APPLICATION FOR FOOD DISTRIBUTION

FOR OFFICE USE ONLY: I.D. LOCATION: DATE RECEIVED: APPLICATION FOR FOOD DISTRIBUTION You may complete this form at home and mail, fax, or email it in or bring it to the office. Or, another member of your household or an adult who knows you may complete and return it to us with your permission. IMPORTANT: When you are interviewed, please bring proof of all household income (pay stubs, award letters, copies of checks, etc.) You must provide proof/verification of all income and allowable deductions. Name (Head of Household): Mailing Address: City/State/ZipCode: Tribe: Household Size: Telephone No.: Residence Address/Directions HOUSEHOLD MEMBERS: Complete the following for each member of your household. Your household means yourself and the people who live with you. List your name first. (Attach a separate sheet if you need to list additional household members.) RELATIONSHIP TO HEAD NAME(S) OF ALL HOUSEHOLD MEMBERS OF HOUSEHOLD DATE OF (Last, First, Middle Initial). Please Print. (self, spouse, daughter, son, cousin etc.) BIRTH SOCIAL SECURITY # 1. 2. 3. 4. 5. 6. 7 8. 9. Are you or anyone in your household currently receiving SNAP (Food Stamp) benefits? Yes No If yes, list names: Have you or anyone in your household recently applied for SNAP (Food Stamp) benefits? Yes No If yes, list names: Have you or anyone in your household been disqualified from the Supplemental Nutrition Assistance Program (SNAP) [Food Stamps] for an intentional program violation? Yes No. If yes, list name(s): Are you or anyone in your household currently receiving SSI with a food allowance? Yes No If yes, list names: 1220 Blosser Lane Willits, California 95490 ~ Phone: 707-456-1710 or 1712 ~ Fax: 707-456-1714 E-mail: sherwoodvlyfdpir@sbcglobal.net

INCOME (EARNED & UNEARNED): List income from all sources for each household member including wages, social security, 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. Attach a separate sheet, if you need to list additional household members. HOUSEHOLD MEMBER Employer/ SOURCE OF INCOME TYPE OF INCOME (Wages, Social Security, TANF, Child Support, etc.) GROSS AMOUNT HOW OFTEN PAID Monthly, Bi-weekly, Weekly Zero Income Household** SELF-EMPLOYMENT INCOME: Are there any members in your household who are self-employed? Yes No If yes, complete the following section. 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 HOUSEHOLD MEMBER TYPE OF BUSINESS (Farm, Ranch, Rental, Day care, etc) OCCUPATION Is your self-employment the primary source of income for meeting your living expenses? STUDENTS: Are there any students in your household who receive education grants, scholarships or loans? Yes No If yes, complete the following section. Please provide verification. HOUSEHOLD MEMBER AMOUNT OF LOAN/GRANT PERIOD OF TIME FUNDS INTENDED TO COVER TYPE OF PAYMENT (Pell Grant, Student Loan, BIA) Amount Used to pay Tuition/School Fees/Other Rel. Exp. AUTHORIZED REPRESENTATIVE: To authorize someone outside your household to act on your behalf and/or pick up your food, complete this section. NAME(S) ADDRESS TELEPHONE NUMBER ALLOWABLE DEDUCTIONS [Please provide verification]: STANDARD SHELTER/UTILITY EXPENSE: Does anyone in your household pay, on a monthly basis, at least one shelter/utility expense? Yes No If yes, type of shelter/utility expense paid monthly: DEPENDENT CARE: 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? Yes No If yes, name and address of person providing care: Amount Paid: $ How often paid (weekly, monthly, etc.) CHILD SUPPORT: Does anyone in your household pay court ordered child support for a non-household member? Yes No If yes, complete the following: Amount ordered to pay: $ Amount actually paid: $ EXCESS MEDICAL EXPENSES: Anyone in your household elderly and/or disabled? Yes No If yes, complete the following: Monthly total of medical expenses, excluding special diets: $ 2

RACIAL/ETHNIC DATA COLLECTION: This 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 or Not Hispanic or Latino 2. What is your race? American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Other Pacific Islander 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 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. Applicant s Signature Date 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: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider. FDPIR Application Form, Rev. 9/2013 Office Use Only: Approval Pending Denied Certifier Signature: Date 3

YOUR RESPONSIBILITIES AND RIGHTS CASE NAME YOU HAVE BOTH RESPONSIBILITIES AND RIGHTS THINGS YOU MUST DO AND THINGS YOU MAY EXPECT WHEN YOU APPLY. YOUR RESPONSIBILITIES AND RIGHTS ARE LISTED ON THIS FORM. PLEASE READ THEM VERY CAREFULLY TO BE SURE YOU UNDERSTAND THEM. ASK ANY QUESTIONS IF YOU DO NOT UNDERSTAND. YOU ARE VERIFYING THAT YOU UNDERSTAND YOUR RESONSIBILITIES AND RIGHTS WHEN YOU (OR YOUR AUTHORIZED REPRESENTATIVES) SIGN THIS FORM. YOU HAVE A RESPONSIBILITY TO: YOU HAVE A RIGHT TO: 1. Give true, correct, and complete information on all forms including the application. 2. Follow all applicable rules and regulations. 3. Cooperate with FDPIR giving proof of your situation and of the information you give. If you are not able to give proof, give permission to get it by signing this release form. 4. Report the following to your worker: Change of address Any income that causes your household to exceed its maximum monthly income limit Any change of persons living in your home When anyone for whom you get commodities gets a job or leaves a job When someone begins to get regular money payments or there is a change in the amount you get (for example: the start of unemployment compensation or a salary increase). 1. Ask about the commodity program 2. Apply for program benefits 3. Get courteous and fair treatment with no discrimination because of marital status, race, color, sex, national origin, handicap, political beliefs, age, or religious creed 4. Get a decision on your eligibility for benefits within 7 days 5. Be advised of the maximum monthly income limit for your household size at the time of initial certification and at each recertification. I have read (or have heard read to me) my responsibilities and rights. I understand what I must do and I agree to carry out those responsibilities. Signature of Applicant/Recipient(s): SIGNATURE OF HEAD OF HOUSEHOLD DATE 1220 Blosser Lane Willits, California 95490 ~ Phone: 707-456-1710 or 1712 ~ Fax: 707-456-1714 ~ E-mail: sherwoodvlyfdpir@sbcglobal.net

