GA Timesheet Employable | Lower Elwha Klallam Tribe

I am applying for financial assistance for services for myself, as I am in need. I agree to supply information regarding resource and income and to notify LEKT GA Staff of any changes to my situation within ten (10) days of changes. LEKT GA is authorized to obtain information to establish eligibility. Monthly GA timesheets are due by the 15th of each month.

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 a timesheet is not received by the last day of the month, a check 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 March

What is your email address?

Case Type(Required)

High School / College / Vocational Student

Medical / Treatment Exempt

Employable

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 employed during this reporting period?(Required)

Yes

If Yes, Where were you employed?

Unearned and/or in-kind

3. Have you been offered employment?(Required)

Yes

If YES, Where:

4. Are you a High School or College enrolled student?(Required)

If YES, attach a class schedule/grades, at the beginning of the quarter/semester, list you weekly attendance on the attendance log.

Yes

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

Yes

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If yes, what is the amount of Food Benefits Received

6. Do you have medical coverage?(Required)

Yes

This field is hidden when viewing the form

What additional Insurance do you have?

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

Yes

If Yes, What dates?

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

If Yes, apply for TANF

Yes

N/A

9. 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

10. 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

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

Treatment Center Name

Total Hours per week

Counselor Names

Counselor Phone Number

12. 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

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

Week One - High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for Week 1

Number of Class Hours ONLY

Week Two - High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for Week 2

Number of Class Hours ONLY

Week Three - High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for Week 3

Number of Class Hours ONLY

Week Four - High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for Week 4

Number of Class Hours ONLY

Week Five- High School/College/Vocational Attendance Log

School Name - Phone Number

Total Class Hours for Week 5

Number of Class Hours ONLY

List all Appointments for Medical Exemption/SSI Appointments

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

Other Appointments Log

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

** Five Job Contacts Per Week Required: Submit a picture of your Completed Job Search Form

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

List all Appointments for Medical Exemption/SSI Appointments

Other Appointments Log

** Five Job Contacts Per Week Required: Submit a picture of your Completed Job Search Form

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.