Yankton Sioux Food Distribution Program

Zero Income Form

In order to determine your eligibility for the Food Distribution Program, you need to provide proof of income for the past 30 days prior to the date of your application. If you had zero income for the past 30 days or are currently claiming zero, please answer the following questions:

Name

First Name

Last Name

Date of Birth

YYYY

What was the total income for all members of your household for the past 30 days?

How do you pay your utility bills?

How do you pay for your housing?

How do you get food for your household?

Have you for any members of your household applied for any benefits/programs? (such as SSI, Social Security, TANF, Unemployment, General Assistance, etc.)

Applicant Signature

I hereby certify that the information that I have provided accurately represents the total income for all members of my household. I understand that I must report any changes in household size, income and/or resources within 10 days of the date the changes become known. I understand that if I fail to report a change and, as a result, receive commodities that my household was not entitled to, a monetary claim may be filed against my household.

Signature Date

YYYY