Food Distribution Program Application

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.
Name (Head of Household)
County
Street Address
Household Size
City/State/Zip Code
Telephone No.
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.

Are you or anyone in your household currently receiving SNAP benefits?

YesNo
If yes, list names
Have you or anyone in your household recently applied for SNAP benefits?

YesNo
If yes, list names
Have you or anyone in your household been disqualified from the Supplemental Nutrition Assistance Program (SNAP) for an intentional program violation?

YesNo
If yes, list names

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.

Self Employment Income
Are there any members in your household who are self-employed?

YesNo
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
Full Name
Type of Business
Farm, Ranch, Rental, Day care, etc.
Occupation
Is your self-employment the primary source of income for meeting your living expenses?

Household Member #2
Full Name
Type of Business
Farm, Ranch, Rental, Day care, etc.
Occupation
Is your self-employment the primary source of income for meeting your living expenses?

Students
Are there any students in your household who receive education grants, scholarships or loans?

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

Household Member #1
Full Name
Amount of Loan/Grant
Period of Time Funds Intended to Cover
Type of Payment
Pell Grant, Student Loan, BIA
Amount Used to pay Tuition/School Fees/Other Rel. Exp.
Pell Grant, Student Loan, BIA

Household Member #2
Full Name
Amount of Loan/Grant
Period of Time Funds Intended to Cover
Type of Payment
Pell Grant, Student Loan, BIA
Amount Used to pay Tuition/School Fees/Other Rel. Exp.
Pell Grant, Student Loan, BIA

Allowable Deductions
Standard Shelter/Utility Expense: Does anyone in your household pay, on a monthly basis, at least one shelter/utility expense?

YesNo
If yes, type the 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 education which is preparatory to employment?

YesNo
If yes, 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?

YesNo
Amount ordered to pay
Amount actually paid
Excess Medical Expenses: Anyone in your household elderly and/or disabled?

YesNo
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.

What is your ethnic category?

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

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
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