Monthly Eligibility Report

Important Form Information:

Please provide copies of paycheck stubs for each adult for all weeks earned income was received. Please provide supporting documents demonstrating unearned income.

An email address and phone number are necessary to complete the form. If you do not have an email address, please contact the office for assistance. For additional assistance regarding this online form, please contact the office.

Contact Us

Particpant Name(Required)

First Last

This report is for (MM/YYYY)(Required)

CIF Number

Family Advocate

First Last

Phone #(Required)

Please list 999-999-9999 if you do not have an phone. It is required to submit online applications.

Email Address(Required)

Please call XXX-XXX-XXX, if you do not have an email address. We will help you set up an email address. It is required to submit online applications.

Earned Income Information

Did anyone in your household earn money from Work/Employment or On-the-Job-Training?(Required)

If Yes, complete below.

Yes

Person 1 Earned Income

Earned Income

Non Needy Caretaker Relatives, unless the biological parent of the child on TANF, do not need to fill out this section. Include tips, vacation pay or income in kind, such as earned housing. List gross amounts before deductions for each week. Attach pay stubs or other proof of earnings. If self-employed: Attach proof of income. If you claim actual expenses, list and attach proof of business expenses.

Who received income?

Employer Name

Position

Employment Type

Hours Worked

List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.

Week 1 Earnings

Gross Amount

Date Received

Week 2 Earnings

Gross Amount

Date Received

Week 3 Earnings

Gross Amount

Date Received

Week 4 Earnings

Gross Amount

Date Received

Week 5 Earnings

Gross Amount

Date Received

Person 1 Paycheck stubs

Drop files here or

Max. file size: 40 MB.

Section Break

Do you have additional earned income to add for additional individuals?

Yes

Person 2 Earned Income

Earned Income

Who received income?

Employer Name

Position

Employment Type

Hours Worked

List gross amounts, before any deductions and actual date(s) received. Attach proof of ALL Paycheck Stubs or Proof of Earnings. *Please provide copies of your paycheck stubs.

Week 1 Earnings

Gross Amount

Date Received

Week 2 Earnings

Gross Amount

Date Received

Week 3 Earnings

Gross Amount

Date Received

Week 4 Earnings

Gross Amount

Date Received

Week 5 Earnings

Gross Amount

Date Received

Person 2 Paycheck stubs

Drop files here or

Max. file size: 40 MB.

Unearned Income Information

Did anyone in your household receive unearned income?(Required)

If Yes, complete below. Attach proof.

Yes

Unearned Income

Include: Child/spousal support; interest or dividends; gambling/lottery winnings; insurance or legal settlements; strike benefits; cash, gifts, loans, scholarships; tax refunds; any government benefits, like social security, SSI, SSP, unemployment, worker’s compensation, retirement; rental income and rental assistance, free housing/utilities/clothing/food, per capita, foster care, adoption support; or anything else.

Who Received Income

Source of Income

Gross Amount

Date Received

Personal Information

Does anyone in your household have any changes to report in the last 30 days?(Required)

If you answered “YES,” Check all the boxes that apply and attach proof.

Yes

Household Change Information

Check ALL household changes in the last 30 days.

Arrested/Incarcerated

Checking/Savings Accounts- Closed/Open

Employment – Start/Ended

Home, or land (personal or business)

Pregnant – start/stop

Property-Buy, sell, trade, give away or receive a motor vehicle

Other: Please Explain

Explain ALL Other household changes:

File Upload for Household changes

Drop files here or

Max. file size: 40 MB.

List Household Change Information

Name of Person

Type of Change

Date of Change

Who moved in/out?

Adult moves in/out of home

Birth of Child

Child moves in/out of home

Move to new home

Recently Separated/Newly Married

Other: Please Explain

Explain ALL Other changes to household composition:

List Household Composition Information

Name of Person

Type of Change

Description

Date Change Occurred

Have you physically moved or have a new mailing address?(Required)

Yes

New Physical Address

Street Address Address Line 2 City State ZIP Code

New Mailing Address (if different)

Street Address Address Line 2 City State ZIP Code

School Enrollment information

Did any Adult or Child enroll in school, stop or get expelled from school?(Required)

List who and attach proof if applicable.

Yes

File Upload for School Information

Drop files here or

Max. file size: 40 MB.

List School Information

Student Name

Age

Grade Level

Name of School

Type of Change

Background Information

Has anyone in your household been charged with or convicted of a felony?(Required)

Yes

List Background Information

Name

Date of Offense

Date of Conviction

Conviction for

Has anyone been arrested for or been involved in Domestic Violence in the past month?(Required)

Yes

Is there anything else to report?(Required)

Yes

Additional Information to Report

Certification

Certification(Required)

I must contact my Family Advocate within 5 days of any changes in my household that may affect my eligibility for the amount of my cash assistance.

Certification(Required)

Facts I report may result in an increase, decrease, or termination of cash assistance.

Certification(Required)

Cash assistance maybe delayed or terminated because of an incomplete or late MER.

Certification(Required)

It is considered fraud if I knowingly and purposely give false facts about my income, property or family status to continue receiving benefits or cash assistance.

Signature of Head of Household(Required)

I declare under penalty of perjury that all of the above information is true and complete. I understand that falsification of any information is grounds for termination from the XXXX Tribal TANF program. The penalty will include financial recovery of any assistance provided to me while in the XXXX Tribal TANF program, and up to 2 years denial of XXXX Tribal TANF assistance.

Signature of Spouse or Parent

Head of Household Phone(Required)

Spouse or Parent Phone

Date(Required)

MM slash DD slash YYYY

Date

MM slash DD slash YYYY