Enclosure: Direct Verification Form- FoodShare (SNAP), W-2 Cash Benefits (TANF) or FDPIR FoodShare (SNAP), W-2 Cash Benefits (TANF), or FDPIR office DIRECT VERIFICATION FORM Case Number Child’s Name Date Benefits FoodShare, Last name, first name, middle Start Date of Terminated W-2 Cash Benefits, or (if initial Benefits (if applicable) FDPIR applicable) If the child listed is not currently receiving benefits (or has not been within the past 180 days) please indicate in the Start Date of Benefits column. “no” ____________________________________________________________________________________ Signature/Title of FoodShare, W-2 Cash Benefits or FDPIR Official Date ______________________________________________________________________________ Address City/State/Zip Code ______________________________________________________________________________ Telephone Number/Email
Enclosure: Direct Verification Form- FoodShare (SNAP), W-2 Cash Benefits (TANF) or FDPIR FoodShare (SNAP), W-2 Cash Benefits (TANF), or FDPIR office DIRECT VERIFICATION FORM Child’s Name Last name, first name, middle initial (if applicable) Case Number FoodShare, W-2 Cash Benefits, or FDPIR Start Date of Benefits Date Benefits Terminated (if applicable) If the child listed is not currently receiving benefits (or has not been within the past 180 days) please indicate “no” in the Start Date of Benefits column. ____________________________________________________________________________________ Signature/Title of FoodShare, W-2 Cash Benefits or FDPIR Official Date ______________________________________________________________________________ Address City/State/Zip Code ______________________________________________________________________________ Telephone Number/Email
verification-forms.docx