SNAP E & T Consent 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