North Dakota SNAP Application

SNAP (Supplemental Nutrition Assistance Program) is a federal program that provides resources to low-income households to purchase groceries. Completing this form is the first step to see if you are eligible for benefits.

You can learn more about SNAP here: USDA SNAP Information

If you have difficulty completing this form, please contact Great Plains Food Bank's SNAP Outreach Team at 855.405.0000 or SNAP@greatplainsfoodbank.org

How the Process Works
1. Submit your information

On the following pages, enter your information. The form should take about 15-30 minutes to complete. Because you will be asked to enter personal information, we are using a form that is HIPAA (Health Insurance Portability and Accountability Act) Compliant to protect the privacy and security of your information.

2. Submit proof of your living situation

You will need to provide verification of various factors such as citizenship, assets, income, expenses, and other items. Acceptable documents may include ID, birth certificates, paystubs, bank statements, and utility bills. You can do this using the "File Upload" section at the end of this form. If you choose not to do this now, you can submit documents at the time of your interview or directly to the state Customer Support Center within 30 after submission. To submit documents to the Customer Support Center, use the following contact information:

Email: applyforhelp@nd.gov

Phone: 1.866.614.6005 or 701.328.1000

Fax: 701.328.1006

Mail: Customer Support Center

PO Box 5562

Bismarck, ND 58506

3. Processing and determining eligibility

Great Plains Food Bank's SNAP Outreach Team will review your application for potential errors within two business days following receipt of this form. If no errors are noticed, your application will be submitted to North Dakota Health and Human Services (ND HHS). If errors are found, you will be contacted via the information you provide to correct them prior to submitting your application.

Once the application is submitted, ND HHS will process it and determine eligibility. It can take 30 days to process the application. HHS will contact you to schedule an interview, review your application, and gather any additional information needed. If you miss your interview, you can contact them to schedule a new one.

If approved, SNAP benefits are received through the ND Electronic Benefit Transfer (EBT) card, which is a plastic card that is used like a debit card. Each month, your approved monthly benefit amount is placed in the card's account.

Great Plains Food Bank (GPFB) is a trusted partner with ND HHS, but we do not determine eligibility. Eligibility is only determined by ND HHS. GPFB receives information regarding approval or denial of benefits, but does not receive any details regarding your case.

Please use the above contact information for the Customer Support Center to check the status of your application or report changes to your case.

Not all fields are required. However, providing as much information as possible in the application may reduce the wait time for case processing.

Verification Document Information

A more detailed list of proof that you may need to submit. This is not a complete list.
Proof of Alien or Citizenship Status such as:

Birth Certificate (if born in the United States)

American Indian/Alaskan Native Tribal Document

Passport

Permanent Resident Card (Form 1-551)

Employment Authorization Document (Form 1-766)

Arrival-Departure Record (Form 1-94)

For SNAP, if any of these persons do not want to give information about their citizenship or immigration status, they will not be eligible for benefits. These persons must provide their financial information to determine eligibility for other household members. Other household members may still get benefits if they are otherwise eligible. We will not share alien or citizenship information about non-applicants with the United States Citizenship and Immigration Service.

Proof of the value of current assets such as:

Checking/Saving/Credit Union Accounts

IRA/401K Plans

Life Insurance

Property

Trusts

Proof of most current expenses such as:

Child/Dependent Care

Court Ordered Payments

Utility/Shelter Expenses

House Payment

Rent

Phone Bill

Proof of most current income (last month and this month) such as:

Pay (pay stubs or employer statement)

Social Security Benefits

Supplemental Security Income

Unemployment Benefits

Child Support

Money from Friends or Relatives

Pension/Retirement Benefits

Self-Employment Income (most recent copy of Federal Income Tax Return)

Proof of other information such as:

Identity (Birth Certificate, Driver's License, Work/School ID, Passport)

Age (Birth Certificate, Driver's License)

Residency (Rent Receipts, Utility Bills, Lease)

Social Security Numbers (card or proof of application for SSN)

Authorized Representative
You can give a trusted person permission to talk about this application with ND HHS and see your information.

This individual can act on your behalf on matters related to this application, including giving and getting information, signing your application, and acting for you on all future matters. This person is called an "authorized representative".

This person can also give information at your interview and can also receive the Electronic Benefit Transfer (EBT) card for you. This gives the representative access to your food benefits. Any benefits spent by the representative will not be replaced.

