• If received on or before the 15th, checks will be processed on time, and checks will arrive by the 1st of the next month. • If received between the 16th and the last day of the month, they will be processed late, and checks will arrive by the 15th. • If received after the 1st of the reporting month, they will not be processed. • If there is no landlord statement on file, a non-shelter grant will be calculated and processed. Date submitted(Required) MM slash DD slash YYYY Name(Required) First Middle Last 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 MarchWhat is your email address? Case Type(Required) High School College/Vocational 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. Are you a High School Student?(Required)If YES, Attach monthly grades and attendance from School Office Yes No Week Ending Date MM slash DD slash YYYY Hours per weekWeek Ending Date MM slash DD slash YYYY Hours per weekWeek Ending Date MM slash DD slash YYYY Hours per weekWeek Ending Date MM slash DD slash YYYY Hours per week4. Are you a College/Vocational School Student?(Required)If YES, Attach class scheduled/grades, at beginning/end of quarter/semester, list weekly attendance on back page Yes No Week Ending Date MM slash DD slash YYYY Hours per week5. If you are a High School or College Student, did you stop attending during this reporting period?(Required)If YES, a new ISP is required. Yes No 6. Are you currently receiving Food Benefits?(Required) Yes No If yes, what is the amount of Food Benefits Received7. Are you currently receiving medical coverage from another source, other than IHS?(Required) Yes No What additional Insurance do you have?8. Were you incarcerated at any time during this reporting period(Required) Yes No If Yes, What dates?9. If you are female, did you recently find out you are pregnant?(Required)If Yes, apply for TANF Yes No 10. 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 change11. 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 12. 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 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 NumberAttendance LogAll High School / College / Vocational Students Participants are required to attend classes as scheduled. Week One - High School/College/Vocational Attendance LogSchool Name - Phone NumberTotal Class Hours for the Week 1Number of Class Hours ONLYWeek Two - High School/College/Vocational Attendance LogSchool Name - Phone NumberTotal Class Hours for the Week2Number of Class Hours ONLYWeek Three- High School/College/Vocational Attendance LogSchool Name - Phone NumberTotal Class Hours for the Week 3Number of Class Hours ONLYWeek Four- High School/College/Vocational Attendance LogSchool Name - Phone NumberTotal Class Hours for the Week 4Number of Class Hours ONLYWeek Five - High School/College/Vocational Attendance LogSchool Name - Phone NumberTotal Class Hours for the Week 5Number of Class Hours ONLYAppointments for Medical, Dental, Mental Health, and Other Agencies/Providers.Date 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.
