SNAP Pre-Enrollment Form

Date of Birth(Required)

Social Security Number(Required)

Email(Required)

Phone(Required)

County(Required)

How many people live at this address INCLUDING you?

Race

*Non-citizens and/or their children can still apply. Will not affect parent's/child/s immigration status. Non-citizens must either be under 18 or a lawful permanent resident of at least 5 years.

If yes, what is your 10-digit case number?

Estimate your total gross earned income (before taxes or deductions) that your household will receive this month

Estimate your total gross unearned income (SSI, child support, unemployment) that your household will receive this month

The total amount is checking AND savings accounts

How much is your monthly rent/mortgage (if applicable)?

Please list the names and information for all others in the household that are applying for SNAP

Date of Birth

Social Security Number

Relationship to you

Race

*Non-citizens and/or their children can still apply. Will not affect parent's/child/s immigration status. Non-citizens must either be under 18 or a lawful permanent resident of at least 5 years.

Date of Birth

Social Security Number

Relationship to you

Race

Date of Birth

Social Security Number

Relationship to you

Race

Date of Birth

Social Security Number

Relationship to you

Race

Date of Birth

Social Security Number

Relationship to you

Race

For questions, contact Kim Douglas, Agency Relations/SNAP Coordinator:

Direct: 479-480-4610 Email: kdouglas@rvrfoobank.org

Phone

This field is for validation purposes and should be left unchanged.

Please list the names and information for all others in the household that are applying for SNAP

For questions, contact Kim Douglas, Agency Relations/SNAP Coordinator: