Forms for SNAP clients
Many of the forms that you may need to submit as part of your SNAP case are below.
If you need help understanding or completing any of these forms, you can always contact your caseworker.
Our Economic Assistance Eligibility Client Services team is also available to help. You can reach them at 800-948-3050.
application forms
SNAP / TANF Application (MDHS EA Form 900)
English | Spanish | Vietnamese
- Use the SNAP/TANF Application (MDHS EA Form 900) to apply for SNAP benefits and/or TANF benefits. You can complete this form if you are applying for SNAP or TANF for the first time or if you need to recertify for benefits.
- For more information on how to submit your application, see our Applying for SNAP page or our Applying for TANF page.
SNAP Simplified Application for the Elderly (ESAP) (MDHS EA 904)
English | Spanish | Vietnamese
- Use the SNAP Simplified Application for the Elderly (ESAP) form (MDHS EA 904) to apply for SNAP if:
- Everyone in the household is aged 60 or older, or all household members aged 60 or older purchase and prepare food separately from the other household members, and
- No household member receives earnings from work.
Reporting and verification forms
SNAP/TANF Employment Wage Verification Form (MDHS EA Form 910)
English | Spanish | Vietnamese
- Use the SNAP/TANF Employment Wage Verification Form (MDHS EA Form 910) if your caseworker asks you to get an Employment Wage Verification form completed by your current or former employer. Please note that this form must be signed by your caseworker to request employment verification.
SNAP/TANF Change Reporting Form (MDHS EA Form 946)
English | Spanish | Vietnamese
- Use the SNAP/TANF Change Reporting Form (MDHS EA Form 946) to report any changes to your household’s circumstances, including a change in your income, someone moving into or out of your household, changes in your rent or mortgage amount, and more.
- See SNAP Participant Rights and Responsibilities for the full list of changes that must be reported to MDHS within 10 days.
administrative hearing forms
MDHS Programmatic Appeal Request (MDHS-OIG-200)
- Use the MDHS Programmatic Appeal Request form (MDHS-OIG-200) to request a fair hearing.
Administrative Disqualification Hearing Waiver (MDHS Form F091)
- Use the Administrative Disqualification Hearing Waiver Form (MDHS Form F091) if you would like to waive your right to an Administrative Disqualification Hearing.
Administrative Hearing Face-to-Face Hearing Request (MDHS Form F091A)
- Use the Administrative Hearing Face-to-Face Hearing Request form (MDHS Form F091A) if you want to request a face-to-face hearing instead of having your hearing conducted over the phone.
Request for Continuance of Administrative Hearing Date (MDHS EA Form 956)
- Use the Request for Continuance of Administrative Hearing Date form (MDHS EA Form 956) if you would like to request a change to the administrative (fair) hearing date that was listed on your hearing notice.
Stolen Benefits
MDHS Lost Benefit Attestation Form (Reporting Stolen SNAP Benefits)
Online Lost Benefit Attestation Form
Downloadable Lost Benefit Attestation Form English | Spanish | Vietnamese
- Use the MDHS Lost Benefit Attestation Form to request replacement SNAP benefits lost due to theft due to card skimming, card cloning, or other similar fraudulent methods (i.e. electronic benefit theft).
- Learn more about stolen SNAP benefit replacement on the Reporting Stolen SNAP Benefits page.
Replacement benefits
Household Statement of Food Loss Due to Household Disaster (Replacement benefits) (MDHS EA Form 508)
English | Spanish | Vietnamese
- Use this form to report that food purchased with SNAP benefits was destroyed in a household misfortune or disaster and to request replacement SNAP benefits.
- A household misfortune or disaster might include a house fire, flooding, or an extended power outage caused by a storm or other natural disaster. Learn more about having your SNAP benefits replaced after a household disaster on our SNAP Replacement Benefits page.