Appendix C: Shelters for Battered Individuals and Children Certification Notice

___________________________________________
Executive Director

___________________________________________
County Assistance Office

_______________________________________________________________________________________________________________________
Name and address of facility/residence

has been certified by the Department as having met the requirements of a __________________________ for SNAP purposes.
                                                                                                           Type of facility

Effective _____________________________, the _____________________________
             Month/Day/Year                                   Name of county

County Assistance Office is authorized to certify applicants for SNAP benefits under special provisions set forth in the SNAP regulations relating to this type of facility.