GA Medical Exempt | Lower Elwha Klallam Tribe

Date submitted(Required)

This Report is for (M/Y)(Required)

Reports are due on the 5th of each month for the month prior. January MR is turned in Feb; Feb MR in March

What is your email address?

Source of Income

Gross Amount

Date Received

Source of Income

Gross Amount

Date Received

If Yes, Where were you employed?

Unearned and/or in-kind

If YES, Where:

If yes, what is the amount of Food Benefits Received

What additional Insurance do you have?

If Yes, What dates?

If Yes, Explain the change

Treatment Center Name

Total Hours per week

Counselor Names

Counselor Phone Number

Date Moved

Phone Number

List all Appointments for Medical Exemption/SSI Appointments

Date

Office/Physician

Phone Number

Purpose of Appointmnet

Date

Office/Physician

Phone Number

Purpose of Appointmnet

Date

Office/Physician

Phone Number

Purpose of Appointmnet

Date

Office/Physician

Phone Number

Purpose of Appointmnet

Photo of Attendance / Class Schedule / Other Required Documents

Please send a clear photo that can be printed. If the photo can't be read when printed, we will request a different copy.

Attachments

Max. file size: 50 MB.

CERTIFICATION

All income must be reported, earned or unearned, to determine continued eligibility. If you are uncertain what to report, please talk to the Case Manager. Participants who make fraudulent misrepresentations in order to obtain or continue to receive assistance will be denied further benefits until the overpayment is repaid and the case may be referred to the LEKT Prosecuting Attorney. By signing this document, I certify the information that I have provided is true and accurate and that I understand the above information. If I am not clear or have questions, I understand I can ask staff at any time.

I declare under penalty of perjury under the laws of the United States and the State of Washington that the facts contained in this report are true and correct and complete for the entire report month

Signature(Required)

List all Appointments for Medical Exemption/SSI Appointments

Photo of Attendance / Class Schedule / Other Required Documents

CERTIFICATION

I declare under penalty of perjury under the laws of the United States and the State of Washington that the facts contained in this report are true and correct and complete for the entire report month

You must sign this report or it will be considered incomplete.