SNAP E&T Self-Attestation Form

Is this for?

Orieintation/Assessment

Activity

I am unable to produce receipts to verify that I paid for my transportation expenses to attend a SNAP E&T Orientation and/or Assessment on the date listed below:

Date

By my signature below, I attest that I paid for this expense.

I understand I will only be reimbursed for reasonable and necessary program-related activity based on funding availability.

I am unable to produce receipts to verify that I paid for my SNAP E&T allowable expenses to attend a SNAP E&T Activity for the month of:

Month

By my signature below, I attest that I paid for this expense.

I understand I will only be reimbursed the actual amount that I spent:

Activity Completed

Amount Reimbursed

Full Name

Case Number

Signature

Sign Here

Date

An equal opportunity/employer program. Auxiliary aids and services are available upon request to individuals with disabilities.