Supplemental Nutrition Assistance Program (Snap) Application/recertification Page 3
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7LDSS-4826
Page 2
(Rev.8/12)
INCOME
List ALL your income and the income of anyone living with you. This includes, but is not limited to wages, income from self-employment
(for example: babysitting, cleaning, income from a roomer or boarder) child support, pensions, veterans benefits, disability, social
security or SSI, grant for scholarships for rent or food, Temporary Assistance, and income from friends or relatives.
How Often is it Received?
Gross Amount Received
Name of Person Receiving Income
Source of Income
Hours Worked Per Month
(for example, weekly, bi-weekly,
Before Deductions
monthly)
Do you or does anyone living with you have child/dependent care costs related to employment or training?
Yes
No If Yes, who
.
Amount paid $ ____________. How often paid (e.g., weekly, monthly) _________________________.
Have you or has anyone living with you changed or quit jobs or reduced any form of income in the last 30 days – including reduced work hours or income?
Yes
No
Do you or does anyone living with you have any potential income that has not yet been received?
Yes
No If Yes, explain on Page 6.
Do you or does anyone living with you receive a Personal Needs Allowance (PNA) or a Meal Allowance?
Yes
No If Yes, who
.
Have you or has anyone in your household set aside any income under “PASS: Plan To Achieve Self Support” approved by the Social Security Administration?
Yes
No If Yes, who
.
Are you or is anyone living with you participating in a strike
Yes
No If Yes, who
?
.
RESOURCES
Resources do not affect the eligibility of most households applying for SNAP. However, some resource information is used to determine if you qualify for expedited processing of your
application.
How much money does everyone in your household have? (For example, on your person; in your home, in checking and savings accounts, or other locations, including
jointly held accounts)
$______________ Belongs to
.
Other financial assets? (For example, stocks, bonds, retirement accounts, savings bonds, mutual funds, IRAs, trust funds, money market certificates)
Yes
No
If Yes, amount $_______________ Type ________________________________ Owner _________________________________
.
How many cars, trucks or other vehicles do you or anyone in your household have?
#1 Year
Make
Model
Owner
___
_____
_______________________
________________________
_________________________
2 Year
Make
Model
Owner
___ #
_____
_______________________
________________________
_________________________
Do you or anyone applying own any property including your own home?
Yes
No if yes, list property_________________________ Owner
____________________
Has anyone applying sold, given away or transferred cash or property in the last three months to qualify for SNAP?
Yes
No
LIVING ARRANGEMENTS AND EXPENSES
Check all the descriptions that apply to your household:
Own home or paying for home
Renting
Migrant/seasonal farmworker
No permanent residence
Live with relatives or friends
List expenses:
Monthly rent or mortgage payment $ _____________ Tax on home per year $ ____________ Insurance on home per year $ _____________.
Pay separately for Heat?
Yes
No If yes, specify type of heating:
Gas
Electric
Oil
Wood
Coal
Propane
Other (list) _________________
Heat Co. Name ___________________________
Heat Co. Acct. No. ______________________________
You may use the page 6 if you need more room or there is other information that you think we might need.
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