FOOD DISTRIBUTION PROGRAM COLLATERAL STATEMENT OF UNEMPLOYMENT (UES)

FOOD DISTRIBUTION PROGRAM COLLATERAL STATEMENT OF UNEMPLOYMENT (UES)
P.O. Box 59

Watonga, OK 73772

(405)276-6049

Toll Free: (888)747-9520

Fax: (405)422-8261

Statement: These statements are needed to verify if an adult household member is unemployed.
During the course of the certification period, we may call on one or both of the Collateral Contacts to verify if a client is working or not.

Instructions: Please have two people WHO ARE NOT LIVING IN YOUR HOUSEHOLD write a statement verifying that they know you, or other household members over 18 years of age, are unemployed. Be sure to include their name, address, and phone number.
Name of Client*

First NameLast Name
Household ID*
Email*
example@example.com
WRITTEN STATEMENT

#1 of 2
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Scanned Written Signed Statement*

Browse Files

Cancelof
WRITTEN STATEMENTS

#1 of 2
WRITTEN STATEMENT*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Phone Number*

Area CodePhone Number
Scanned Written Signed Statement*

Browse Files

Cancelof
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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FOOD DISTRIBUTION PROGRAM COLLATERAL STATEMENT OF UNEMPLOYMENT (UES)

WRITTEN STATEMENT

WRITTEN STATEMENTS