CLARKE COUNTY DHS State Of Mississippi

29 HARRIS AVENUE Department Of Human Services

QUITMAN , MS 39355

COUNTY : 120
DANIEL BLACK TELEPHONE : (601)776-3756
7945 CO RD 514 Case Number: 150781647
MERIDIAN , MS 39301 WORKER : KRISTY CLEMENT

DATE : 03/25/2024

Form: F905 SNAP - REQUEST FOR INFORMATION F905

Only the paragraph(s) marked with "XXX" apply to your case.
_XXX_ This is to give you in writing the information which we must have in order to complete your
application and determine your eligibility. We need you to provide this office with the information
listed below.
__ We have received information about your household which may affect your SNAP eligibility or
level of benefits. We need you to provide this office with the information listed below. Failure to
provide this needed information will be considered a refusal to cooperate and action will be taken
to close your SNAP case.
__ We have received information about your household which may affect your level of SNAP benefits.
We need you to provide this office with the information listed below.
____ We have received information about your household which may result in an increase in SNAP
benefits. We need you to provide this office with the information listed below. Your SNAP case
cannot be reworked until we receive this information.
Needed information/verification: VERIFY SCHEDULE C TAXES FOR L33T CUSTOMS LLC THAT YOU OWN.
____ Because you are a change reporting household, failure to respond to this request or provide
the requested information will lead to closure of your SNAP case.
____ Because you are a simplified reporting household, if you do not respond to or provide the
requested information, the person identified in this letter will be removed from your SNAP case.

Please return this information by APRIL 4, 2024.

It is our responsibility to assist you in obtaining required verifications, provided you are
cooperating with our agency. Therefore, if you have questions or need help in obtaining
verification of requested information, Please contact K CLEMENT 6017763756 for assistance.
Please read the back of this notice for information about your rights and responsibilities and
reporting requirements for changes in household circumstances.