Fillable Native Village of Eyak Food Distribution Program PO (Native Village of Eyak)

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Native Village of Eyak Food Distribution Program PO (Native Village of Eyak)

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Native Village of Eyak
Food Distribution Program
PO Box 1138
Cordova, Alaska 99574
PHONE: (907) 424-7738 FAX: (907) 424-7739
HEAD OF HOUSEHOLD SOCIAL SECURITY
NUMBER:
HAVE YOU APPLIED FOR FOOD STAMPS
YES OR NO
DO YOU RECEIVE FOOD STAMPS NOW
YES OR NO
HOW MANY PEOPLE IN YOUR HOUSEHOLD
APPLICATION FOR FOOD DISTRIBUTION
ANSWER THE FOLLOWING QUESTIONS HONESTLY AND COMPLETELY. IF YOU KNOW BUT REFUSE TO
ANSWER OR GIVE NEEDED INFORMATION, YOUR HOUSEHOLD (MEMBERS WHO PREPARE AND PURCHASE
MEALS TOGETHER) WILL NOT BE ELIGIBLE FOR FOOD DISTRIBUTION BENEFITS.
APPLICATIONS CAN BE FILED BY THE APPLICANT OR AN AUTHORIZED REPRESENTATIVE AT THE TRIBAL
OFFICE, BY MAIL, OR BY FAX MACHINE.
IMPORTANT: WHEN YOUR HOUSEHOLD IS INTERVIEWED, PLEASE BRING PROOF OF ALL HOUSEHOLD
INCOME. FOR EXAMPLE: PAY STUBS, A COPY OF ALL PAYSTUBS OR COPIES OF AWARD LETTERS FROM
SOCIAL SECURITY BENEFITS, SUPPLEMENTAL SECURITY INCOME, GA, PA, AND TANF. COMPLETED
APPLICATIONS WILL SPEED UP THE REVIEW OF YOUR APPLICATION.
HEAD OF HOUSEHOLD:
MAILING ADDRESS: AK
STREET CITY STATE: ZIP
AK
PO BOX # CITY STATE ZIP
TELEPHONE NUMBER WHERE YOU CAN BE REACHED:
HOUSEHOLD LOCATION:
HOUSEHOLD RACIAL-ETHNIC HERITAGE:
ALTHOUGH, YOU ARE NOT REQUIRED TO PROVIDE THIS INFORMATION, YOUR COOPERATION
WILL HELP DETERMINE COMPLIANCE WITH THE FEDERAL CIVIL RIGHTS LAW. IN NO
INSTANCE WILL THIS INFORMATION BE USED IN CONSIDERING YOUR ELIGIBILITY FOR
ASSISTANCE. IF YOU DECLINE TO PROVIDE THIS INFORMATION IT WILL IN NO WAY AFFECT
CONSIDERATION OF YOUR APPLICATION. WE ARE AUTHORIZED TO ASK FOR THIS INFORMATION
UNDER TITLE VI OF THE CIVIL RIGHTS ACT OF 1964.
BLACK/AFRICAN AMERICAN: FOR OFFICE USE ONLY:
HISPANIC or LATINO:
ASIAN OR PACIFIC ISLANDER:
CASE NUMBER:
AMERICAN INDIAN OR ALASKAN NATIVE:
DATE RECEIVED:
WHITE - NOT OF HISPANIC ORIGIN:
FORM: FDP001 Page 1 Revised: October 2019
BIA or ANCSA ENROLLMENT NUMBER:
ANCSA CORPORATION NAME:
DO YOU RESIDE WITHIN THE VILLAGE BOUNDARY?
(YES OR NO) (YES OR NO)
NAME (First, Middle, Last)
DATE OF BIRTH SOCIAL SECURITY # RELATIONSHIP
1.
SELF
2.
3.
4.
5.
6.
7.
8.
9.
10
11
HOUSEHOLD LOCATED ON OR NEAR VILLAGE BOUNDARY? YES OR NO
HOW WAS LOCATION VERIFIED?
EIS CHECKED FOR THIS APPLICANT'S SNAP/FOOD STAMP STATUS
YES OR NO
WHO CHECKED (INITIAL):
DATE:
SOA Case #'s: Case # 2:
Native Village of Eyak OFFICIAL USE ONLY
FOR ANTHC FDPIR OFFICE USE ONLY
ARE YOU OR ANYONE IN YOUR HOUSEHOLD ENROLLED WITH THE BUREAU OF INDIAN AFFIAIRS (BIA) OR AN
ALASKA NATIVE REGIONAL CORPORATION OF THE ALASKA NATIVE CLAIMS SETTLEMENT ACT (ANCSA)?
