• USDA Foods Application

  • YOU ARE NOT ELIGIBLE FOR FOOD DISTRIBUTION

  • 1.If you are on SNAP (food stamps) you are not eligible for Food Distribution Program. If you draw from both programs, you can be penalized and you will have to reimburse USDA for the cost of the food you received while you were ineligible.

    IF YOU ARE ELIGIBLE FOR FOOD DISTRIBUTION, WE WILL NEED THE FOLLOWING INFORMATION TO ESTABLISH YOU IN OUR SYSTEM

    • LIST ALL HOUSEHOLD MEMBERS: The date of birth and social security numbers for everyone in your household you are claiming on your application.
    • TRIBAL ID NUMBER: This is NOT your fishing number.
    • INCOME: Pay check stub for one month.
    • NO INCOME FORM: For all unemployed applicants over the age of 18 and not in school.
    • SOCIAL SECURITY OR SOCIAL SECURITY INSURANCE; VETERANS BENEFIT; PENSION OR RETIREMENT; UNEMPLOYMENT; L&I, TANF, CHILD SUPPORT & FOSTER CARE etc.: A copy of a check, award letter, or bank deposit slip.
    • SNAP: A copy of award letter stating you are not receiving food stamps if switching programs.
    • PER CAPITA: A copy of award letter or check verifying how often monies are received.
    • TRIBAL ELDERS: A copy of check or award letter.
    • CHILD CARE: Reciept for child care for one month.
    • STANDARD SHELTER EXPENSE DEDUCTION: Copy of your rent/mortgage receipt.
    • MEDICAL DEDUCTION FOR TRIBAL ELDERS: Copy of any bills paid on a monthly basis.
    • A COPY OF YOUR UTILITY BILL: We need the bill with your name and address so we are able to verify we have your correct address on file.

    Please verify all income for the household and circle items wanted on the attached food order. If all attachments are not with the application, your application will be placed into a Pending file until all the required information is received and verified. Once you are certified eligible for food distribution we will add you to the delivery list for your area.

    YOUR APPLICATION MUST BE ANSWERED HONESTLY AND COMPLETELY. PLEASE DO NOT LEAVE QUESTIONS BLANK AS THIS WILL DELAY YOUR CERTIFICATION.

    Please return this applcation to the main SPIPA office located at:

    3104 SE Old Olympic Hwy., Shelton WA 98584

    or fax to: 360.427.8003

    Serving: The Confederated Tribes of the Chehalis Reservation, Nisqually Indian Tribe, Port Gamble Klallam Tribe, Skokomish Indian Tribe, and Squaxin Island Tribe 

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  • South Puget Intertribal Planning Agency Food Distribution Program

    4822 She-Nah-Num Drive S.E. Olympia WA 98513 360.426.3990

  • 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
    Mailing Address:      Social Security:      
    Physical Address:     DOB:      
    City/State/Zip:       Ph:      
    Name of Tribe & Roll No:      

  •  

  • Are you or anyone in your household currently receiving SNAP benefits?         If yes, list names:      
    Have you or anyone in your household recently applied for SNAP benefits?        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?        If yes, list names:       

  •  

  • SELF-EMPLOYMENT INCOME: Are there any members in your household who are self-employed?         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)

  •  

  • STUDENTS: Are there any students in your household who receive education grants, scholarships or loans?         If yes, complete the following section. Please provide verification.

  •  

  • ALLOWABLE DEDUCTIONS (Please provide the following verification):
    STANDARD SHELTER/UTILITY EXPENSE: Does anyone in your household pay, on a monthly basis, at least one shelter/utility expense?       If yes, type of shelter/utility expense paid monthly.        

  • DEPENDENT CARE: Does anyone in the 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?       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?         If yes, complete the following: Amount ordered to Pay:      Amount actually paid:      

  • EXCESS MEDICAL EXPENSES: Anyone in your household elderly and/or disabled?         If yes, complete the following: Monthly total of medical expenses, excluding special diets:      

  •  

  • RACIAL/ETHNIC DATA COLLECTION: This information is voluntary. If you do not provide this information, it will not affect your eligibility.

    1. What is your ethnic category?           
    2. What is your race?                       

  • 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 requst a fair hearing in writing or orally. If you request a fair hearing, your case may be presented by a houshold member or representative, such as 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 withohold 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 willingly violates the rules above 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 total of 12 months for the first violation, for a period of 24 months for a second violation; and permanently for the third violation. Individual(s) comitting an IPV may be referred to authorities for prosecution. 

    AUTHORIZATION: I authorize the release of any necessary informatino or forms to the Food Distribution Office from individuals, businesses, schools, banking institutions, Federal/State/Tribal agencies needed to determine/verify my eligibility. I understand that this information will be used only for the purpose of helping to document my eligibility for Food Distribtuion 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 the falsification of informatino on this form may be grounds for disqualification and/or claim action. I further understand that I must report within twn (10) calendar days after the change becomes known with 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 or utility expense; or change in the legal obligation to pay child support. 

  • Clear

  • USDA Nondiscrimination Statement

    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 on line 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:


      (l) mail: U.S. Department of Agriculture
          Office of the Assistant Secretary for Civil Rights
          1400 Independence Avenue, SW
          Washington, D.C. 20250-9410;
      (2) fax: (202) 690-7442; or
      (3) email: program.intake@usda.gov 


    This institution is an, equal opportunity provider.

  • FOOD DISTRIBUTION PROGRAM ZERO INCOME FORM


    In determining your eligibility for the Food Distribution Program, you must provide proof of income for 30 days prior to the date of application. If you had zero income for the past 30 days, you must please answer the following questions:

    1. What was the total income for your household for the past 3 months?       
    2. How do you pay your utility bills?       
    3. How do you pay your rent?       
    4. How do you get food for your household?       
    5. Are you receiving income from your friends or family?       How much?       
    6. Are you looking for work?       
    7. Have you applied for PA or GA?       
    8. If you are residing with others (such as family or friends), do you purchase, prepare, and eat your food separately?       


    I hereby certify that the information that I have provided accurately represents the total income for each member of my household (18 years and older). I understand that I must report changes in household size or composition; increases in gross monthly income of more than $100; changes in residence and/or address; when the household no longer incurs a shelter or utility expense; or a change in the legal obligation to pay child support to the Food Distribution Office within ten calendar days after the change becomes known to the household.

  • Clear

  • The US Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disabilitty, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all of part of an indivudal's income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) 

    If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office or call (866)632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Ave., S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov .

    Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800)877-8339; or (800)845-6136 (Spanish).

    For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers found online at http://www.fnsusda.gov/snap/contact_info/hotlines.htm 

     

    USDA is an equal opportunity provider and employer. 

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