Application For Food Stamps printable pdf download

Application For Food Stamps

FSP 901 (Rev. 8/04)

(Page 1) (English)

APPLICATION FOR FOOD STAMPS

Section 1

Applicant:



Please use a pen.



Fill in this form carefully and truthfully.



IF YOU ARE NOT SURE OF ANY QUESTION LEAVE THE SPACE BLANK.

You have the right to file an application for food stamps immediately.

Provide:



your name.



address.



signature.



date signed.



If you are determined to be eligible, your benefits will be paid from that date.

If your application is mailed to the County Welfare Agency (CWA):



Your benefits start the date received by the CWA.



When you file an application, you must provide all the required information about your situation.



To complete the application a face to face interview is required.



If you are found eligible, you can get food stamps within 30 days. (From the date the Food Stamp office receives your

application.)

Applicant’s name:

_____________________________________________________________________ SSN# ____________DOB ________

(Last)

(First)

(MI)

(Maiden)

Resident Address: Homeless clients must provide a mailing address. You should go to the County agency for immediate

assistance.

(The place where you actually live.)

(Number and Street or RFD)

(City)

(State)

(Zip Code)

Address where your mail goes:

(If different from your resident address.)

(P.O. Box, Street Address, or RFD)

(City)

(State)

(Zip Code)

Daytime telephone number: ( ) _____________________

Evening: (

) ___________________

2. You can allow a person(s) outside your household to



apply for Food Stamps for you.



obtain Food Stamp benefits for you.



use your Families First card to buy food for you.

3. To select such a person, complete the following:

Name of Authorized

Telephone

Representative

Address

SSN

DOB

Number

Signature of Applicant/Recipient

Date:

Application For Food Stamps

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