(YES OR NO)
FILL IN ALL BLANKS FOR EACH HOUSEHOLD MEMBER, INCLUDING YOURSELF. PEOPLE WHO LIVE AND EAT
WITH YOU SHOULD BE LISTED AS HOUSEHOLD MEMBERS. (Do not list roomers and boarders)
ALTHOUGH YOU ARE NOT REQUIRED TO DO SO, WE WOULD LIKE YOU TO INCLUDE THE SOCIAL SECURITY
NUMBER OF EACH MEMBER OF YOUR HOUSE-HOLD WHO HAS ONE. THIS WILL HELP US TO IDENTIFY YOUR
HOUSEHOLD CORRECTLY. THESE SOCIAL SECURITY NUMBERS MAY ALSO BE USED IN PROGRAM REVIEWS
OR AUDITS TO MAKE SURE YOUR HOUSEHOLD IS ELIGIBLE FOR FOOD DISTRIBUTION BENEFITS. WE ARE
AUTHORIZED TO ASK FOR THIS INFORMATION UNDER THE TAX REFORM ACT OF 1976.
FORM: FDP001 Page 2 Revised: October 2019
YES OR NO
YES OR NO
YES OR NO
Are you a senior 60 years of age or older? Do you pay out of pocket medical expenses in excess of $35 a month, not covered b
Indian Health Service? YES OR NO IF YES, TOTAL AMOUNT:
Do you have or pay for a personal care attendant (PCA)? YES OR NO IF YES, TOTAL AMOUNT:
Do you pay Medicare Part B, Part D, or both premiums?
YES OR NO IF YES, TOTAL AMOUNT:
Answering "YES" to any medical question above requires documented verification (e.g., award letters or receipts).
1. EARNED INCOME
SELF EMPLOYED
- Is anyone in your household self-employed?
YES OR NO
Total gross self-employment income:
Total gross business expenses:
2. WAGES AND SALARIES: Is anyone in your household employed?
Fill in all blanks for each member with a full or part-time job. If a member has more than one job, list each job separately.
Include members who receive income from the Comprehensive Employment & Training Act (CETA). Do not include self-
employed household members. Please indicate whether the job is 1. Full Time Permanent-FTP., 2. Full Time Temporary-FTT.
3. Part Time Permanent-PTP., 4. Part Time Temporary-PTT.
If it's a Temporary Job, when will the job end? Date:
HOW OFTEN PAID
FTP
WEEKLY Bi-Weekly Twice/month MONTHLY
FTT
HOUSEHOLD MEMBER EMPLOYER WAGES WAGES WAGES WAGES
PTP
PTT
TOTALS: -$ -$ -$ -$
3. EDUCATIONAL GRANTS, SCHOLARSHIPS
Gross monthly income from educational grants, scholarships:
-$
Enter monthly tuition and mandatory fees: -$
RESOURCE TEST NO LONGER REQUIRED
INCOME
If yes, please ask for and complete the Self-Employment Income form (FDP004) and bring in the Federal Income Tax forms
filed by all self-employed members in your household. If no such tax forms were filed last year, bring proof of all self-
employment income and expenses.
As of September 26, 2013, the resource test is no longer a requirement. However, bank statements may contain direct
deposits of unearned income information (e.g., SS, SSI, SSD, UI, GA, etc.) and may be used to help verify income.
UTILITY/SHELTER, EXPANDED MEDICAL & HOME CARE DEDUCTION(S)
STANDARD SHELTER/UTILITY DEDUCTION BASELINE FOR
WESTERN REGION (AK, AZ, CA, ID, NV, OR, WA) - $400
IF YES, ADD BASELINE DEDUCTION:
RENT/MORTAGE RECEIPT?
HEAT/ELECTRIC RECEIPT?
PHONE RECEIPT?
FORM: FDP001 Page 3 Revised: October 2019
UNEARNED INCOME
HOW OFTEN RECEIVED
Income Source Who Receives
Monthly Twice Month Bi-weekly Weekly
Social Security
Benefits
SSI (Supplemental
NAME
Security Income)
Pensions or
Retirement Income
VA (Veterans
Benefits)
Unemployment
Insurance
GA (General
Assistance)
PA (Public
Assistance)
TANF (Temporary
Assistance to Needy
Families)
Child Support or
Alimony
Other (specify)
TOTALS: -$ -$ -$ -$
1. Dependent Care Costs
Monthly
Dependent's Name Provider Date of Birth Cost
2. Legally required child support paid to a non-household member:
(Legal obligation and actual payment must be verified)
TOTAL DEDUCTIONS: -$
FDPOO1
DEDUCTIONS: Care for child or other dependents - must be provided by someone outside of the household and
necessary for a household member to search for, accept, or continue employment or continue employment or to attend
training and pursue education that is preparatory to employment.
ATTENTION: Please indicate if anyone
in your household is disabled
FORM: FDP001 Page 4 Revised: October 2019
1) To report any changes in residence within 10 days.
2) To report any changes to my household size within 10 days.
3) To report any changes in my shelter/utility expenses within 10 days.
4) To report any changes or increase in gross monthly income over $100 within 10 days.
5) To report any changes in a household member's obligation to pay child support within 10 days.
6) It is prohibited to receive both SNAP (food stamps) or FDPIR benefits within the same month.
7) It is prohibited to give any false or misleading information to receive food distribution benefits.
