SNAP Intake - Central Pennsylvania Food Bank

Supplemental Nutrition Assistance Program (SNAP) Intake Form

The Central Pennsylvania Food Bank (CPFB) 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 SNAP application by the Central Pennsylvania Food Bank. This information will be included in the COMPASS SNAP application and shall be used by CPFB, DHS, and your local County Assistance Office. Your information is confidential and WILL NOT be shared with additional parties.

Please note: This is not a SNAP application. This form collects the information our SNAP team needs to help you apply. After you submit the form, a CPFB SNAP Outreach representative will contact you by phone to complete the process and submit your SNAP application to the PA Department of Human Services.

Primary Applicant Information

Please provide your personal information below.

First Name

Last Name

Phone

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 in 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 Information

Please provide information for the primary applicant's income and expenses and personal characteristics.

First Name

Last Name

Birthdate (MM/DD/YYYY)

Age

Legal Gender

Marital Status

Citizenship Status

Physical Address

Physical City

Physical State

Physical Postal Code

Is your Mailing Address different than your physical street address?

Mailing Address

Mailing City

Mailing State

Mailing Postal Code

What is your race/ethnicity? Select all that apply.

American Indian or Alaska NativeAsianBlack or African AmericanHispanic, Latino or SpanishMiddle Eastern or North AfricanNative Hawaiian or other Pacific IslanderWhite or CaucasianDo not wish to answer

Select all that apply to the Primary Applicant:

Veteran/Active Military MemberWidow(er) or Minor Child of Veteran/Active Military MemberHomeless (without permanent residence)Interested in registering to voteFleeing from law enforcementMigrant or Seasonal FarmworkerNone of these apply

Select all medical conditions that apply to the Primary Applicant:

Chronic Medical ConditionPermanent DisabilityRequire Health-Sustaining Medication None

Have you or anyone in your household received food stamps (SNAP) in PA before?

Will you need a new Access/EBT card?

Has anyone received medical or cash benefits in PA before?

If you have ever received food stamps (SNAP) in another state, please indicate which one.

Is the Primary Applicant currently enrolled as a student anywhere at this time?

Name of School

Enrollment Status

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

Family/Household Information

Please provide information for the rest of the household.

Household Member First Name

Household Member Last Name

Birthdate (MM/DD/YYYY)

Age

Legal Gender

The Primary Applicant is my:

If other, please describe the relationship:

Marital Status

Citizenship Status

What is their race/ethnicity? Select all that apply.

Select all that apply to Household Member:

Select all medical conditions that apply to Household Member:

Chronic Medical ConditionPermanent DisabilityRequire Health-Sustaining Medication None

Are they currently enrolled as a student anywhere at this time?

Name of School

Enrollment Status

Household Member Earned Income Information

Does this household member work or have a job that will start in the next 30 days?

Are they self-employed, an independent contractor, or gig worker?

What is the Employer's name?

What is the hourly wage/rate?

Number of Hours Worked per Week

How often do they get paid?

If the Household Member is self-employed, an independent contractor, gig worker, or make tips, please enter how much they make on average per month.

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

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

Has this household member 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 they work per week?

Has this household member 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 this household member receive unearned income (unemployment, social security, pension, disability, child support, etc.)?

Total Household Member Earned Income

Household Member Unearned Income Information

Please enter all sources of this household member'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.

Household Member Total Unearned Income

Please Click "Add Another Household Member" to enter the details for each member in your household

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

Please select all utility expenses you pay:

ElectricityGasKeroseneOilWaterSewageTelephoneGarbageOther

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?

Contact Information

Page 3: Income Verification

Page 4: Application Questions

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