Public Benefits Pre-Screening Form

Please complete the form below and click submit.. The Public Benefits Specialist will contact you usually within 24 hours to complete the pre-screening process and let you know if you are eligible for SNAP and/or other benefits and to schedule an appointment
Name*
First Last
Primary Phone*
Address
Street Address Address Line 2 City ZIP Code
County*
Email*
Are you currently a student?
Are you or anyone in your household a veteran or serving in the military?*
Is This a Renewal*
Number of People in Your Home
Please enter the number of people in each age group that will be included with your application. If it's only you, put "1". If none, put "0"
Age 59 and under Age 60 and over
Income
Does your household have ANY income?*
Total Monthly Income*
Combined income of adults 18 or older that will be included on your public benefits application. If none, put "0"
I certify that any information I provide will be true and accurate to the best of my knowledge.
Typed Signature*

Age 59 and under	Age 60 and over

Income