Appendix F CAP State Template

Template for Combined Application Project Cost Neutrality Report Submission									OMB No.0584-NEW
Please note: When submitting reports to FNS, do NOT include clients’ Personally Identifiable Information (PII).									Exp xx-xx-xxxx
Instructions
Insert Sample Data into the Columns Below
Case #	Household Size	Monthly SSI Amount	Monthly Earned Income	Monthly Other Income	Medical Expense Deduction OR SMD	Actual Utility Costs OR SUA	Actual Shelter Expenses, Excluding Utility Costs	Regular SNAP Benefit	CAP Standardized Shelter Amount (if applicable)	CAP Benefit
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