Supplemental Nutrition Assistance Program (Snap) Application/recertification (Page 7 of 7) in pdf

Supplemental Nutrition Assistance Program (Snap) Application/recertification Page 7

LDSS-4826

Page 6

(Rev.8/12)

Use this area for additional information:

Who: ________________________________________Explanation:

I CONSENT TO WITHDRAW MY APPLICATION/RECERTIFICATION. I understand that I may reapply at any time.

SIGNATURE

DATE

For Agency Use Only

Eligibility Determined by ____________________________________________________________ Date ___________________

Signature of Person Who Obtained Eligibility Information: ________________________________________ Date _______________

Employed by:

Social Services District

Provider Agency

(Specify) ______________________________________________________________________________________

Reason _____/_____/______

Withdrawal

Denial

Recert. Closing

Eligibility Approved by ______________________________________________________________ Date __________________

SNAP Authorization Period: From ______________________ To ______________________

IN-PERSON INTERVIEW

TELEPHONE INTERVIEW

Comments:

Supplemental Nutrition Assistance Program (Snap) Application/recertification Page 7