SNAP Stretch Reimbursement Form- POS Discount Sites
THIS FORM IS INTENDED FOR USE BY MARKETS AND RETAILERS WHO OPERATE SNAP STRETCH VIA REGISTER DISCOUNT. In order to accurately track the amount of funds available, and guarantee payment, this form must be submitted at least once a month (for a list of the required dates for reimbursement - 11 business days after the end of the month - check your MOU on file). We continue to use this data for future funding requests to continue SNAP Stretch and required grant reporting. Sections 1, 2, and 4 must be completed, however, if you do not readily have the information requested for Section 3 please do not worry about completing it. The questions with asterisks (*) are required. Please contact us if you have questions: (304)926-0567 or SNAPStretch@wvfoodandfarm.org.
Name of person submitting this form
*
First Name
Last Name
Email
*
example@example.com
What month are you reporting on?
*
January
February
March
April
May
June
July
August
September
October
November
December
Which dates are this report for? Please be specific.
*
This will help us prevent double reporting. If you serve customers daily you can put a range like "11/8-11/20".
Period of Time Accounted For (the weeks or months in which the transactions reported occurred)
Market/Business Name
*
Total of all market customers
*
Total of all market customers using SNAP/EBT
*
Total dollar amount ran on SNAP/EBT machine
*
How many single adults (AGE 18-59) used SNAP/EBT
How many adults with children used SNAP/EBT
How many seniors (AGE 60+) used SNAP/EBT
If you have SNAP Stretch provided by outside funding or other non-SNAP Stretch incentives offered (ex. Double Dollars/Veggie Vouchers), please indicate the amount redeemed. (optional)
If you redeemed any outside-funded SNAP Stretch or other non-SNAP Stretch incentives, please select which one(s) here. (optional)
Double Dollars
Veggie Vouchers
SNAP Stretch (funded by additional grants, not the Coalition)
How many 50% discounts did you distribute?
How many 67% discounts did you distribute?
How many 75% discounts did you distribute?
This table will be used as the invoice to reimburse your market. Please fill out this table to indicate the SNAP Stretch dollars that were distributed via register discount within the reporting period. If sales took place in multiple counties, please indicate distribution by county by using an additional line in the table.
*
List the County Sales Occurred In
Dollar amount given out via 50% discount
Dollar amount given out via 67% discount
Dollar amount given out via 75% discount
County #1
County #2
County #3
County #4
County #5
Total of SNAP Stretch distributed (to be reimbursed)
This number will automatically calculate from the chart above and should not require editing. If you do change it, please leave a note in the suggestion box below explaining why.
This table will be used as the invoice to reimburse your market. Please fill out this table to indicate the SNAP Stretch dollars that were REDEEMED within the reporting period. If sales took place in multiple counties, please indicate redemption by county by using a second line in the table. The last two columns of the table (requesting the ESTIMATED split between fruit/vegetable redemption and MED items) should add up to 100% of the redeemed funds (EITHER the number should total 100 or the EXACT total of SNAP STRETCH DOLLARS REDEEMED). PLEASE NOTE THAT CELLS CORRESPONDING IN EACH OF THE 5 COLUMNS MUST BE FILLED OUT. ** Cells C6 and E6 should total appropriately - if C6 does not equal the total amount in SNAP Stretch you are requesting to be reimbursed please check your reporting and similarly if E6 does not total the same number or 100 do the same. Any questions on how this table should be completed should be directed to Bethany Lewis/in the Question box at the bottom of this report.
Now that we know WHO redeemed SNAP Stretch, let's see WHAT they purchased with it?
Of the total number of SNAP Stretch Redeemed how many dollars were used for MED (Meat, Eggs, or Dairy) items?
*
Of the total number of SNAP Stretch Redeemed how many dollars were used for fruits/vegetables?
*
Total should equal total submitted to be reimbursed above (if it does not please correct your two totals above until it does)
We have all of the numbers compiled. Please don't forget to provide/upload the following supporting documents as requested below.
Did you have any of the following activities at your market during the reporting period? (optional)
Live Music
SNAP Outreach
WVU Extension Outreach
Cooking demo
Gardening Instruction
WIC/Senior Voucher outreach
Contest/Taste Testing/Kids activities
Health Fair
Please upload your time log(s) for this period. *LINK FOR TEMPLATE BELOW*
*
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If you have multiple pages or files to upload here we ask that you upload them as one single file.
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Template for timelog can be found
here
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Please upload either an authorized total of SNAP/EBT distributed by your market/site within this reported time period or a report already generated from your POS that includes both the reporting period dates and the SNAP/EBT total ran on your machine (please ensure that it matches that which has been reported here).
*
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REMINDER: We ask that at least twice a year you share some pictures with us so that we may share your successes with donors and the community at large, please include captions or context in the Success/Challenges box below.
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Successes/Challenges to share? Questions for WVFFC program staff?
Please don't be shy! This program can only improve with your feedback. If you have any clarifications or things we should know about this submission, please feel free to include them here as well.
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