Food Assistance
Months Received In State
Toggle Button
Number of Months
Start Period
End Period
Case Reference
[field-value]
[Date]
[Date]
[Case Reference No.]
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Months Received In Other States
Toggle Button
Number of Months
Start Period
End Period
State
[field-value]
[Date]
[Date]
[field-value]
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Exemption
Toggle Button
Reason
Start Period
End Period
Case Reference
[field-value]
[Date]
[Date]
[Case Reference No.]
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Regain Eligibility
Toggle Button
Reason
Start Period
End Period
Case Reference
[field-value]
[Date]
[Date]
[Case Reference No.]
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Additional Three Months Extension
Toggle Button
Granted
Start Period
End Period
Case Reference
[True]
[Date]
[Date]
[Case Reference No.]
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