GA Monthly Timesheet - Student | Lower Elwha Klallam Tribe

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 March

What 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

Source of Income

Gross Amount

Date Received

MM slash DD slash YYYY

Source of Income

Gross Amount

Date Received

MM slash DD slash YYYY

2. Are you employed or were you during this reporting period?(Required)

Yes

If Yes, Where were you employed?

Unearned and/or in-kind

3. Are you a High School Student?(Required)

If YES, Attach monthly grades and attendance from School Office

Yes

Week Ending Date

MM slash DD slash YYYY

Hours per week

Week Ending Date

MM slash DD slash YYYY

Hours per week

Week Ending Date

MM slash DD slash YYYY

Hours per week

Week Ending Date

MM slash DD slash YYYY

Hours per week

4. 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

Week Ending Date

MM slash DD slash YYYY

Hours per week

5. 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

6. Are you currently receiving Food Benefits?(Required)

Yes

If yes, what is the amount of Food Benefits Received

7. Are you currently receiving medical coverage from another source, other than IHS?(Required)

Yes

What additional Insurance do you have?

8. Were you incarcerated at any time during this reporting period(Required)

Yes

If Yes, What dates?

9. If you are female, did you recently find out you are pregnant?(Required)

If Yes, apply for TANF

Yes

10. Has your family unit changed, meaning that person has entered, joined your family unit or you got married?(Required)

Yes

If Yes, Explain the change

11. 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

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

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

Address

Street Address City State ZIP Code

Date Moved

MM slash DD slash YYYY

Phone Number

Attendance Log

All High School / College / Vocational Students Participants are required to attend classes as scheduled.

Week One - High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for the Week 1

Number of Class Hours ONLY

Week Two - High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for the Week2

Number of Class Hours ONLY

Week Three- High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for the Week 3

Number of Class Hours ONLY

Week Four- High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for the Week 4

Number of Class Hours ONLY

Week Five - High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for the Week 5

Number of Class Hours ONLY

Appointments for Medical, Dental, Mental Health, and Other Agencies/Providers.

Date

MM slash DD slash YYYY

Office/Physician

Phone Number

Purpose of Appointmnet

Date

MM slash DD slash YYYY

Office/Physician

Phone Number

Purpose of Appointmnet

Date

MM slash DD slash YYYY

Office/Physician

Phone Number

Purpose of Appointmnet

Date

MM slash DD slash YYYY

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)

Attendance Log

Appointments for Medical, Dental, Mental Health, and Other Agencies/Providers.

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.