APPLICATION FOR STOWW FOOD DISTRIBUTION PROGRAM
Date Received:______
Does anyone in your household receive Food Benefits from DSHS?
( Must initial one ) Yes______No______
Answer the following questions honestly and completely. If you know but refuse on purpose to give any needed information, your household (you and the people who live and eat with you) will not be eligible for the Food Distribution Program (commodities). You may complete this form at home and mail it or bring it to the office. Another member of your household, or an adult who knows you may complete and return this application to us.
IMPORTANT: When you are interviewed, please bring proof of all household income -- for example: Pay stubs and Award Letters for government benefits (such as Social Security.) We may also require statements of all household saving-checking accounts and dependent care costs. Having these items with you will speed up your application.
Name: Telephone Number where you can be reached:
Mailing address: City State Zip
Tribe: Do you live within the city limits?
( ) YES ( ) NO
HOUSEHOLD MEMBERS:
Print the information below for each household member, including yourself first. People who live and eat with you (except roomers and boarders) should be listed as household members. We would like you to include the social security number of each member of your household who has one, although you are not required to do so. This will help us to identify your household correctly. These social security numbers may also be used in program reviews or audits to make sure your household is eligible for commodities. We are authorized to ask for this information under the Tax Reform Act of 1976.
Name(s) SS # Birth date
1.(Self)
2.
3.
4.
5.
6.
7.
8.
INCOME FROM WORK:
Fill in all blanks for each household member with a full or part time job. If a member has more than one job, list each job separately.
Household Member Name of Employer Amount of each Paycheck before How
deductions such as taxes, retire- often
ment, or union dues are deducted. paid?
1.______
2.______
3.______
4.______
Is anyone in your household self employed? ( ) YES ( ) NO
If YES, complete Self Employment Income Sheet.
Please bring last years' Federal Tax Forms for self employed members of your household, Or, if no such tax forms were filed last year, bring proof of self employed cost/income.
OTHER INCOME AMOUNTS:
Source of Income: Household Members who Amount of each How often receive this income check or payment received
TANF (Temporary Aid
To Needy Families) 1. $
2. $
Social Security
1. $
2. $
SSI (Supplemental
Security Income) 1. $
2. $
GA
(General Assistance) 1. $ 2. $
VA
(Veterans Assistance) 1. $
2. $
Pensions or Retirement
Income 1. $ 2. $
OTHER INCOME AMOUNTS:
Source of Income Household Members who Amount of each How often
Receive This Income Check or Payment Received
Unemployment or Worker's
Compensation 1. $
2. $
Child Support and
Alimony 1. $
2. $
Money from friends or
relatives (other than loans) 1. $
2. $
Other (specify) 1. $
2. $
DEPENDENT CARE:
Does anyone in your household pay for someone to baby-sit or care for a child or a disabled adult so that a member can work, train, or look for a job? ( ) YES ( ) NO
If yes, how much do you pay? $ How often?
Who provides this care? Name and Address: Telephone Number
RESOURCES: (For example: Cash on hand, savings/checking accounts, stocks, bonds, other negotiables)
CHILD SUPPORT PAID TO A NON-HOUSEHOLD MEMBER
If a household member pays child support, please provide copy of court order, divorce decree or any other document. (May be used to calculate adjusted income.)
YOUR RACIAL-ETHNIC HERITAGE:
Although you are not required to provide this information, your cooperation will help determine compliance with Federal Civil Rights Law. In no instance will this information be used in considering your application. If you decline to provide this information, it will in no way affect consideration of your application. We are authorized to ask for this information under Title VI of the Civil Rights Act of 1964. Circle one.
African American White Hispanic Asian or Pacific American Indian or
Islander Alaskan Native
AUTHORIZED REPRESENTATIVE:
You can authorize someone outside of your household to pick up your commodities for you. If you would like to authorize someone, write the person's name below.
Name: Telephone
PENALTY WARNING:
If your household receives food distribution, you must follow the rules listed below:
¨ DO NOT trade or sell commodities.
¨ DO NOT use someone else's commodities for your household.
¨ DO NOT give false information, or hide information to receive or continue to receive commodities.
I understand the questions on this application. My answers are correct and complete to the best of my knowledge.
I understand that I may have to provide documents to prove what I've said. I agree to do this. If documents are not available, I agree to give the name of a person or organization the office may contact to obtain the necessary proof.
Signature: Date:
You or your representative may request a fair hearing either orally or in writing if you disagree with any action taken on your case. Your case may be presented at the hearing by any person you choose.
In accordance with Federal law and U.S. Department of Agriculture policy, this institution prohibits discrimination on the basis of race, color, national origin, age, disability, and where applicable, sex, maritial status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or a part of an individual's income is derived from any public assistance program.
There have been no changes in my situation since I filed this application.
Signature: Date:
Rev 04/2009