SNAP E & T Consent and Intake Form

Do you want to know if you may be eligible for...

Assistance with applying for Rochester EOC (REOC) or obtaining employment?
Financial assistance to help with books, supplies, exam fees, and/or uniforms?
Bus passes when transportation problems occur?
Assistance with communicating with DHS?

The following information is necessary to assist us in determining where an individual is eligible to receive services from the REOC SNAP program and/or communicate with DHS.
Name Name First Last
Student ID # (Starts with U)
Maximum of 9 characters allowed. Currently Entered: 0 characters.
U00123456
REOC Consent to Communicate and Release Information.

I consent and fully understand that SNAP E & T Venture IV/V provider, my local Department of Human Services (DHS), Department of Labor (DOL), and employment verification agencies share information and data. The information may include identification verification, SNAP program eligibility, employment status, income, or assistance with DHS concerns.

This data may include my name, address, telephone number, last four digits of my social security number, SNAP case information, and related SNAP authorization dates.

I understand that any changes in my employment status or income that occur during or after my participation in this program may be reported to the DHS and could change my current SNAP or Cash Assistance benefits.

I also understand that if I do not elect to sign this consent form, I will not be eligible for assistance from the REOC DHS/DOL liaison and unable to participate in the REOC SNAP E & T Venture IV/V program.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Date Date / MM / DD YYYY
Personal Information
SS# SS# - ### - ### ####

111 11 1111
Date of Birth
Maximum of 10 allowed. Currently Entered: 0 .
01/01/2021
Phone Phone - ### - ### ####
Email Address (a copy of this document will be sent after submission)
Program Enrolled/Completed
Are you receiving SNAP/Food Stamps benefits or on someone else's SNAP/Food Stamps benefits?

Are you receiving SNAP/Food Stamps benefits or on someone else's SNAP/Food Stamps benefits? Yes No
Eligibility requirement for SNAP/EBT benefits change often. Would you like to know how to apply?

Eligibility requirement for SNAP/EBT benefits change often. Would you like to know how to apply? Yes No
Do you need to update your address?

Do you need to update your address? Yes
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Check all that apply

Check all that apply Misdemeanor Felony Limited English Speaking Limited English Writing Substance Concerns Mental Health Concerns Alcohol Concerns Domestic Violence Concerns Housing/Shelter Concerns Non Custodian Parent Other None Apply
Education (check all that apply)

Education (check all that apply) HS Diploma/HSE Trade License Trade Certification
Employment History

Enter current or last employment
Have you ever been employed?

Have you ever been employed? Yes No
Start Date of Employment Start Date of Employment / MM / DD YYYY
Job Title/Position
Name of Employer
No Longer Employed

No Longer Employed Click here
Last Date of Employment Last Date of Employment / MM / DD YYYY
Reason for Leaving Job

Reason for Leaving Job Not Enough Hours Conflict in Hours Personal Reason Terminated Transportation Other Other

SNAP E & T Consent and Intake Form

Personal Information

Employment History