Case number: / Date of notice:
Case name:
Able Bodied Adults Without Dependents (ABAWDs) are people who are at least 18 but not yet 50 years of age. ABAWDs have special requirements to receive more than three months of food
benefits between 1/1/2016 and 12/31/2018. We believe
is an ABAWD. Please read the back of this form to see if these special ABAWD rules are for you.

We need to see if any of the months you received food benefits counts as one of your three months.

We need to see if you are doing the activities required to stay eligible for food benefits.

If the SNAP office does not have the items asked for below by
you will be required to do the special ABAWD activities. Also some of the months you received food benefit may count as one of your three months. If this causes your food benefits to be less or to stop you will receive another notice.
Please give the information or proof listed below to your SNAP office / Date completed
(agency use only)
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If one of the following is true you may not have to do the special ABAWD activities.

Please let the SNAP office know right away if any of the following apply to you.

  • I have a child under 18 years old living and eating with me.
  • I am pregnant.
  • I am attending school at least half time.
  • I am caring for a disabled person and this prevents me from working.
  • I am attending an alcohol or drug treatment program.
  • I am getting unemployment insurance benefits.
  • I am working at least 30 hours a week for pay.
  • I am being paid at least $935.25 a month for work I do.
  • I am self-employed and earning at least $935.25 and have no business costs.
  • I am self-employed and earning at least $1870.50 and have business costs.
  • I am not able to work at this time. Please explain this to your worker.

You may already be doing the special ABAWD activities. Please tell the SNAP office right away if you are doing any of the following.

  • Working for pay at least 20 hours per week.
  • Doing unpaid work for 20 hours per week.
  • Working for at least 20 hours per week in exchange for something other than money. Attending an approved training program.

Worker’s signature: / Print Worker’s name:
Phone number: / Extension: / Branch name:
Branch address:

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