SNAP Eligibility Screening Form

How many people are in your household?

* Make sure to include all the people with whom you live and buy and prepare meals on a regular basis
* Spouses, children under the age of 22 living with their parents, and children under the age of 18 who are being provided with full financial support by someone in the household (even if not the parent) must be included

Is there someone in your household 60 years of age or older?

Yes No

Is there someone in your household disabled as defined by the Social Security Administration (SSI or SSD)?

Yes No

Is someone in your household working?

Yes No

Please provide your phone number (US format):

Please provide your zip code:

Does someone in your household have to pay for childcare or dependent care costs to work? For example, childcare center fees, babysitter, etc.

Yes No

What is your household’s monthly gross income (if any)?

* Please make sure to include your income before taxes. Examples of income include wages, salaries, self-employment, social security benefits, unemployment, child support, etc.

Do any of the following apply to any member of your household?

U.S. Citizen An adult that is 18 years of age or older and has a Legal Permanent Resident status for a minimum of five years An adult (18+) who is a Legal Permanent Resident and receives disability benefits An adult (18+) who is a Legal Permanent Resident and has 40 work quarters earned with the Social Security Administration A child under the age of 18 with a Legal Permanent Resident status Other immigration status (e.g., Refugee, Asylee, Cuban/Haitian Entrant, Uniting For Ukraine, etc.) None of the options above apply