FOOD DISTRIBUTION PROGRAM APPLICATION

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.
Name (Head of Household) *

First Name Last Name
Email *
example@example.com
County *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Household Size *
Phone Number *

Area Code Phone Number
Directions to your Home *
HOUSEHOLD MEMBERS
Complete the following for each member of your household. Your household means yourself and the people who live with you. List your name first. Click the "+" sign at the bottom to add additional household members.
Are you or anyone in your household currently receiving SNAP benefits? *

Yes No
List name(s) *
Have you or anyone in your household recently applied for SNAP benefits? *

Yes No
List name(s) *
Have you or anyone in your household been disqualified from the Supplemental Nutrition Assistance Program (SNAP) for an intentional program violation? *

Yes No
List name(s) *
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.
Income (Click the "+" to add additional income)
SELF-EMPLOYMENT INCOME
Are there any members of your household who are self-employed? *

Yes No
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.
Self-Employment Income (Click the "+" to add additional income)
Students
Are there any students in your household who receive education grants, scholarships, or loans? *

Yes No
Complete the following section. Please provide verification.
Student Information (Click the "+" to add additional student information)
Allowable Deductions

Please provide verification
Standard Shelter/Utility Expense
Does anyone in your household pay, on a monthly basis, at least one shelter/utility expense? *

Yes No
Type of shelter/utility expense paid monthly *
Dependent Care
Does anyone in your household pay for the care of a child or other dependent when necessary for a household member to accept or continue employment or to attend training or pursue which is preparatory for employment? *

Yes No
Name and address of person providing care *
Amount paid *
How often paid? (weekly, monthly, etc.) *
Child Support
Does anyone in your household pay court ordered child support for a non-household member? *

Yes No
Amount ordered to pay *
How often paid? (weekly, monthly, etc.) *
Excess Medical Expenses
Anyone in your household elderly and/or disabled? *

Yes No
Monthly total of medical expenses, excluding special diets *
Authorized Representative

To authorize someone outside your household to act on your behalf and/or pick up your food, complete this section
Authorized Representative Information (Click the "+" to add additional authorized representative)
Racial/Ethnic Data Collection

This information is voluntary. If you do no provide this information, it will not affect your eligibility.
What is your ethnic category?

Hispanic or Latino Not Hispanic or Latino
What is your race?

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander White
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.
Applicant's Signature *

Clear
Date

Month Day Year
Date
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.
Should be Empty:

FOOD DISTRIBUTION PROGRAM APPLICATION

HOUSEHOLD MEMBERS

INCOME (Earned and Unearned)

SELF-EMPLOYMENT INCOME

Students

Allowable Deductions

Authorized Representative

Racial/Ethnic Data Collection