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.

Note: This certification notice is issued to indicate that the facility is considered an institution for SNAP purposes.

Reissued April 8, 2016 , replacing March 1, 2012