What Happens After I Return My Application to Social Services?
Once we receive this signed application, we will determine if you continue to be eligible for SNAP.
We will send you a letter telling you about your benefits. This letter will explain your right to
request a fair hearing if you are not satisfied with our decision on your application. If you do not
agree with the decision made on your case, follow the instructions on the letter to request a
What If I Need Someone to Apply For or Use My SNAP Benefits For Me?
If you want someone other than yourself to use, or obtain information about your benefits, please
check the box below. If you check Yes, we will mail you a form. You and the person you want to
help can complete the form and return it to our office. This person will receive an EBT card and
will have access to your Food and Nutrition Services benefits.
I need someone to help me get and use my benefits. Yes
Thank you for your continued participation in the Simplified Nutritional Assistance Program
(SNAP). We hope this way of receiving benefits will be easier for you and prove to be more
helpful in purchasing food.
Do you want to receive your notices in a language other than English? If yes, what language?
If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program
Discrimination Complaint Form (PDF), found online at
, or at any USDA office, or call (866) 632-9992 to
request the form. You may also write a letter containing all of the information requested in the form.
Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director,
Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202)
690-7442 or email at firstname.lastname@example.org. Individuals who are deaf, hard of hearing 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.
For Agency Use Only – Do Not Write In Space Below
Certification Period: From_______________ to________________________
Reason for Denial: ______________________________________________
Certification Worker Signature: _____________________________________________________
Date of Disposition: _____________________________________________________________
Economic and Family Services