FOOD AND NUTRITION SERVICE

REPORT OF DISASTER FOOD
STAMP BENEFIT ISSUANCE

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0584-0037. The time required
to complete this information collection is estimated to average .42 hours per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data need, and completing reviewing the collection information.

Submit completed report to: Regional Administrator, Food and Nutrition Service, USDA no later than 45 days after completion of disaster relief operations.
DISASTER FOOD STAMP BENEFIT ISSUANCE. Complete items 1 through 15. If the authentication to issue food stamp benefits under disaster procedures is extended, a separate report should
be submitted for each authorization period.
3. AGENCY CODE (7 Digits)
4. DISASTER DATE
1. STATE NAME 2. AGENCY NAME
5. BRIEF DESCRIPTION OF AREA AFFECTED (counties, cities, towns, etc., located within area of disaster.)

6. PRESIDENTIAL DECLARATION
YES __ NO
8. APPLICATION PERIOD
FROM

THROUGH

(MM, DD, YYYY)

__ FLOOD

__ HURRICANE

__TORNADO

__ WINTER STORM

__ WILDFIRE

__OTHER(Specify)__________

(MM, DD, YYYY)

9. BENEFIT PERIOD OF ISSUANCE
FROM

7. TYPE OF DISASTER

10. ALLOTMENT ISSUED TO EACH HOUSEHOLD

THROUGH

NEW HOUSEHOLDS:
__ 1 MONTH MAXIMUM ALLOTMENT
ONGOING HOUSEHOLDS:
__ SUPPLEMENT UP TO THE MAX. ALLOTMENT
AUTOMATIC
SUPPLEMENTS?
___YES ___NO
(MM, DD, YYYY)
(MM, DD, YYYY)
11. GIVE TOTAL BREAKDOWN OF DISASTER FOOD STAMP BENEFIT ISSUANCE FOR EACH PROJECT AREA AFFECTED
NEW APPLICANT
HOUSEHOLDS APPROVED

NAME OF PROJECT AREA

NUMBER OF NUMBER OF
HOUSEHOLDS PERSONS
ISSUED
ISSUED
BENEFITS
BENEFITS

__OTHER (Specify)_________
__OTHER (Specify)_________

ONGOING RECIPIENT
HOUSEHOLDS APPROVED

GRAND TOTAL
OF BENEFITS
ISSUED (1) + (2)

TOTAL
NUMBER OF TOTAL VALUE
NUMBER OF
NUMBER OF
VALUE OF
OF
PERSONS
HOUSEHOLDS HOUSEHOLDS
BENEFITS
SUPPLEMENTS
ISSUED
DENIED
ISSUED
ISSUED (1)
ISSUED (2)
SUPPLEMENTS SUPPLEMENTS

TOTALS

$

12. REMARKS (if more space is needed, attach sheet)

13. SIGNATURE

FORM FNS-292-B (4-08) Previous Editions are Obsolete

15. DATE

14. TITLE

This report is required by Regulations (7 CFR, Part 274).
The result of the emergency relief operations need to be
comprehensive, accurate, and timely.

SBU

Electronic Version Designed in Adobe 8.1 version