CAPECO721 SE 3rd, Suite D Pendleton, OR 97801 541-276-5073 | 800-752-1139
All fields marked with an asterisk (*) are required.
Instructions: Complete the following information. If you refuse to cooperate/provide verification, your application will be denied. You must provide proof/verification of all income and allowable deductions.
Address verification is required.
Complete the following for each member of your household. Your household means yourself and the people who live with you. List your name first.
Additionally, in order for CAPECO to determine eligibility for this application you will need to provide Social Security Numbers (SSN) for every household member. You may provide it in the last blank space on each line or you can contact us with that information.
INCOME (EARNED & UNEARNED)
List income from all sources for each household member including wages, social security, SSI, TANF, general/public assistance, foster care payments, unemployment or worker’s compensation, child support, alimony, pensions, Veteran’s benefits, per capita payments from gambling enterprises, work/training allowances, etc. Verification of income is required for all household members (pay check stubs, award letters, etc.).
Households with earned income must provide a full month’s wage statements.
Each person listed above must complete a 'Zero Income Form' because they are over 18 years old and did not earn any income.
A link to the online 'Zero Income Form' will be provided after you submit this form.
Check the box below if you would prefer a 'Zero Income Form' by mail for each name listed.
Verification of income is required for all household members (pay check stubs, award letters, etc.). Households with earned income must provide a full month’s wage statements. Upload a photo and/or .pdf file of all documents or mail copies of all income documentation.
Please provide a copy of last year’s Federal Income Tax form (1040, Schedules F, C, E, if applicable), or other proof of self-employment costs and income (current books showing income and expenses). Upload a photo and/or .pdf file of all documents or mail copies of all income documentation.
Please provide verification. Upload a photo and/or .pdf file of all documents or mail copies of all Education Grants, Scholarships or Loans documentation.
Verification is required for all household members. Upload a photo and/or .pdf file of all documents or mail copies of all allowable deductions.
Please provide verification. Upload a photo and/or .pdf file of all documents or mail copies of all Standard Shelter/Utility Expense documentation.
Please provide verification. Upload a photo and/or .pdf file of all documents or mail copies of all Dependent Care documentation.
Please provide verification. Upload a photo and/or .pdf file of all documents or mail copies of all Child Support documentation.
EXCESS MEDICAL EXPENSES
Please provide verification. Upload a photo and/or .pdf file of all documents or mail copies of all Excess Medical Expenses documentation.
RACIAL / ETHNIC DATA COLLECTION
This information is voluntary. If you do not provide this information, it will not affect your eligibility.
FAIR HEARING: If you disagree with any action taken on your case, you or your representative have the right to request a fair hearing. You may request a fair hearing in writing or orally. If you request a fair hearing, your case may be presented by a household member or representative, such as a legal counsel, a relative, a friend or other spokesperson. To request a Fair Hearing contact Confederated Tribes of the Umatilla Indian Reservation (CTUIR) at 541-429-7300 or by mail at 46411 Timine Way, Pendleton, OR 97801.
PENALTY WARNING: If your household receives USDA foods, it must follow the rules below. Failure to comply with these rules may result in a monetary claim being filed against the household and /or disqualification from participation in the Food Distribution Program.
INTENTIONAL PROGRAM VIOLATION (IPV) PENALTIES: If you or any member of your household knowingly and willing violates the rules above it is considered an Intentional Program Violation (IPV). Household members determined to have committed an IPV will be ineligible to participate in the Food Distribution Program for a period of 12 months for the first violation, for a period of 24 months for the second violation; and permanently for the third violation. Individual(s) committing an IPV may be referred to authorities for prosecution.
AUTHORIZATION: I authorize the release of any necessary information or forms to the Food Distribution Office from individuals, businesses, schools, banking institutions, Federal/State/Tribal agencies needed to determine/verify my eligibility. I understand that this information will be used only for the purpose of helping to document my eligibility for Food Distribution benefits. This authorization is good for 12 months from the date signed or until revoked by me in writing.
CERTIFICATION STATEMENT: I certify that I have read this application and that the information contained in it is true and correct to the best of my knowledge. I understand that I must comply with Program rules and provide additional documentation if required, and that falsification of information on this form may be grounds for disqualification and/or claim action. I further understand that I must report within ten (10) calendar days after the change becomes known the following changes: a change in household size or composition; an increase in gross monthly income of more than $100; a change in residence/address; when the household no longer incurs a shelter or utility expense; or a change in the legal obligation to pay child support.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, religious creed, disability, age, political beliefs, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.
Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:
This institution is an equal opportunity provider.