Attachment B - FNS form -292B

OMB APPROVED NO. 0584-0037
Expiration Date: 07/31/2014

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U.S. Department of Agriculture - Food and Nutrition
Services

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
REPORT OF DISASTER
estimated to average .42 hours per response, including the time for reviewing instructions, searching
SUPPLEMENTAL NUTRITION
existing data sources, gathering and maintaining the data needed, and completing and reviewing the
ASSISTANCE BENEFIT ISSUANCE
collection of information.
Submit completed report to: Regional Administrator, Food and Nutrition Service, USDA, no later than 45 days after completion of emergency relief operations.
DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE BENEFIT ISSUANCE. Complete items 1 through 15. If the authentication to issue supplemental nutrition
assistance 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, zip codes., located within area of disaster.)

6. PRESIDENTIAL DECLARATION
YES
NO
8. APPLICATION PERIOD
FROM
THROUGH
(MM, DD, YYYY)

THROUGH

(MM, DD, YYYY)

FLOOD

HURRICANE

WINTER STORM

WILDFIRE

TORNADO
OTHER (Specify)

(MM, DD, YYYY)

9. BENEFIT PERIOD OF ISSUANCE
FROM

7. TYPE OF DISASTER

(MM, DD, YYYY)

10. ALLOTMENT ISSUED TO EACH HOUSEHOLD
NEW HOUSEHOLDS:

1 MONTH MAXIMUM ALLOTMENT

OTHER (Specify)

ONGOING HOUSEHOLDS:

SUPPLEMENTAL UP TO THE MAX. ALLOTMENT

OTHER (Specify)

YES

AUTOMATIC SUPPLEMENTS?

NO

11. GIVE TOTAL BREAKDOWN OF DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE BENEFIT ISSUANCE FOR EACH PROJECT AREA AFFECTED
ONGOING RECIPIENT
HOUSEHOLDS APPROVED

NEW APPLICANT
HOUSEHOLDS APPROVED

NAME OF PROJECT AREA

NUMBER OF NUMBER OF
HOUSEHOLDS PERSONS
ISSUED
ISSUED
BENEFITS
BENEFITS

TOTAL
VALUE OF
BENEFITS
ISSUED (1)

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

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

TOTALS

$

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

13. SIGNATURE

FORM FNS-292B (04/11) Previous Editions Obsolete

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

15. DATE

SBU

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