PART D - List all liquid resources your household will be able to get to during the disaster period (October 28, 2020
and November 26, 2020.
PART F - ELIGIBILITY
COMPUTATION
1.
Total anticipated
income (PART C)
2.
Total accessible
cash resources
PART D)
3.
Add #1 and #2
4.
Total disaster
expenses (PART E)
5.
Total available funds
(Subtract #4 from #3
*Income to use to
Determine Eligibility)
=
6.
Maximum Gross
Income Limit (GDIL)
7.
ELIGIBLE (#5 is
equal to or less
than #6)
8.
INELIGIBLE (#5
is greater than
#6)
$_________
+
$_________
=
$_________
$_________
$_________
$_________
Is the
household
eligible?
Yes No
PART E - EXPENSES Your household must have disaster related
expenses in order to qualify for D-SNAP.
______ I certify under penalty of perjury that my household has paid or
expects to pay out of pocket disaster–related expenses (which include
food loss) as a result of the hurricane that occurred in my county of
residence on October 28, 2020. I will not be reimbursed for these
expenses during the period of October 28, 2020 through November 26,
2020.
Cost to protect property during disaster
Cost to repair or replace items for home or self- employment property
Dependent care due to disaster
Food destroyed in disaster
Funeral/medical expenses due to disaster
Moving and storage costs due to disaster
Other disaster-related expenses
Temporary shelter expenses
If your household gets food assistance benefits, it must follow the rules listed below. We may choose your household for a Federal or State review
sometime after you receive your food assistance benefits to make sure you were eligible for disaster aid.
DO NOT give false information or hide information to get or to continue to get food assistance benefits.
DO NOT give or sell food assistance benefits or authorization documents to anyone not authorized to use them.
DO NOT alter any food assistance benefits or authorization documents to get food assistance benefits you are not entitled to.
DO NOT use food assistance benefits to buy unauthorized items such as alcohol or tobacco.
DO NOT use another household's food assistance benefits or authorization document for your household.
PART H - CERTIFICATION AND SIGNATURE
I understand the questions on this prescreening form and the penalties for hiding or giving false information. My household is in need of immediate food
assistance as a result of the disaster. I certify, under penalty of perjury, that the information I have given is correct and complete to the best of my knowledge.
I also authorize the release of any information necessary to determine the correctness of my certification. I understand that if I disagree with any action taken
on my case, I have the right to request a fair hearing orally or in writing.
APPLICANT, AUTHORIZED REPRESENTATIVE, OR WITNESS (if signed with an X) DATE SIGNED
_____________________________________________________ ____________________________
DEPARTMENT OF HUMAN RESOURCES/ADVOCATE DOCUMENTATION OF ATTESTATION DATE SIGNED TIME SIGNED
(if completing on behalf of the household, verbal attestation of form completion and signature given)
____________________________________________________ ___________________________
Date/Time of 1
st
Interview Attempt Date/Time of 2
nd
Interview Attempt Date/Time of 3
rd
Interview Attempt
___________________________ ___________________________ ___________________________
D-SNAP pre-screeners should be submitted online at the DHR website. D-SNAP pre-screeners submitted online will receive a
confirmation email. Please retain this email for your records. If you need assistance completing the D-SNAP pre-screener,
contact the local DHR county office to complete the pre-screener by telephone. D-SNAP pre-screeners should not be emailed.
Interviewer: _____________________ Date: ____________________
Data Entry: _____________________ Date: ____________________
Disposition: Awarded Denied
