February 2020 1
Monthly Eligibility Report
(MER)
NAME
: MONTH/YEAR:
________
Pleas
e complete, sign, date and return the MER. If your MER is incomplete, a sanction will be imposed. If your MER is
not received by the 10
th
of the month, your case will be closed. Please print neatly.
Please check if there have been any changes with the following between ________________________ for anyone in
the TANF Household: Attach supporting documentation of any changes
Situation Change
School Attendance
School Enrollment
Residence
Custody
Income
Health/Medical
Food Stamps
Child Support _______
Child Support Received Amount Received: _$___________________________________________
Contact Information
Certification
I UNDERSTAND THAT:
• I must contact my TANF Case Management Specialist within 10 days of any changes in my household that may affect
my eligibility for cash assistance.
• Facts I report may result in my benefits increasing, decreasing, or being stopped.
• If I knowingly give false facts or do not report changes in order to continue receiving assistance or benefits, my
assistance or benefits will be terminated.
• If I do not report all the facts or give false information to get or keep getting aid or benefits, I can be legally prosecuted.
And I may be charged with committing a felony if cash aid is wrongfully paid out. I understand that the penalties for
welfare fraud can be up to $10,000 fine and/or three years in prison. Conviction or proof of welfare fraud can also
result in the discontinuation of future aid from the MCN TANF Program.
I certify under penalty of perjury that all of the above information is true and complete. I understand that falsification of any
information is grounds for termination from the Tribal TANF Program. Must sign, date and submit on or after the last day of the
month.
Signature of Head of Household
Signature of Spouse/Other Adult
