The DFA SNAP 2 form, provided by the West Virginia Department of Health and Human Resources, is a critical tool for individuals and families participating in the Supplemental Nutrition Assistance Program (SNAP). It serves as a conduit for reporting changes that may affect the amount of benefits received, ensuring recipients get the aid they are entitled to. This form is particularly important when a household's gross income crosses the threshold limit, when there are substantial lottery or gambling winnings, or if an Able-Bodied Adult Without Dependents (ABAWD) in the home sees a reduction in work hours below the 20-hour weekly average. The form also gathers detailed information regarding changes in household composition, address, income, and expense allocations. It emphasizes the importance of truthful reporting, warning of the severe consequences, including fines, jail time, or disqualification from SNAP, for those found guilty of misinformation or fraud. Participants can report both temporary and permanent changes, ensuring their SNAP benefits accurately reflect their current circumstances. Additionally, the form addresses changes in shelter or utility expenses, household members' names, income adjustments, asset variations, and even changes in court-ordered child support payments, illustrating the comprehensive nature of the report and its significance in the management of SNAP benefits.
| Question | Answer |
|---|---|
| Form Name | Dfa Snap 2 Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | unearned, abawd, wv dhhr report changes, West_Virginia |
West Virginia Department of Health and Human Resources
Supplemental Nutrition Assistance Program (SNAP)
If you wish to report changes for your SNAP benefits, you may use this form to do so. This will help make sure you get the correct benefits you are eligible to
receive. If you receive SNAP benefits, you are not required to report changes except when the gross earned and unearned income of everyone who lives in your home exceeds the gross income limit for your assistance group’s size, if anyone in your home wins substantial lottery or gambling winnings, and, if your household contains an
are reduced to less than 20 hours a week, averaged monthly. The gross income limit for your assistance group can be found on any recent notification letter or may be obtained by contacting the Customer Service Reporting Center. However, any changes that you choose to report will be acted on for all programs if required. If you are unsure of the reporting requirements for the benefits you receive, please contact the Customer Service Reporting Center at
If you intentionally give FALSE INFORMATION or WITHHOLD INFORMATION, you will have to pay back your SNAP benefits and may be disqualified from SNAP for 12 months, 24 months or permanently. In addition, you may be found guilty of FRAUD. Punishment upon conviction may be a fine up to $250,000 or a jail sentence of up to 20 years.
Name (Please print): |
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Case Number: |
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SIGNATURE: |
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DATE: |
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Social Security Number: |
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Telephone Number: |
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1.Please check one of the following boxes:
The changes I am reporting are only for this month.
The changes I am reporting will be continuing.
2.If the address where you live has changed, please write your NEW address below.
Street Address: |
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Phone: |
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Directions to your home: |
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If the address where you get your mail is different, please write your new mailing address below.
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Post Office Box #: |
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or Street Address: |
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Apt. #: |
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City, State: |
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3. |
Has anyone moved into or out of your household? |
Yes |
No |
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If yes, complete the chart below. Use another page if necessary. |
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Name: |
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Name: |
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Date of Birth: |
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Date of Birth: |
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Social Security #: |
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Social Security #: |
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Relationship to you: |
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Relationship to you: |
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Date moved in: |
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Date moved in: |
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Date moved out: |
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Date moved out: |
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Income Types: |
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Income Types: |
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Income Amounts: |
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Income Amounts: |
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Does this person buy |
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Does this person buy |
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and eat meals with you? |
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and eat meals with you? |
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4.Please enter the amount paid each month for the items below or zero (0) if you no longer pay this expense. If you now pay a shelter or utility expense that is not listed, please write it in the section listed as other. If any agency or individual not living in your home now pays all or part of these expenses, please list the amount that they pay and whether it is paid to you or directly to the company that bills you. PLEASE CIRCLE YOUR PRIMARY SOURCE OF HEATING OR COOLING.
Type of Expense |
Amount Owed Each Month |
Paid By (Self, HUD, etc.) |
Rent/Mortgage Payment, Lot Rent, Property Tax, Homeowner’s Insurance, etc. |
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Electric |
$ |
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Gas |
$ |
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Propane |
$ |
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Fuel Oil |
$ |
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Sewer/Water |
$ |
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Other |
$ |
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5. Has anyone in the household changed his or her name? Yes
No
If so, please complete the chart below.
Old Name
Date of Birth
New Name
Reason for Name Change
6. |
Has there been a change in the income of anyone in the home? |
Yes |
No |
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If yes, please list all changes and new sources of earned and/or unearned income received in your household. |
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Name |
Source of Income |
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Gross Amount |
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7. Does anyone in your household have any new assets and/or a change in value for any of the following assets? Yes
No
If so, list who and the current amount. Please also list accounts on which the name of any household member is listed, even if the other person does not live with you.
Name |
Amount |
Checking accounts
Savings accounts
Stocks and Bonds
Burial Funds
Other Assets
8.Has anyone in your household won more than $3500 through a single bet, game of chance, or lottery? If yes, write in the information below:
Name of Person Who Won the Money
Amount of Money Won
When the Money Was Won
9.Does anyone in your household now pay or have a change in the amount they pay for
medical insurance for a child? |
Yes |
No |
If yes, please provide the following for each of the last 3 months: |
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Name |
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Month |
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Payment Actually Made |
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10.Has an
Name
Date of Birth