Yurok Food Distribution Program

Instructions: Complete the following information. If you refuse to cooperate or provide verification, your application will be denied. You must provide proof/verification of all income and allowable deductions.
Name (Head of Household):

First NameLast Name
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Household Size*
Directions to Your Home: *

HOUSEHOLD MEMBERS: Complete the following for each member of your household. Your household means yourself and the people who live/eat with you. Do not include boarders. List your name first. (Attach a separate sheet if you need to list additional household members.) *

	Name(s) of all Household Members (Last, First, Middle Initial) Please Print	Relationship to Head of Household	DOB	Social Security #
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Are you or anyone in your household currently receiving SNAP (Food Stamps) benefits?*

YesNo
If yes, list names:
Have you or anyone in your household recently applied for SNAP (Food Stamp) benefits?*

YesNo
If yes, list names:
Have you or anyone in your Household been disqualified from SNAP for an Intentional program violation?*

YesNo
If yes, list names:

INCOME:

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 is required for all household members who receive income (Check stubs, SSI award letters, ETC.) Households are required to provide the past 30 days of income.

	HOUSEHOLD MEMBER	EMPLOYER/ SOURCE OF INCOME	TYPE OF INCOME (Wages, social security, TANF, child support, etc.)	HOW OFTEN PAID (Monthly, bi- weekly, weekly)	Gross Amount
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SELF-EMPLOYMENT INCOME: Are there any members in your household who are self- employed?*

YesNo

If yes, complete the following section. (Payments from rental property, roomers, boarders, farming, ranching, and/or operating your own business are 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	TYPE OF BUSINESS (Farm, ranch, Rental, Day Care, ETC.)	OCCUPATION	Is this your primary source of Income for meeting your living expenses?
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STUDENTS: Are there any students in your Household who receive education grants, scholarships or loans?*

YesNo

If Yes, please complete the following section. Please provide verification.

	HOUSEHOLD MEMBER	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 related expenses.
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STUDENTS VERIFICATION

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ALLOWABLE DEDUCTION (Please provide verification):
STANDARD SHELTER/UTILITY EXPENSE: Does anyone in your household pay monthly, at least one shelter/utility expense?*

YesNo
If yes, type of Shelter/Utility expense paid monthly:
File Upload

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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 an education which is preparatory to employment?*

YesNo
If yes, Name and address of person providing care:
If yes, Name and address of person providing care:
If yes, Amount Paid:
If yes, How often paid (weekly, monthly, ETC):
If yes, How often paid (weekly, monthly, ETC):
File Upload

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CHILD SUPPORT: Does anyone in your household pay court ordered child support for a non-household member?*

YesNo
If yes, Amount ordered to pay:
If yes, Amount actually paid:
If yes, Amount actually paid:
If yes, How often:
File Upload

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EXCESS MEDICAL EXPENSES: Anyone in your household elderly and/or disabled?*

YesNo
If yes, Monthly total medical expenses: (Milage for medical, prescriptions, medical insurance, payments for medical devices, etc. Do not include expenses from special diets.)
File Upload

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AUTHORIZED REPRESENTATIVE: To authorize someone outside of your household to act on your behalf with paperwork and/or pick up your food, complete this section. *

	NAME(S)	PHONE NUMER	Pick Up	Paperwork	Both
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RACIAL/ETHNIC DATA:
What is your ethnic category?*

Hispanic or LatinoNot Hispanic or Latino
What is your race?*

American Indian or Alaskan NativeAsianWhiteBlack/African AmericanNative Hawaiian or Pacific Islander

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 legal counsel, a relative, a friend or other spokesperson.
PENALTY WARNING:

If your household receives USDA food benefits, 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, household size, and/or participation in the Supplemental Nutrition Assistance Program (SNAP) in order to obtain Food Distribution benefits which your household is not entitled to receive.

2. Do not misuse (trade, sell, ETC.) USDA foods

3. Do not participate simultaneously in the Supplemental Nutrition Assistance Program (SNAP) and the Food Distribution Program.

4. INTENTIONAL PROGRAM VIOLATION (IPV) PENALTIES: If you or any member of your household knowingly and willingly violates the rules above it is considered and Intentional Program

5. 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. Individual(s) committing an IPV may be referred to authorities for prosecution.
AUTHORIZATION TO RELEASE INFORMATION: All adult household members must sign.

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. I 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.

Adult Household 1 (Required)
Name*

First NameLast Name
DOB*

MonthDayYear
Date
Signature*

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Date*

MonthDayYear
Date

Adult Household 2 (Optional)
Name

First NameLast Name
DOB

MonthDayYear
Date
Signature

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Date

MonthDayYear
Date

Adult Household 3 (Optional)
Name

First NameLast Name
DOB

MonthDayYear
Date
Signature

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Date

MonthDayYear
Date

Adult Household 4 (Optional)
Name

First NameLast Name
DOB

MonthDayYear
Date
Signature

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Date

MonthDayYear
Date

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 10 calendar days after the change becomes known the following changes: a change in household size or composition; an increase in monthly income of more than $100; a change in residence/address; when the household no longer incurs a shelter or utility expense; or a change in the legal obligation to pay child support.
Signature*

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Date*

MonthDayYear
Date
Please verify that you are human*
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Yurok Food Distribution Program

Food Dist. | Email: fdp@yuroktribe.nsn.us

Instructions: Complete the following information. If you refuse to cooperate or provide verification, your application will be denied. You must provide proof/verification of all income and allowable deductions.

INCOME:

ALLOWABLE DEDUCTION (Please provide verification):

RACIAL/ETHNIC DATA:

FAIR HEARING:

PENALTY WARNING:

AUTHORIZATION TO RELEASE INFORMATION: All adult household members must sign.

CERTIFICATION STATEMENT: