2016-2017 Verification of SNAP (Food Stamp) Benefits
A. STUDENT INFORMATION (For institutional identification purposes) ID: _______________
_______________________________________________________
(Last Name)
(First Name)
(M.I.)
_________________
(Telephone Number)
______________________________________________________________________________
(Current Address)
(City)
(State)
(Zip Code)
INSTRUCTIONS: You indicated on the FAFSA that someone in your household received SNAP
benefits in 2015. Please complete the sections below to verify the information.
Your financial aid cannot be processed until this information is received.
B. Food Stamp Verification – All lines MUST be complete
Has anyone in the household received benefits from the Supplemental Nutrition Assistance
Program or SNAP (formerly known as food stamps) any time during the 2014 or 2015 calendar
years? Yes _______ No ______
C. Please attach a copy of your eligibility letter from the agency that issues the SNAP benefits.
By signing this worksheet, I (we) certify that all of the information reported on this worksheet is
complete and correct. If the student is a dependent, at least one parent must sign.
________________________________________________
(Student Signature)
__________________
(Date)
________________________________________________
(Parent Signature – If dependent student)
__________________
(Date)
Warning: If you purposely give false or misleading information on the worksheet, you may be fined, sentenced to jail, or both.
Forms can be returned to:
Valley City State University Financial Aid Office
101 College St SW, Valley City ND 58072
Fax: 701-845-7545 Phone: 1-800-532-8641 or 701-845-7542
E-mail: [email protected]