MONTHLY ELIGIBILITY REPORT (MER)

YesNo
• If “YES” complete below. Include tips, vacation pay or income in kind, such as earned housing. List gross amounts before deductions for each week in the month. Attach pay stubs or other proof of earnings.

• If self –employed: Attach proof of income. If you claim actual expenses, list business expenses on a separate sheet of paper and attach proof of expenses.
Proof of Income

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Proof of Expenses

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2) If you are not paid for work activities, but need to document your approved work participation hours, please do so in this area. (attach proof)
File Upload

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3) If anyone above paid for care of a child, disabled person or other dependent while working, seeking work, or in training, list here and attach proof of payment.

Rows	Name of Person Who Received Care	Cost	Name of Person Who Received Care	Cost
1

YesNo
Include: Child/spousal support; interest or dividends; gambling/lottery winnings; insurance or legal settlements; strike benefits; cash, gifts, loans, scholarships; tax refunds; any government benefits, like social security, Supplemental Security Income/State Supplementary Payment (SSI/SSP), unemployment, worker’s compensation, state disability indemnity, veterans or railroad retirement, other private or government disability or retirement; rental income and rental assistance; free housing/utilities/clothing/food; or anything else. If “YES”, complete below. Attach proof.
File Upload

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Rows	Name of Person Who Paid:	For Whom:	Cost:
1

Rows	Full Name of Person	Date Drug Committed	Date of Felony Conviction	Conviction Was For	Other Conviction Explained (If Needed)
1

Rows	Full Name of Person	Relationship To You	Explain What Changed	Date of Change
1

Rows	Full Name of Person	Relationship To You	Explain What Changed	Date of Change
1

MOVED? CHANGE YOUR ADDRESS NOW! CALL
707-465-8305 Crescent City
707-445-2422 Eureka
New Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Mailing Address If Different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date Moved

MonthDayYear
Date

STATEMENT OF TRUTH
Under penalty of perjury or un-sworn falsification, I certify that the statements made on this application and during my interview for assistance regarding the persons in my home, the income, resources, property, and all other items that pertain to my possible eligibility for benefits are true and correct to the best of my knowledge.

Termination Due to Fraud: In cases where there has been a termination for deliberate fraud, i.e., collecting TANF benefits from multiple sources, knowingly providing fraudulent information when participant was receiving SSI or was employed independently or deliberate withholding or misstating resource information, the TANF program, at the discretion of the Program Manager, may declare the participants ineligible for a period up to two years.
YOU MUST SIGN AND DATE THIS REPORT AFTER THE LAST DAY OF THE REPORT MONTH OR IT WILL BE CONSIDERED INCOMPLETE. I declare under penalty of perjury that the facts contained in this report are true and correct and complete for the entire report month. *
Date*

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Spouse or Other Parent of Cash Aided Child(ren)
Date

MonthDayYear
Date
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

TANF CLIENT WORK ACTIVITIES
PI CIF#
For the Month of:*
Client Name:

First NameLast Name
When completed return to your Case Worker with your MER by the 5 th day of the Month.

Please indicate the number of hours per day that you participated/worked in each of the acceptable work activities.

24 hours of approved work participation are required per two parent family, 20 hours per week are required per single parent family.
YesNo
Reason hours not met

STATEMENT OF TRUTH