Appendix D ESAP Application Form

OMB Control Number 0584-NEW

Expires xx/xx/xxxx

Type of Request: Date of Request Click here to enter a date.

State Region:

Statutory Citations

Section 3(f). Defines “certification period” as the period for which households are eligible to receive SNAP benefits. The certification period shall not exceed 12 months, except that the certification period may be up to 24 months if all adult households members are elderly or disabled. A State agency shall have at least one contact with each certified household every 12 months.

Section 11(e)(3). Requires that the State verify all non-excludable income and households size (if questionable).

Regulatory Citations

7 CFR 273.2(f). Requires the State agency to verify gross nonexempt income, utility expenses, medical expenses, social security numbers, residency, and identity.

7 CFR 273.10(f)(1). Allows the State agency to certify households in which all adult members are elderly or disabled for up to 24 months.

7 CFR 273.14(b)(3). Requires that the State agency interview application households prior to recertification.

Justification for request

Pilot or demonstration projects are designed to test program changes that might increase the efficiency of the Supplemental Nutrition Assistance Program (SNAP) and improve the delivery of SNAP benefits to eligible households. Please use this space to describe how implementing an ESAP in your State will achieve these and any other objectives.

Description of alternative procedures

As you describe alternative procedures, please consider and address the areas, comments, and questions below regarding proposed ESAP procedures.

1. Eligibility:

Describe the specific populations who will be eligible for the ESAP such as the elderly with no income and/or the disabled with no income.

2. Application Form:

Describe any changes to the application form used for eligible households. Describe any specialized instructions on the form such as a description of deductions or accompanying materials. Indicate if the ESAP application will be available in paper, online, or both.

3. Expedited Service:

Describe any alternative procedures that specifically address ESAP households eligible for expedited service such as immediate screening. How will ESAP applicants be screened for expedited service? What alternative procedures, if any, will there be for processing expedited ESAP applications?

4. Conversion of Households:

Describe the State’s strategy for converting eligible households in regular SNAP to ESAP. Similarly, describe the State’s strategy for converting ESAP households to regular SNAP if they are no longer eligible for the ESAP, but remain eligible for SNAP. Similarly, describe the State’s strategy for converting ESAP households to regular SNAP if they are no longer eligible for the ESAP, but remain eligible for SNAP.

5. Interview:

Describe the State’s interview process under the ESAP demonstration. How will the State notify the eligible household that a recertification interview is not required, but may be requested? What information will be included on the notices?

6. Verification:

Describe the State’s procedures for addressing the specific verification components of the ESAP. How will the State verify information for ESAP applicants? How often will this information be verified? What databases will be used in data matching? What data fields will be matched? What are the procedures for discrepancies in information? What documents will the household need to provide verification for? How often will this information be verified? What databases will be used in data matching? What data fields will be matched? What are the procedures for discrepancies in information? What documents will the household need to provide verification i.e. medical deductions, residency? Below is an example of how the information should be provided:

• Beneficiary & Earnings Data Exchange (BENDEX) – monthly

• Electronic Disqualified Recipient System (eDRS) – at initial certification

• National Database of New Hires (NDNH) – monthly

• Old Age, Survivors, and Disability Insurance (OASDI) – daily

• Supplemental Security Income (SSI/SDX) – daily

• Systematic Alien Verification for Entitlements Program (SAVE) – ran prior to initial certification

7. Certification Period and Recertification:

Describe any systems changes needed to address the 36 month certification period of ESAP households. Describe the specifics of the recertification process under the ESAP. How will the State manage the 36 month certification period for ESAP households? How will the State manage the 12 month interim reports?

8. Reporting:

What reporting system does the State use for ESAP households? Describe the State’s reporting process for ESAP households such as anticipating changes in household circumstances, acting on changes, ensuring appropriate deductions over time. How will the State inform participants of these reporting requirements, in the eligibility notice and initial interview?

9. Outreach:

Describe the outreach plan for ESAP such as identifying partner organizations, providing training on ESAP applications and eligibility criteria, creating a community resource guide.

10. Training:

Describe the training plan and strategies the State will implement. How will the State train eligibility workers on ESAP certification procedures and other components of the demonstrations?

The State will provide an annual report for each year of the project. Annual reports are due three months after the end of each reporting period. The annual reports include three parts: certification and recertification, timeliness, and QC. The State will use the templates in the ESAP Reporting Template spreadsheet provided by FNS.

The State must select cases for the annual review at random. Cases reviewed through the QC process may be included in the project evaluation. If an insufficient number of cases are pulled through the regular QC process to meet minimum evaluation requirements, the State may select additional cases and conduct a desk review of case information, including verification of client information via telephone if necessary. State reports should describe methods of data collection and analysis, including the random case selection process, in an executive summary of the report.

Describe any issues that may prevent the State from implementing the evaluative components of this demonstration project.

Description of anticipated changes in program enrollment, cost, or other impacts on households and State agency operations.

Please note all ESAP demonstrations are required to be cost neutral. Please click here to enter text.

Caseload information:

Percent of caseload eligible under the waiver (60+, no earned income): XX%.

Additional relevant characteristics such as special demographic characteristics, trends in enrollment etc.: Click here to enter text.

Anticipated implementation date: Click here to enter a date.

Signature of requesting official:

Print Name: Click here to enter text.

Title: Click here to enter text.

State Agency Contact

Name: Click here to enter name.

Email: Click here to enter email.

Telephone: Click here to enter telephone number.

Regional Office Contact

Name: Click here to enter name.

Name: Click here to enter email.

Name: Click here to enter text.

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not 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 OMB No.0584-NEW. The time required to complete this information collection is estimated to average 1105 hours per response for new demonstration project request and 24 hours for a modification and/or extension of an existing demonstration project.

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Last updated 10/27/2021