• PAWNEE NATION FOOD DISTRIBUTION PROGRAM APPLICATION P.O. BOX 470 PAWNEE, OK 74058

    (918) 762-2541 Fax: (918) 762-6463

    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.

  • 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.

    • Household Member #1  
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    • Household Member #2  
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    • Household Member #3  
    •  -  -
      Pick a Date
    • Household Member #4  
    •  -  -
      Pick a Date
    • Household Member #5  
    •  -  -
      Pick a Date
    • Household Member #6  
    •  -  -
      Pick a Date
    • Household Member #7  
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    • Household Member #8  
    •  -  -
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    • Household Member #9  
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  • 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. Attach a separate sheet, if you need to list additional household members.

    • Household Member #1  
    • Household Member #2  
    • Household Member #3  
    • Household Member #4  
    • Household Member #5  
  • Self Employment Income

  • If yes, complete the following section. Payment from rental property, roomers, boarders, farming, ranching, and/or operating your own business is considered to be 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).

    • Household Member #1  
    • Household Member #2  
  • Students

  • If yes, complete the following section. Please provide verification.

    • Household Member #1  
    • Household Member #2  
  • Allowable Deductions

  • Authorized Representative

     To authorize someone outside your household to act on your behalf and/or pick up your food, complete this section.

    • Person #1  
    • Person #2  
  • Clear
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