2019-2020
RECEIPT OF SNAP BENEFITS
(INDEPENDENT)
(FFFA03)
S
TUDENT
I
NFORMATION
__________________________________________________________ ______________________________
Last Name First Name M.I.
Student ID#
By signing this form the student certifies that a member of the student’s household, received benefits from the
Supplemental Nutrition Assistance Program or SNAP (formerly known as the Food Stamp Program) sometime during
2017 or 2018. SNAP may be known by another name in some states (CalFresh). For assistance in determining the
name used in a state, please call 1-800-4FED-AID (1-800-433-3243).
The student’s household includes:
• The student.
• The student’s spouse, if the student is married.
• The student’s or spouse’s children if the student or spouse will provide more than half of the children’s support
from July 1, 2019, through June 30, 2020 even if the children do not live with the student.
• Other people if they now live with the student and the student or spouse provides more than half of their support
and will continue to provide more than half of their support through June 30, 2020.
Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we
may require documentation from the agency that issued the SNAP benefits in 2017 or 2018.
C
ERTIFICATION AND SIGNATURE(S)
Each person signing this form certifies that all the information
reported is complete and correct. If married, spouse’s signature is
optional.
Student: Date:
Spouse: Date:
RETURN TO FINANCIAL AID OFFICE:
WARNING: If you purposely give false or
misleading
information on this worksheet,
you may be fined,
sentenced to jail, or both.