CASE NAME WORKER ID VERIFICATION OF HOUSEHOLD COMPOSITION Please have someone outside of your home who knows about your household composition sign this form. No person shall knowingly aid or abet any person to unlawfully obtain commodities. Violators will be prosecuted. To the best of my knowledge, (client s name) lives at (address) On Reservation: yes no Verified by Circle one Name of Reservation/Rancheria The following is a complete list of all persons who live at that address: The above information is true and correct to the best of my knowledge. X Signature of person outside of the home to verify Household Information Date Address of person signing form Phone # City State Zip Comments: 1220 Blosser Lane Willits, California 95490 ~ Phone: 707-456-1710 or 1712 ~ Fax: 707-456-1714 ~ E-mail: sherwoodvlyfdpir@sbcglobal.net

FOOD DISTRIBUTION PROGRAM ZERO INCOME FORM In determining your eligibility for the Food Distribution Program, you must provide proof of income for the 30 days prior to the date of application. If you had zero income for the past 30 days, you must please answer the following questions: 1. What was the total income for your household for the past 3 months? (Do not include revenue sharing trust funds or per capita payments UNLESS received monthly) 2. How do you pay your utility bills? 3. How do you pay your rent? 4. How do you get food for your household? 5. Are you receiving income from friends or family? How much? 6. Are you looking for work? 7. Have you applied for PA or GA? 8. If you are residing with others not included in your food distribution household (such as family or friends), do you purchase, prepare, and eat your food separately? I hereby certify that the information that I have provided accurately represents the total income for each member of my household (18 years and older). I understand that I must report changes in household size or composition; increases in gross monthly income of more than $100; changes in residence and/or address; when the household no longer incurs a shelter or utility expense; or a change in the legal obligation to pay child support to the Food Distribution Office within ten calendar days after the change becomes known to the household. Signature: Date: 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 (click the link for a listing of hotline numbers by State); found online at http://www.fns.usda.gov/snap/contact_info/hotlines.htm. USDA is an equal opportunity provider and employer. Source: NAFDPIR 2003, rev. 09/2013

USDA FNS NON-DISCRIMINATION STATEMENT 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: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. This institution is an equal opportunity provider.

FOOD DISTRIBUTION PROGRAM ON INDIAN RESERVATIONS The Food Distribution Program on Indian Reservations (FDPIR) is a program of the Food and Nutrition Service of the U.S. Department of Agriculture. This program provides foods for good health to households living on or near Indian reservations in approved FDPIR service areas. You may qualify to receive these foods if you have little or no earnings or live on a fixed income such as social security, cash aid from social services, or TANF. WHAT SERVICES WILL I RECEIVE IF I QUALIFY FOR THE PROGRAM? On a monthly basis, a variety of basic foods such as meats, fruits and vegetables, dry beans and pastas, designed to help you maintain a healthy diet. Information about nutrition, proper storage of foods, and food preparation. HOW DO I APPLY? Pick up an application form at the Food Distribution Office for your reservation, or call the office and have one mailed. Fill out the form completely and honestly, return it to the office either by mail, fax, or in person, and arrange for an interview at the Food Distribution Office, either by telephone or in person. HOW IS MY ELIGIBILITY FOR COMMODITIES DETERMINED? Income guidelines- Your eligibility for commodities is based on how much income, such as earnings or pensions, you have after several deductions. 20% of earned income is deducted from your gross earnings. Additional deductions from income can include expenses such as child care costs, child support payments, Medi-Care Part B payments, excess housing/utilities costs, excess out of pocket medical costs (for elder and disabled only) Unearned Income- Income such as MONTHLY tribal revenue sharing or per capita payments, unemployment, disability, retirement, social security (other than SSI), or other forms of income not earned from a job are called unearned income, and must be reported as part of your monthly income. Indian Certification- At least one member of your household must submit proof of Indian enrollment, or your household must submit proof that you reside on Indian reservation land within our service area. Only households with monthly income wihtin the allowable limits may qualify for commodities. The amount of income you are allwed and the amount of food you can receive depends on the size of your household. 2016 MONTHLY INCOME STANDARDS (10/1/15-9/30/16) 1 $1,136 2 $1,483 3 $1,830 4 $2,189 5 $2,565 6 $2,941 7 $3,287 8 $3,624 For each additional member add $347 IF YOU ARE RECEIVING FOOD STAMPS OR SSI YOU ARE NOT ELIGIBLE TO RECEIVE COMMODITY FOODS. WHAT INFORMATION SHOULD I BRING TO THE OFFICE WHEN I AM INTERVIEWED? Proof of income, such as checkstubs or a letter from Social Services, Social Security, or Tribe Proof of the costs for childcare or other deductable payments Proof of Indian enrollment Social Security Number and Date of Birth for all household members. FOR MORE INFORMATION CALL THE SHERWOOD VALLEY FOOD PROGRAM AT: (707) 456-1710 v. 2016.11.23.15 1