Student Name Student ID Number

______

Student Name Student ID Number

You have indicated that a member of your household, received benefits from the Supplemental Nutrition Assistance Program or SNAP (formerly known as the Food Stamp Program) sometime during 2015 or 2016. Your household includes:

·  You the student.

·  Your spouse, if married.

·  You and/or your spouse’s children, you will provide more than half of their support from July 1, 2017, through June 30, 2018, even if the children do not live with the student.

·  Other people living with you if you and/or your spouse provides more than half of their support and will continue to provide more than half of their support through June 30, 2018.

Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we may require documentation from the agency that issued the SNAP benefits in 2015 or 2016.

Check this box if you or a member of your household did NOT receive SNAP benefits in 2015 or 2016.

Certification and Signature

Each person signing below certifies that all of the

information reported is complete and correct.

______

Student Signature (Required) Date

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Spouse Signature (Optional) Date

Please return completed form to:

Doane University Office of Financial Aid 303 N 52 St, Lincoln NE 68504

(402) 466-4774 phone (402) 466-4228 fax