Appendix C_D-SNAP_Request_Template_0584-0336_9-29 Edits_Clean

APPENDIX C - WAIVER REQUEST

DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM

This is the public burden statement necessary for all instruments: Public reporting burden for this collection of information is estimated as 10 hours per response for initial D-SNAP requests and 3 hours per response , including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Policy Support, 1320 Braddock Place, 5^th Floor, Alexandria, VA 22314 ATTN: PRA (0584-0336*). Do not return the completed form to this address.

Type of request: Initial, Extension, Expansion, or Modification

State: Click here to enter text.

Region: Click here to enter text.

Regulatory Citations: 7CFR 273.1(a), 273.2(f), 273.7, 273.8(e), 273.9(a), 273.10(e), and 273.10(f)

Disaster Information: Identify type of disaster. Date the disaster struck or date of mandatory evacuation order. Counties or other areas included in the Presidential disaster declaration for individual assistance. Explain which counties or areas are included under this request and why.

Disaster Impact: Include number of households/businesses impacted. Use joint FEMA, state and local Preliminary Damage Assessments (PDAs); power outage information; and/or flood/mandatory evacuation maps. Are commercial channels of food distribution up and running?

Benefit Period: List the start and end dates for the 30-day benefit period beginning date disaster struck/date of mandatory evacuation order.

Application Period: List the start date and end date for the application period (typically 7 days). Describe locations, dates and hours of operation for application sites (note if sites are opened on weekends/holidays).

Eligibility Criteria: Will eligibility extended to households who lived or who lived/worked in the disaster area? Is food loss alone a qualifying factor? Is the State using the DSED?

Ongoing Households: Will the State issue supplements? If so, automatic or by affidavit? If automatic, who is eligible? If by affidavit what is the process for requesting?

Anticipated Issuance: Include estimated number of new D-SNAP applicants. Estimated number of ongoing clients that will request/receive supplements. If automatic supplements, include total estimated value of benefit issuance. How was estimate derived?

EBT: Describe issuance procedures; number of disaster EBT cards on hand’ plans for requesting, receiving, and distributing additional cards as needed. State whether the cards on hand have been tested and are viable. Include name of card vendor.

Duplicate Participation: Describe how/when checks will be conducted.

Program Integrity: Describe fraud prevention strategies and security measures in place.

Logistics: Describe application sites, plans for publicity, and security/crowd control. Include plans for ensuring access to persons with disabilities, the elderly and other vulnerable populations, as appropriate (e.g. authorized representatives, satellite application sites, special public transport, home visits, use of Skype or similar technology to conduct interviews, or other alternative procedures).

Staffing: Describe plans for utilizing staff from other areas, as appropriate. Indicate number of staff/supervisors available and how they will be distributed among application sites.

Employee Applications: Describe procedure for handling applications from State agency employees.

Attachments: Required supporting documentation including: draft press releases, D-SNAP application, PDAs, FEMA declaration, map of disaster area. Any other optional supporting information (such as client notices).