SNAP Pre-Enrollment Form - River Valley Regional Food Bank

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SNAP Pre-Enrollment Form

SNAP Pre-Enrollment FormSteph - CSMS2023-11-01T12:24:32-05:00

SNAP Pre-enrollment Form

Name(Required)

First Last

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Other

Social Security Number(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address City State ZIP Code

County(Required)

Mailing Address (if different from above)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How many people live at this address INCLUDING you?

Race

Hispanic or Latino

Yes

No

U.S. Citizen

Yes

No

*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.

Are you currently receiving assistance from the State of Arkansas (SNAP, TANF, Medicaid)?

Yes

No

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)?

Do you pay to heat or cool your home?

Yes

No

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

Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Other

Social Security Number

Relationship to you

Race

Hispanic or Latino

Yes

No

U.S. Citizen

Yes

No

*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.

Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Other

Social Security Number

Relationship to you

Race

Hispanic or Latino

Yes

No

U.S. Citizen

Yes

No

Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Other

Social Security Number

Relationship to you

Race

Hispanic or Latino

Yes

No

U.S. Citizen

Yes

No

Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Other

Social Security Number

Relationship to you

Race

Hispanic or Latino

Yes

No

U.S. Citizen

Yes

No

Name

First Last

Date of Birth

MM slash DD slash YYYY

Gender

Male

Female

Other

Social Security Number

Relationship to you

Race

Hispanic or Latino

Yes

No

U.S. Citizen

Yes

No

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

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

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Contact

River Valley Regional Food Bank
1617 Zero St, Fort Smith, AR 72901

Hours:

Monday – Friday: 8:00 am to 4:30 pm
Saturday: closed
Sunday: closed

For SNAP information please call Kim Douglas
(479) 785-0582 or kdouglas@rvrfoodbank.org

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