Food (Snap) And Cash Assistance Combined Application printable pdf download

Virgin Islands Department of Human Services

Date Received:

Case Number:

Division of Family Assistance

COMBINED APPLICATION – PART I

Food (SNAP) and Cash Assistance

We consider all applications without regard to race, color, national origin, sex, age, or disability

PLEASE PRINT

Step 1 COMPLETE PART I

To begin to apply for SNAP/cash assistance and establish your application date to receive benefits, you can complete Part I and give it to us today. You are only required to give us

your name, address and signature for your application to be considered filed. We are required to verify information you provide and to take action on your application within 30 days

from the date you give us this completed Part I, unless you qualified for SNAP right away.

If you qualify to get SNAP benefits right away, we are required to take action on your

application within 7 days from the date you gave us this completed Part I. The amount of benefits for the first month is based on the date of application. So, the sooner you give us

this Part I and any required verification, the quicker you will know whether you will receive SNAP /cash benefits. The eligibility worker will tell you what information needs to be verified

and the items to bring for your interview.

Step 2 COMPLETE PART II

The Certification Office will schedule an interview at which time the Eligibility worker will assist you in completing Part II.

Name

EXPEDITED SERVICE

SNAP only:

The answers to the questions below will help us decide if we

SNAP only:

must process your application quickly to see if you qualify to get

DO YOU LIVE IN AN APARTMENT?

DO YOU LIVE IN A HOUSE?

ARE YOU A BOARDER?

SNAP

within 7 days.

1. How many people live in your home and eat with you?

YES

(Include yourself) __________.

Address where you live

2. How much is your monthly rent or mortgage?

City

State

Zip

$________________________.

Mailing Address (if different)

3. How much are your monthly utilities? $___________.

City

State

Zip

4. Did all of your household income recently stop?

Phone Number where you can be reached

Yes

If yes, when? _________________.

Home:

Other:

5. What is the total income you expect your household to

receive this month? $____________________.

YOU MAY GET SNAP BENEFITS RIGHT AWAY IF YOUR HOUSEHOLD:

6. How much does your household (Including children) have in

• Monthly rent/mortgage and utilities are more than your household’s gross monthly income; & liquid resources;

cash, checking or savings?

• Gross monthly income is less than $150 and your household’s resources,

such as cash or checking /savings accounts, are $100 or less; or

(Give best total estimate)$____________________

Is a migrant or seasonal farmworker household

•

7. Is anyone in your household a migrant or seasonal

DECLARATION

farmworker?

Yes

I understand the questions on this application form and the penalty for hiding or giving false information or breaking

8. If anyone in your household was a migrant or seasonal

any of the rules listed in the penalty warning.

I understand and agree to provide documents to prove what I have

farmworker at any time during the current migration season,

said. I understand and agree that the Certification Office may contact other persons or organizations to obtain the

was your household approved for a postponement of

necessary proof of my eligibility and level of benefits. I understand that information through IEVS will be requested

verification requirements?

and such information may affect my household’s eligibility and level of benefits.

I understand that the alien status of

Yes

If yes, when and where?

any household member may be subject to verification by USCIS, and that the submitted information received from USCIS

__________________________________________________

may affect the household’s eligibility and level of benefits. I understand that I or others in my home might have to take part

in an EMPLOYMENT and TRAINING program to receive cash assistance or SNAP.

I certify, under penalty of perjury, that

__________________________________________________

all my answers are correct and complete to the best of my knowledge, including information about the citizenship or

Signature and date of person screening for expedited service

alien status of each household member.

Please read Rights and Responsibilities attached to this form before signing.

Signature of Applicant or Authorized Representative

Date

Worker Signature

Date

Food (Snap) And Cash Assistance Combined Application

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