Supplemental Nutrition Assistance Program (SNAP) Intake Form

The Central Pennsylvania Food Bank will use the information you provide in this form to submit an application to the PA Department of Human Services (DHS) on your behalf. However, BEFORE we can submit it to DHS, we will most likely need to speak with you.

By filling out this form, you give consent to and authorize the collection of information for a food stamps (SNAP) application by the Central Pennsylvania Food Bank. This information will be included in the COMPASS SNAP application and shall be used by the Food Bank, the PA Department of Human Services, and your local County Assistance Office. Your information is confidential and WILL NOT be shared with additional parties.

Primary Applicant Information

Please provide your personal information below.

First Name

Last Name

Phone

Email

Would you like to receive text message reminders from our food bank & the Department of Human Services about renewals and needed verifications?

County of Residence

What language do you most easily understand?

If other, please specify your language:

If an interview is necessary, would you like an interpreter?

Outside of Service Territory

Unfortunately, you live outside of our service territory. To find help in your county, please go to https://www.centralpafoodbank.org/snap-partners/.

To find a local food pantry, please call 211 or text your zip code to 898-211.

CaseId

Household Information

How many people are living your SNAP household, including yourself? A SNAP household is anyone who lives together and buys, eats, and shares food with one another. Children living in the home under the age of 22 and spouses are required to be included in the same household.

Has anyone received food stamps (SNAP benefits) this month?

Why are you wanting to apply?

If other, please specify:

Renewal Follow-up Required

Before we proceed, we will need to call you for your case record and social security number and to discuss your personal circumstances. When would be the best day and/or time for us to reach you?

Best Time to Call

Renewal Follow-Up Stage

Contact Statewide Customer Service Center

You may not need to apply at this time. Please contact the Statewide Customer Service Center at 877.395.8930 before proceeding.

Page 3: Income Verification

Household Income

Is your household's gross monthly income (before taxes or deductions are taken out) more or less than what is listed for your household size in the table below?

It appears that you may not be eligible for SNAP at this time, would you still like to apply?

Page 4: Application Questions

Primary Applicant Earned Income Information

Does the Primary Applicant work or have a job that will start in the next 30 days?

Is the primary applicant self-employed, an independent contractor, or gig worker?

What is the Employer's name?

What is the start date of employment? (if known)

What is the hourly wage/rate?

Number of Hours Worked per Week

How often do they get paid?

If you are self-employed, an independent contractor, gig worker, or make tips, please enter how much you make on average a month.

If the Primary Applicant has a 2nd job, please enter details regarding the Name of Employer, wage and frequency of pay.

Has the Primary Applicant lost their job in the last 30 days?

What is the former Employer's name?

When was the last day of employment (if known)

What is the date of the last paycheck (if known)

How many hours did the Primary Applicant work per week?

Has the Primary Applicant applied for unemployment or disability benefits which they have not yet received?

Please describe which benefit they applied for (unemployment or disability), when they applied, and how much and when they expect to get their benefit (if known).

Does the Primary Applicant receive unearned income (unemployment, social security, pension, disability, child support, etc.)?

Total Monthly Earned Income

Primary Applicant Unearned Income Information

Please enter all sources of the Primary Applicant's unearned income below. Skip any categories that do not apply.

Unemployment Compensation

Frequency of Payment

Social Security Retirement Benefits (SSRB/SSA)

Frequency of Payment

Social Security Disability Income (SSDI)

Frequency of Payment

Supplemental Security Income (SSI)

Frequency of Payment

Veterans Benefits

Frequency of Payment

Pension/Retirement

Frequency of Payment

Child Support

Frequency of Payment

Workers Compensation

Frequency of Payment

Other

Frequency of Payment

If you receive other types of unearned income, please describe what they are below and how much is received:

Total Monthly Unearned Income

Household Expenses

Does your household pay shelter expenses (such as rent, mortgage, utilities?)

Shelter Expenses

Rent or Mortgage

Frequency of Payment

Lot Rent or Condo Association Fees

Frequency of Payment

Property Taxes (if not escrowed into mortgage)

Frequency of Payment

Homeowners Insurance (if not escrowed into mortgage)

Frequency of Payment

Total Shelter Expenses

Total Monthly Rent

Total Monthly Insurance

Total Monthly Property Tax

Other Household Expenses

Does anyone in the household pay for childcare services or adult daycare while they work or go to school?

Child Care or Adult Day Care Expenses

Frequency of Payment

Please enter the following information for each child or disabled adult in care: The name of child/disabled adult in care, Name of household member paying for care, How much is paid, How often is it paid (weekly, monthly, etc.), How many months of the year does the child/disabled adult need to be in care?

Does anyone in the household who is permanently disabled or 60+ years old pay recurring out-of-pocket medical expenses (health insurance premiums, copays for Rx or doctor, payment plans for unpaid medical bills, etc)?

Recurring Out-of-Pocket Medical Expenses

Frequency of Payment

Please enter the following information for anyone in the household who is permanently disabled or 60+ and pays out-of-pocket medical expenses: The name of household member, Type of medical expenses they pay, how much they pay for each expense, how often they pay it (weekly, monthly, quarterly, etc.)

Does anyone in the household pay court-ordered child support?

Court Ordered Child Support

Frequency of Payment

If there are two or more people in your household, please list who pays child support, how much they pay, and how often they pay it.

Total Monthly Dependent Care Costs

Total Monthly Court Ordered Child Support Costs

Total Monthly Unreimbursed Medical Expenses

Household Resources

Please enter details about the household's total combined resources below. Skip any categories that do not apply.

Checking Account Balance

Savings Account Balance

Cash On Hand Balance

Pre-Paid Debit Card/ Pay Card Balance

Other

If there are other types of personal income on hand, please describe what they are below:

Total Household Resources

Intake Confirmation

How would you like to sign your application?

How would you like us to send you the Signature Page?

In the case that our team needs to clarify any of the information you provided and.or to e-Sign your application, please provide the best time of day to call you:

Comments/Questions?