You also have the choice to name a different authorized representative who will not receive notifications about your SNAP case, including the application, but can access your food benefits for you by using your EBT card.
YesNo
If yes, list that person's name here*

First NameLast Name
What is their address?*

Street Address

Apartment/Unit Number

CityState Abbreviation

Zip Code
What is their phone number?*
Please enter a valid phone number.Format: (000) 000-0000.
Your signature*
Today's Date*

MonthDayYear
Date
YesNo
If yes, list that person's name here*

First NameLast Name
What is their address?*

Street Address

Apartment/Unit Number

CityState Abbreviation

Zip Code
What is their phone number?*
Please enter a valid phone number.Format: (000) 000-0000.
Your signature*
Today's Date*

MonthDayYear
Date

Text/Email Notifications from ND HHS
By opting to receive text message or e-mail notifications, you agree to the following:

A text message or e-mail notification will be sent to the cell phone number or e-mail address you entered when a review or full application is needed to determine eligibility or continued eligibility for the program(s) you are enrolled in.

Cell phone carrier text message rates may apply and ND HHS will not be liable for any text message charges.

You are responsible for notifying your case worker of any changes to your e-mail address, cell phone carrier or cell phone number, or if your cell phone is lost or stolen.

It is the policy of HHS not to transmit confidential information by text or e-mail as unencrypted e-mail and text messaging is NOT a secure form of communication. There is some risk that any Protected Health Information (PHI) and other confidential information that may be contained in such e-mail or text messages may be misdirected, disclosed to, or intercepted by, unauthorized third parties. I consent and accept the risk in transmitting PHI and other confidential information via unencrypted e-mail or text messaging.

Opting to receive text message or e-mail notifications requires an additional signature and will not be sent without your signature.
YesNo
If yes, list cell phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Cell phone provider*
YesNo
If yes, list email address*
example@example.com
Your Signature*
Today's Date*

MonthDayYear
Date

Signature Page

Please read the following information before signing and submitting this form
SNAP Work Registration

I understand and agree that to receive SNAP, certain members of the household need to register for work. This means that certain members of the household must:

A) Register for work at time of application and recertification

B) Not quit a job of 30 or more hours/week without good cause

C) Not reduce work hours under 30 hours per week without good cause

D) Not refuse a bona fide offer of suitable employment without good cause

Anyone who does not follow the work requirements may be disqualified from receiving SNAP. This form also acts as a work registration notice. You, along with other nonexempt household members, will be considered work registered and must comply with the requirements associated with work registration once this form is signed.
Understanding and Agreement

I have received, reviewed, and understand my rights and responsibilities as explained in the Guidebook (found here: Application for Assistance Guidebook).

I declare under penalty of law, the information on this application is correct. This includes information about identity, citizenship, and alien status of the household members applying for assistance.

I understand that alien status information and other information will be verified when discrepancies are found. The alien status of application household members may be subject to verification by USCIS through the submission of information from the application to USCIS. Verification received may affect eligibility and level of benefits.

I understand the information I provide on or with this application is subject to verification by federal, state, and local officials to determine if the information is correct. If any of the information is incorrect, assistance may be denied and I may be subject to criminal prosecution for knowingly providing incorrect information. There are penalties for giving false information or breaking the rules. Information about this is provided in the Guidebook.

I agree to report to the Customer Support Center any changes in income, assets, or living arrangements as required.

I understand I will not receive a deduction for any allowable expenses I do not report and provide proof of.

I understand that if I have a disability, I may request information about my benefits in a different format.

I understand that I have the right to request a Fair Hearing if I disagree with the agency actions regarding my benefits. Information on this is provided in the Guidebook.

North Dakota Department of Health and Human Services cannot discriminate based on race, color, national origin, sex, age, disability, religious or political beliefs, or other protected identities. Information on how to file a complaint of discrimination is provided in the Guidebook.
I certify, under penalty of law and perjury, that the information provided on this application is true and complete to the best of my knowledge. I understand that my electronic signature will be treated by North Dakota Health and Human Services just like a written signature. I agree that Great Plains Food Bank may use the information provided on this form to submit an application for SNAP on my behalf.*

I agree
Your Signature*
Today's Date*

MonthDayYear
Date
If you would like to provide verification of factors such as citizenship, income, assets, and expenses now, please do so below. Acceptable documents may include ID, birth certificates, paystubs, lease agreement, bank statements, and utility bills. You may also provide these during the time of your interview or directly to the Customer Support Center with the contact information found on Page 2.

Cancelof
Should be Empty:

How the Process Works

Verification Document Information

Your Information

Household Members

Illegal Activity and Disqualification Questions

Household Assets

Household Earned Income

Household Unearned Income

Household Expenses

Authorized Representative

Text/Email Notifications from ND HHS

Signature Page