Appendix E D-SNAP Sample Application

1.2 D-SNAP Application (English)
Disaster Benefit Period
APPLICATION FOR DISASTER SUPPLEMENTAL NUTRITION ASSISTANCE (D-SNAP)

Begin:__________ End:__________

In accordance with Federal law and U.S. Department of Agriculture policy, this institution is Number:______________________
prohibited from discriminating on the basis of race, color, national origin, sex, age, religion,
political beliefs, or disability. To file a complaint of discrimination, write USDA, Director,
Office of Adjudication, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W.,
Application
Washington, D.C. 20250–9410 or call toll free (866) 632-9992. Individuals who are hearing
Date:________________
impaired or have speech disabilities may contact USDA through the Federal Relay service at
(800) 877-8339; or (800) 845-6136 (Spanish). USDA is an equal opportunity provider and
employer.
DO NOT WRITE IN SHADED AREAS.
INSTRUCTIONS: Complete this application honestly and to the best of your knowledge. If your household knows but refuses to
give any required information, it will not be eligible to receive D-SNAP benefits. When you are interviewed, you must show
identification and may be required to verify your residency {inset “place of work” if applicable to disaster} in the disaster area at
the time of the disaster, household composition, and disaster-related expenses. You can authorize someone outside your
household to apply for, receive, or use your Disaster Supplemental Nutrition Assistance benefits.
Head of Household

Verified Authorized Representative

Permanent Home Address with zip code

Verified Temporary Address and Telephone Number (if different)

Phone Number(s):

Mailing Address (if different) with zip code

County:
PART A – HOUSEHOLD SITUATION
Was your household living {inset “working” if applicable to disaster} in the disaster area at the time of the disaster? YES
If yes, please answer the following questions:
Did the disaster damage or destroy your home or self-employment property?
Does your household have any additional expenses as a result of the disaster?
Does your household plan to buy food before {insert end date of disaster period}?
Did the disaster delay, reduce or stop any of your household’s income?
Does your household have money in checking/savings accounts which you cannot get to because the bank is closed or
inaccessible due to the disaster?

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NO

Is anyone in your household employed by (insert name of State SNAP agency)?
Are you a current Supplemental Nutrition Assistance (Food Stamp Program) participant?
If yes, State: _____________________ County: _____________________

List the members of your household, including yourself, who were living and eating with you at the time of the disaster. List each
household member’s social security number (SSN) if available. Applicants are not required to have or give their Social Security
Number on this application in order to qualify for D-SNAP. Also list each household member’s date of birth, sex, race and source and
amount of take-home pay. List any other income your household members have received or expect to receive during the D-SNAP
benefit period (list start/end dates). DO NOT INCLUDE PEOPLE WHO WERE NOT PART OF YOUR HOUSEHOLD WHEN THE DISASTER
HAPPENED. IF YOU ARE TEMPORARILY STAYING WITH ANOTHER HOUSEHOLD BECAUSE OF THE DISASTER, DO NOT LIST MEMBERS
OF THAT HOUSEHOLD.
PART B – HOUSEHOLD MEMBERS (Attach paper for more space)
First Name / Last Name

Social Security No. Birth Date
(if available)

PART C – INCOME
Sex

Race

Source/Type

Amount

PART D – RESOURCES

PART E – EXPENSES

List all cash your household will be able to get to
during the disaster

List disaster-caused expenses that your household paid or expects to pay during
this disaster. DO NOT INCLUDE EXPENSES THAT WERE PAID OR WILL BE PAID BY
SOMEONE OUTSIDE YOUR HOUSEHOLD.

AMOUNT

AMOUNT

Checking accounts

Dependent care due to disaster

Saving accounts

Funeral/medical expenses due to disaster

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Cash on hand

Moving and storage costs due to disaster
Temporary shelter expenses
Cost to protect property during disaster
Cost to repair/replace home or self-employment property
Other disaster-related expenses
Food destroyed in disaster

PART F – CERTIFICATION AND SIGNATURE
I understand the questions on this application and the penalties for hiding or giving false information. My household is in need of
immediate food assistance as a result of the disaster. I certify, under penalty of perjury, that the information I have given is correct
and complete to the best of my knowledge. I also authorize the release of any information necessary to determine the correctness of
my certification. I understand that if I disagree with any action taken on my case, I have the right to request a fair hearing orally or in
writing.
APPLICANT, AUTHORIZED REPRESENTATIVE, OR WITNESS (if signed with an X)
__________________________________________________________________ DATE: __________________

PART G – PENALTY WARNING
If your household gets Supplemental Nutrition Assistance benefits, it must follow the rules listed below. This application is subject
to review by Federal and State authorities to make sure you were eligible for disaster aid.
DO NOT give false information or hide information to get or to continue to get Supplemental Nutrition Assistance benefits.
DO NOT give or sell Supplemental Nutrition Assistance benefits or authorization documents to anyone not authorized to use
them.
DO NOT alter any Supplemental Nutrition Assistance authorization documents to get benefits you are not entitled to.
DO NOT use Supplemental Nutrition Assistance benefits to buy unauthorized items such as alcohol or tobacco.
DO NOT use another household’s Supplemental Nutrition Assistance benefits or authorization documents for your household.

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