CTSI Food Distribution Online Fillable Application CTSI Food Distribution Application Instructions: Complete the following information. If you refuse to cooperate/provide verification, your application will be denied. You must provide proof/verification of all income and allowable deductions and social security numbers for all household members once this initial application has been submitted, during your intake appointment. Name (Head of Household)(Required) First Last County(Required)Street Address(Required) Street Address Address Line 2 City State ZIP Code Household Size(Required)Phone Number(Required)Email(Required) Mailing Address (if different that street address) Street Address Address Line 2 City State ZIP Code Household MembersComplete the following for each member of your household. Your household means yourself and the people who live with you. List your name first. You will need to submit Social Security numbers for all members of the household to the USDA department after submitting your application during the intake appointment.List(Required)Name (Last, First, Middle Initial)Relationship to Head of Household (self, spouse, daughter, son, etc.)Date of BirthEducation Status (Just for Head of Household) Add RemoveUse the plus button to the right to add another household member.Are you or anyone in your household currently receiving SNAP benefits?(Required) Yes No Please list names:(Required)Have you or anyone in your household recently applied for SNAP benefits?(Required) Yes No Please list names:(Required)Have you or anyone in your household been disqualified from the Supplemental Nutrition Assistance Program (SNAP) for an intentional program violation?(Required) Yes No Please list names:(Required)Income (Earned and 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, per capita payments from gambling enterprises, 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. List(Required)Household MemberEmployer/Source of IncomeType of Income (Wages, Social Security, TANF, Child Support, etc.)Gross AmountHow Often Paid (Monthly, Bi-weekly, Weekly) Add RemoveUse the plus button to the right to add another household member.Are there any members in your household who are self-employed?(Required) Yes No Self Employment Income Payment from rental property, roomers, boarders, farming, ranching, and/or operating your own business is considered to be self-employment. Please provide a copy of last year’s Federal Income Tax form (1040, Schedules F, C, E, if applicable, or other proof of self-employment costs and income (current books showing income and expenses). List(Required)Household MemberType of BusinessOccupationIs your self-employment the primary source of income for meeting your living expenses? Add RemoveUse the plus button to the right to add another household member.Are there any students in your household who receive education grants, scholarships or loans?(Required) Yes No Students Please provide verification. List(Required)Household MemberAmount of Loan/GrantPeriod of Time Funds Intended to CoverType of Payment (Pell Grant, Student Loan, BIA)Amount Used to pay Tuition/School Fees/Other Rel. Exp. Add RemoveUse the plus button to the right to add another household member.Allowable DeductionsMust provide verification: Does anyone in your household pay, on a monthly basis, at least one shelter/utility expense?(Required) Yes No Type of shelter/utility expense paid monthly:(Required)Does anyone in your household pay for the care of a child or other dependent when necessary for a household member to accept or continue employment or to attend training or pursue education which is preparatory to employment?(Required) Yes No Name and address of person providing care:Amount Paid:How often paid (weekly, monthly, etc.)(Required)Does anyone in your household pay court ordered child support for a non-household member?(Required) Yes No Amount ordered to pay:(Required)Amount actually paid:(Required)Anyone in your household elderly and/or disabled?(Required) Yes No List monthly total of medical expenses paid out of pocket, excluding special diets:(Required)Authorized RepresentativeTo authorize someone outside your household to act on your behalf and/or pick up your food, complete this section.List(Required)NameAddressTelephone Number Add RemoveUse the plus button to the right to add another authorized representative.Racial/Ethnic Data CollectionThis information is voluntary. If you do not provide this information, it will not affect your eligibility. 1. What is your ethnic category? Hispanic or Latino Not Hispanic or Latino 2. What is your race? American Indian or Alaskan Native Asian Native Hawaiian or Other Pacific Islander Black or African American White 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 24 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(Required)Date(Required)The U.S. Department of Agriculture prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form , found online at http://www.ascr.usda.gov/complaint_filing_cust.html , or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Ave., S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at program.intake@usda.gov Individuals who are deaf, hard of hearing, or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers; found online at http://www.fns.usda.gov/snap/contact_info/hotlines.htm USDA is an equal opportunity provider and employer.
