Tribal Emergency Food Assistance Voucher Program Applicaiton Download a PDF of this form with detailed instructions Download a PDF of the Form W9 InformationTribal Member Name(Required) First Last Mailing Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Phone (or Best Contact Number)(Required)Email (If One Available) Enrollment Number(Required)Preferred Form of Contact(Required) US Mail Phone Email HouseholdHow many people in the household?(Required)Please list the names and DOB for all the individuals in the householdAre you a Tribal Elder?(Required) Yes No Has anyone in your immediate household already applied for this benefit?(Required) Yes No EligibilityTo be eligible for a voucher, the household must have experienced one or more of the below qualifying life changes within the last 90 days from date of application: (check all that apply)Eligibility(Required) Change in legal marital status that affects financial stability (i.e., marriage, divorce, death, legal separation). Change in number of dependents (i.e., birth, adoption, death, or addition of a vulnerable adult). Change in employment status due to job loss. Loss of, or significant change to, current financial status that threatens food stability. Facing eviction or homelessness which is causing food insecurity (e.e., sharing housing due to economic hardship, living in hotels, living in transitional shelters, migrant children, natural disaster temporary housing.) Victim of domestic violence or families/children that fall under protective services and are in need of food assistance. Considered low income and on the Tribe’s STOWW program for utility assistance must have been approved on the STOWW program prior to applying for voucher, must have applied for STOWW within 30 days of applying for this program to ensure verification of low income. Considered a low income Tribal Elder, must be 55+ and only source of income is Social Security benefits, veteran disability, veteran pension, or similar unearned income distribution. Check the following resources used by any/all members TANF SNAP/EBT Unemployment WIC Social Security Veterans Benefits Section 8/HUD BIA Assistance SSI Receipt AgreementReceipts must be submitted to the Tribal Services Department within 60 days of issuance of the check. It is the responsibility of the voucher recipient (“Recipient”) to track and maintain all receipts and submit them in good repair to the General Resources Department. Items purchased using Food Stamps and EBT SNAP will not be considered eligible purchases on receipts submitted for voucher funding. Items not on the eligible items list will be removed from receipt totals. A second or third voucher will not be issued until the previous voucher has been properly recognized. Failure to properly reconcile a voucher will result in the funds being considered taxable income. In the event the improperly used voucher is funded by state or federal funds, the voucher will be reclassified to Tribal hard dollars or the recipient will be required to return the funding to the Tribe. Failure to reconcile a voucher within 60 days will require repayment of the outstanding voucher amount.By signing I certify the information contained in this application is complete and accurate to the best of my knowledge. I agree to follow the requirements and policies. I understand that I am signing this application under penalty of criminal prosecution if I knowingly give false information which results in payment to which I am not entitled. I agree that the General Resources Department may contact other tribal programs for pertinent information as it applies to this application. I agree to repay any funds that the Tribe deems to have been misused, and that the Tribe may pursue any available remedies at law and/or equity to recover misused funds.Signature(Required)DateAttachmentsUpload Forms/Receipts Drop files here or Select files Accepted file types: pdf, doc, docx, tif, tiff, bmp, png, jpg, Max. file size: 256 MB, Max. files: 6.
