Appendix A: Sample Letter

(New State Agency)

RE: Household Name

Case Number

To whom it may concern:

The household listed herein is entitled to restoration of SNAP benefits. Because the household is leaving this state, full benefits cannot be restored prior to the effective date of transfer. This letter provides documentation of the additional amount of benefits to be restored to this household and authorizes the receiving state to restore these remaining benefits accordingly.

1.

Name

__________________________________
(Payment name)

2.

Address

__________________________________
(Former state)

3.

Address

__________________________________
(New state)

4.

Restoration Entitlement:

a. Total amount to be restored

a) __________

b. Amount restored by former state

b) __________

c. Amount to be restored by new state (a-b)

c) __________

5.

Is restoration a result of a hearing decision? // Yes // No

(If yes, a copy of the hearing decision is attached.)

Sincerely yours,

cc: Household

Case Record