• FOOD DISTRIBUTION PROGRAM APPLICATION

  • P.O. Box 59

    Watonga, OK 73772

    (405)276-6049

    Toll Free: (888)747-9520

    Fax: (405)422-8261

    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.

     

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  • HOUSEHOLD MEMBERS

  • INCOME (Earned and 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.
  • SELF-EMPLOYMENT INCOME

  • Complete the following section.  Payment from rental property, roomers, boarders, farming, ranching and/or operating your own business is considered self-employment.  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.

  • Students

  • Complete the following section.  Please provide verification.

  • Allowable Deductions

    Please provide verification
  • Standard Shelter/Utility Expense

  • Dependent Care

  • Child Support

  • Excess Medical Expenses

  • Authorized Representative

    To authorize someone outside your household to act on your behalf and/or pick up your food, complete this section
  • Racial/Ethnic Data Collection

    This information is voluntary. If you do no 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.

    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.
     
    1.       Do not make  false or misleading statements, misrepresent, conceal, or withhold facts regarding income, resources,  household size, and/or participation in the Supplemental Nutrition Assistance Program (SNAP) in order to  obtain Food Distribution Program benefits which your household is not entitled to receive.

    2.        Do not misuse (e.g., trade or sell) USDA foods.

    3.        Do not participate simultaneously in the Supplemental Nutrition Assistance Program (SNAP) and 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. lndividual(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. 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 pr utility expense; or a change in the legal obligation to pay child support.

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    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:

    (1)                   mail: U.S. Department of Agriculture

    Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW

    Washington,  D.C. 20250-941 O;

    (2)                   fax: (202) 690-7442; or

    (3)                  email : program.intake @ usda.gov.

    This institution is an equal opportunity provider.

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