Date submitted(Required) MM slash DD slash YYYY Name(Required) First Middle Last This Report is for (M/Y)(Required)MayJuneJulyAugustSeptemberDecemberJanuaryFebruaryMarchAprilReports are due on the 5th of each month for the month prior. January MR is turned in Feb; Feb MR in MarchThis field is hidden when viewing the formThis 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 MarchWhat is your email address? Case Type(Required) High School College/Vocational Employable Medical/Treatment Exempt 1. Did you received any type of funds earned or other, during this reporting period?(Required)If you marked “Yes”, complete 2). Include all income, such as in kind, per capita, SSI, death benefits, retirement, state GAU, employment, inheritance, casino winnings, etc. Attach pay stubs or proof of income. If it is self-employment, attach proof of business cost for allowable deduction of business costs. Yes No Source of IncomeGross AmountDate Received MM slash DD slash YYYY Source of IncomeGross AmountDate Received MM slash DD slash YYYY 2. Are you employed or were you during this reporting period?(Required) Yes No If Yes, Where were you employed?Unearned and/or in-kind3. Have you been offered employment?(Required) Yes No If YES, Where:4. Have you enrolled in College or a Vocational Program?(Required)If YES, Attach Proof and a NEW ISP is required. Yes No 5. Are you currently receiving Food Benefits?(Required) Yes No If yes, what is the amount of Food Benefits Received6. Are you currently receiving medical coverage from another source, other than IHS?(Required) Yes No What additional Insurance do you have?7. Were you incarcerated at any time during this reporting period(Required) Yes No If Yes, What dates?8. If you are female, did you recently find out you are pregnant?(Required)If Yes, apply for TANF Yes No 9. Has your family unit changed, meaning that person has entered, joined your family unit or you got married?(Required) Yes No If Yes, Explain the change10. Did you have a change in medical condition since the last report, which would prevent you from attending school?(Required)If YES, attach a completed Physician’s Statement or obtain one from staff and a new ISP may be required. Yes No 11. Are you or will you be attending Intensive Outpatient Treatment, Detox, or Impatient Treatment?(Required)If YES, attach verification, and a new ISP is required. Yes No Treatment Center NameTotal Hours per weekCounselor NamesCounselor Phone Number12. Did you apply for SSI during this reporting period or did you receive correspondence from SSI?(Required)If YES, Attach verification and complete appointments section. Yes No 13. Have you had an Address and/or Phone Number Change?(Required)If you have had an address chance, you need to submit a new landlord statement Yes No Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date Moved MM slash DD slash YYYY Phone NumberList all Appointments for Medical Exemption/SSI AppointmentsDate MM slash DD slash YYYY Office/PhysicianPhone NumberPurpose of AppointmnetDate MM slash DD slash YYYY Office/PhysicianPhone NumberPurpose of AppointmnetDate MM slash DD slash YYYY Office/PhysicianPhone NumberPurpose of AppointmnetDate MM slash DD slash YYYY Office/PhysicianPhone NumberPurpose of AppointmnetPhoto of Attendance / Class Schedule / Other Required DocumentsPlease send a clear photo that can be printed. If the photo can't be read when printed, we will request a different copy. AttachmentsMax. file size: 50 MB. CERTIFICATIONAll 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 monthSignature(Required)You must sign this report or it will be considered incomplete.UntitledFirst ChoiceSecond ChoiceThird Choice
