2013-2014 SNAP Benefits Verification for 2011 and 2012 - Terra ...

2013-2014 Supplemental Nutrition Assistance
Program Benefit (SNAP) Certification Form
Student Information
Student’s Full Name:______________ _________________ _____________ SS#_______________
(Please Print) First M.I. Last (or Student ID)
______________________________________
Date of birth
__________________________________
Student Phone number(s) (include area code)
SNAP Benefits Received
_ I, myself, or a member of my household DID NOT receive Supplemental Nutrition Assistance Program Benefits (formerly
known as Food Stamps) in 2011 and/or 2012
OR
_I, myself, or someone in my household DID receive Supplemental Nutrition Assistance Program Benefits (formerly known as
Food Stamps) in 2011 and/or 2012. Please attach a copy of the SNAP eligibility letter for your household.
Sign this Form
This form must be signed by student. By signing this form, I certify that all the information reported on this form is complete
and correct.
______________________________________
Student’s signature
______________________________________
Spouse’s signature or Parent/Guardian
______________________________________
Date
______________________________________
Date
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