8) It is prohibited to barter/trade or sell my household's food distribution benefits. Initials: _________
Initials: _________
FAIR HEARING: If you disagree with any action taken on your case, you and/or your representative have the right to request
a fair hearing. You may request a fair hearing verbally or in writing. If you request a fair hearing, your case may be presented
by a member of your household or representative, such as a legal counsel, a relative, a friend or other spokesperson.
Initials: _________
NON-DISCRIMINATION STATEMENT
1)
2) Fax: (202) 690-7442; or
3)
Email: program.intake@usda.gov.
This institution is an equal opportunity provider.
Initials: _________
INTENTIONAL PROGRAM VIOLATION (IPV) PENALTIES:
If you or a household member knowingly/willingly violate the rules
initialized above, it is considered an Intentional Program Violation (IPV). Households who have been found guilty of committing
an IPV will be ineligible to participate in both FDPIR and SNAP programs for a period of twelve (12) months for the first
violation, 24-months for the second violation and permanently for the third violation; even prosecuted by authorities.
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
online 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:
RULES OF UNDERSTANDING: By my initials below I understand and agree to the following eight (8) rules:
Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410;
FORM: FDP001 Page 5 Revised: October 2019
INITIAL YES: INITIAL NO:
Applicant or Authorized Representative Signature
Tribal Agency Representative Signature
AUTHORIZED REPRESENTATIVE(S): Person(s) identified outside my household are authorized to pick up my food package
#1 - Name:
#1 - Address:
#1 - Phone(s):
#2 - Name:
#2 - Address:
#2 - Phone(s):
#3 - Name:
#3 - Address:
#3 - Phone(s):
Date
AUTHORIZATION: I authorize the release of any necessary information or forms to ANTHC's Food
Distribution Office and Native Village of Eyak, from individuals, businesses, schools, banking
institutions, Federal/State/Tribal agencies needed to verify my eligibility for the Food Distribution
Program. I understand that this information will be kept confidential and used only for the purpose of
helping to document my eligibility for the Food Distribution Program. This authorization is good for the
entire period for which I am deemed certified and eligible to receive food distribution benefits, which
could last up to 24 months or until revoked by me in writing.
OPTIONAL (Parents w/Children): By my initials below I authorize the ANTHC Food Distribution Office
the permission to share my household information with the State of Alaska, Division of Child & Early
Development, Child Nutrition Programs, for the sole purpose of automatically enrolling my child(ren) to
participate in and receive free school meals for as long as I am certified for food distribution beneifts.
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 any false or misleading
information on this form may be grounds for disqualification and/or claim action. By my initials above I
have acknowledged complete understanding of my rights and responsibilities to participate and receive
food distribution benefits, and that I am responsible for reporting any changes in my household's size,
changes income over $100 and/or changes to my contact information to the Food Distrbution Program
Tribal Agency Office, within 10 days of the date the changes become effective.
Date
FORM: FDP001 Page 6 Revised: October 2019
FOOD DISTRIBUTION ELIGIBILITY WORKSHEET
NAME:
SHELTER/UTILITY -$
MEDICARE PART B & PART D -$
EXPANDED MEDICAL ($35 MIN.) -$
HOME CARE DEDUCTION
-$
LEGALLY REQUIRED CHILD SUPPORT -$
Total Deductions: -$
Age of oldest HH member:
INCOME
1. Earned Income 3. Unearned Income
a. Total gross self-employment income:
-$ Unearned income includes Social Security Benefits (SSB),
Supplemental Security Income (SSI), Pensions/Retirement,
b. Total gross business costs:
-$ VA Benefits, UI, GA, PA, TANF, Child Support,
Other - gifts from relatives and friends.
Total Self-employment income: -$
Unearned income in items a, b, c, and d below:
c. Wages received weekly: -$ a. Gross income received weekly: -$
d. Wages received bi-weekly: -$ b. Gross income received bi-weekly: -$
e. Wages received twice monthly: -$ c. Gross income received twice monthly: -$
f. Wages received once a month: -$ d. Gross income received once a month: -$
Total income from wages & salaries:
-$ Total unearned income: -$
Total monthly gross Earned Income:
-$ Total earned, unearned, educational income: -$
20% earned income deduction: -$
e. Total deductions:
-$
Net Earned Income:
-$
2. Educational Income: Net Monthly Income: -$
f. Household Size:
a. Gross monthly income from educational
grants, scholarships, etc. -$
Net Monthly Income Standards Effective 10/1/2020
HH Size $$$ limit
Over /
(under)
b. Monthly tuition and mandatory fees: -$ 1
$1,616
2 $2,082
Total Educational Income: -$ 3
$2,549
4 $3,016
5 $3,482
Date Approved:
6 $3,967
HH Categorically Elig: (yes or no) 7
$4,434
Cert. Pending Verif: (Month CPV) 8 $4,900
Expedited Service: (yes or no) Each additional Member 467.00$
Name of Certifier: Approved
Signature: Certification Period thru
APPLICABLE FDPIR DEDUCTION(S)
ANTHC CASE DISPOSITION
FORM: FDP001 Revised: October 2019
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Completed 27 January 2021

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