Name (Head of Household)
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First Name
Last Name
Street Address:
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Address | City, State, Zip Code
County
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Household Size
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Telephone Number
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(###)
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Directions to your home:
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Do you reside within the Yankton Sioux Reservation boundaries?
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If no, you must provide a copy of Federally Recognized enrollment.
District where you reside
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Ethnicity
This information is voluntary.
Race
This information is voluntary.
Household Members:
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Complete the following for EACH member of your household. Your household means yourself and the people who live with you.
List your name first.
Income (Earned & Unearned): 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, work/training allowances, etc.
Verification of income is required for all household members (pay check stubs, award letters, etc.). Households with earned income must provide a full month's wage statements.
Name | Relationship | DOB | Social Security # | Income Source | Gross Amount | How Often Received
Are you or anyone in your household currently receiving SNAP benefits?
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If yes, list names:
Have you or anyone in your household recently applied for SNAP benefits?
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If yes, list names:
Have you or anyone in your household been disqualified from the Supplemental Nutrition Assistance Program (SNAP) for an Intentional Program Violation?
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If yes, list name(s):
Students: Are there any students in your household who receive education grants, scholarships or loans?
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If yes, complete the following information:
Please provide verification of your Financial Aid documents to jcournoyer@yanktonsiouxtribe.net.
Household Member | College | Amount of Loan/Grant | Period of time funds intended to cover | Type of Payment (Pell Grant, Student Loan, BIA, etc.) | Amount used to pay Tuition/School Fees/Other Expenses.
Standard Shelter/Utility Expense - Do any household members pay a monthly shelter or utility expense?
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If yes, please provide a copy of the expense that is paid monthly to jcournoyer@yanktonsiouxtribe.net.
Dependent Care - Does anyone in your household pay for the care of a child or other dependents when necessary for a household member to accept or continue employment or to attend training or pursue education which is preparatory to employment?
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If yes, please provide the name & address, and amount Paid $:
Child Support - Does anyone in your household pay court ordered child support for a non-household member?
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If yes, please provide documentation of the amount paid. $
Medical Expenses (60+years) - Please provide documentation and amount paid each month. $
Authorized Representative:
To authorize someone outside your household to act on your behalf and/or pick up your food, list the following information:
Name(s) | Address | Telephone Number
Applicant's Signature
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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 a legal counsel, a relative, a friend or other spokesperson.
PENALTY WARNING: If your household receives USDA foods, 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, resources, household size, and/or participation in the Supplemental Nutrition Assistance Program (SNAP) in order to obtain Food Distribution Program benefits which your household is not entitled to receive.
2. Do not misuse (e.g., trade or sell) USDA foods.
3. Do not participate simultaneously in the Supplemental Nutrition Assistance Program (SNAP) and the Food Distribution Program.
INTENTIONAL PROGRAM VIOLATION (IPV) PENALTIES: If you or any member of your household knowingly and willing violates the rules above it is considered an Intentional Program 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: 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.
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 ten (10) calendar days after the change becomes known the following changes: a change in household size or composition; an increase in gross 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 Date
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MM
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