HR1-Grocery Food Assistance Eligibility Pre-Screen.

Required acknowledgments

Did you previously receive SNAP?

Has SNAP ended?

When did SNAP end?

Date

SNAP benefit closure reason

Do you have a DSS notice?

Reason DSS gave

Upload DSS notice (photo, screenshot, or PDF)

Appointment requirement understood

Photo identification available

Legal first name

Middle initial

Legal last name

DSS Client ID

SSN

Date of birth

Date

Street address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Apartment or unit

Primary phone

Please enter a valid phone number.Format: (000) 000-0000.

Alternate phone

Please enter a valid phone number.Format: (000) 000-0000.

Email address

example@example.com

Preferred language

Preferred contact method

Preferred HRA office

Do you need an interpreter?

Interpreter language

Please verify that you are human

HR1 Grocery Food Assistance Eligibility Pre-Screen