Supplemental Nutrition Assistance Program (Snap) Application/recertification Page 6
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7LDSS-4826
Page 5
(Rev.8/12)
READ THE IMPORTANT INFORMATION BELOW (cont’d)
CITIZENSHIP/IMMIGRATION STATUS– I swear and/or affirm under penalty of perjury that the information I have provided about the citizenship and
immigration status of my self and everyone living with me is true and correct. I understand that any information I provide to verify the immigration status of
anyone applying for SNAP may be checked for authenticity with the United States Citizenship and Immigration Services.
For SNAP, citizenship must be documented only if questionable.
NON-DISCRIMINATION NOTICE – In accordance with Federal Law and U.S. Department of Agriculture (USDA) policy, this institution is prohibited from
discriminating on the basis of race, color, national origin, sex, age, religion, political belief, or disability. To file a complaint of discrimination write USDA, Director,
Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (202) 720-5964 (voice and
TDD). USDA is an equal opportunity provider and employer.
AUTHORIZED REPRESENTATIVE – You can authorize someone who knows your household circumstances to apply for SNAP for you. You can also
authorize someone outside your household to get SNAP benefits for you and to use them to buy food for you. If you would like to authorize someone, you must
do so in writing. You may do so by printing the person’s name, address and phone number below. When an Authorized Representative is applying on behalf of
a SNAP Household that does not reside in an institution, both the Authorized Representative and the SNAP Head of Household or other responsible adult
member of the household must sign and date the signature sections at the bottom of this page.
IF YOU WOULD LIKE TO AUTHORIZE SOMEONE, PRINT THE PERSON’S NAME, ADDRESS AND TELEPHONE NUMBER, AND SIGN BELOW.
Name ________________________ Address ____________________________________________________ Phone _______________
CERTIFICATION: I swear and/or affirm under the penalties of perjury that the information I have given or will give to the local
Social Services district is correct. Your signature is required below to complete the application process.
APPLICANT SIGNATURE
DATE SIGNED
X
Authorized Representative SIGNATURE
DATE SIGNED
X
IF YOU HELPED COMPLETE THIS APPLICATION / RECERTIFICATION FOR SOMEONE ELSE, PRINT YOUR NAME AND ADDRESS
HERE. YOU MAY ALSO VOLUNTARILY PRINT YOUR TELEPHONE NUMBER.
Name ________________________ Address ____________________________________________________ Phone _______________
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