Yurok Tribe General Assistance Monthly Eligibility Report (MER)

Yurok Tribe General Assistance Monthly Eligibility Report (MER)

Yurok Tribe General Assistance Monthly Eligibility Report (MER)
Name*

First NameLast Name
Report Month*
Complete, sign, and return this report by the 5th of the month immediately following the Report Month listed above. Questions? Please call us at 855-559-8765, Ext: 3080
1) Did you receive any money, income, or beneﬁts from any source during the Report month?*

YesNo
If "YES", list the gross amounts (before deductions) below and ATTACH PROOF OF INCOME.

Please include income; salary; tips; vacation/sick pay; 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, disability, veterans beneﬁts, railroad retirement, other private or government disability or retirement; rental income; AND any in-kind income (e.g. free housing, utilities, clothing, food, etc).
LIST OF HOUSEHOLD MEMBERS

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PROOF OF INCOME

Rows	Whose Income?	Income Type	DateReceived	GrossIncome
1
2
3
4

2) Did anyone move in or out of your home during the Report month?*

YesNo
If “YES”, list details and all household members below.

Please include anyone who moved in or out of your home, newborns, anyone who died, temporary absences, entered or left a hospital or jail, etc.
What Changed?
Date Change Occurred:

MonthDayYear
Date

PROOF OF INCOME

Rows	Household Member Name	Relationship	Date of Birth
1
2
3
4
5
6
7
8
9
10

3) Did you have a change of address during the Report month?*

YesNo
If “YES”, list details below and ATTACH A NEW W9 FORM.
W9

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New Physical Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
New Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

4) Did any other changes occur during the Report month?*

YesNo
If “YES”, list details below.

- Income: Started, changed, or stopped.
- Insurance: Life, health, or dental insurance started, changed, or stopped.
- Marital Status: Married, divorced, or separated.
- Job/Training: Started, stopped, hours changed, ﬁred, quit, or refused a job or training.
- School-Age 16 or Older: Started or stopped school or college.
- School-Ages 6 through 17: Started or stopped attending school regularly
- Babies: Became pregnant, had a baby, abortion, or miscarriage.
- Bank Accounts: Opened or closed a checking, savings, CD, or money market account.
- Property: Bought, sold, traded, gave away, or received a motor vehicle, home, land, or other personal or business property.
- Disability: Became disabled or recovered from a disability.
What Changed?
Date Change Occurred:

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 general assistance beneﬁts from multiple sources, knowingly providing fraudulent information, the general assistance 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.
Signature*
Date*

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