Supportive services assist in removing barriers that may be preventing a family assistance unit in becoming self-sufficient or ensuring basic needs of the children are being met. Services are based on compliance and whether program requirements are met. The services are not automatic or an entitlement and are contingent on the availability of funds. Services may be denied for any plausible reason, including but not limited to non-compliance, availability of resources, missing documentation, questions of eligibility, frequency of use, availability of program funds, and guidelines. The LEKT TANF Program offers Incentives for Students up to 4 times per year, on the schools official grading period. At the end of the grading period a student can be eligible for either a grade or attendance incentive not both for the same grading period. Because our program encompasses several different schools with varying grading periods’ students are eligible to receive up to 4 incentives allowing for additional incentives for any special recognition your student may receive outside of grades or attendance. An example could be a special recognition award from the school and or awards for academic/sports letters. Date(Required) MM slash DD slash YYYY Head of Household Name(Required) First Last How many children will you be applying for?(Required)1234Child Name First Last Child Name First Last Child Name First Last Child Name First Last 1. Requested Item/Service(Required) Cost of Item/Service(Required)2. Requested Item/Service Cost of Item/Service3. Requested Item/Service Cost of Item/Service4. Requested Item/Service Cost of Item/Service5. Requested Item/Service Cost of Item/ServiceWhat is the urgent need for the item or service request? If Child-Only Case, please know the request must be tied to the needs of a child on the case.(Required)How will you cover this cost in the future?(Required)Have you received assistance from another agency, including LEKT ICW or DCYF CPS?(Required) Yes No If yes, what assistance was provided and what date:(Required)Monthly BudgetPlease complete the budget to show what the projected monthly income and expenses will be for your household. If you are reporting income that you receive more than once per month, estimate what the monthly total will be. Family Cases and Child-Only Cases where the biological parent is the caregiver must report ALL income for the household. Child-Only Cases must report income and expenses specifically for the child (ren) on the case.INCOME SOURCE(Required) TANF Grant Wages SSI/Survivor Benefits Financial Aid Per Capita INCOME SOURCE Food Stamps WIC Benefits Unemployment Income Tax Return LIHEAP/Energy Assistance TANF Grant(Required) Amount Date Received Food Stamps Amount Date Received Wages from Working Amount Date Received WIC Benefits Date Received SSI/Survivor Benefits Amount Date Received Unemployment Amount Date Received Financial Aid Amount Date Received Income Tax Return Amount Date Received Per Capita Amount Date Received LIHEAP/Energy Assistance Amount Date Received Check all the basic living expenses that apply to the TANF Household you are applying for. Enter the amount in each the corresponding box.BASIC LIVING EXPENSES - IF ALREADY PAID(Required) Rent Water/Sewer/Garbage Groceries Child Care Insurance Other BASIC LIVING EXPENSES - IF ALREADY PAID(Required) Electricity Laundry Household/Hygiene Items/Diapers Car Payment / Maintenance Fuel Other Rent AmountWater/Sewer/Garbage AmountElectricity/Gas/Propane/WoodLaundryGroceries (paid for with cash)Child Care AmountHousehold/Hygiene Items/DiapersCar Payment/MaintenanceInsurance AmountOther AmountFuelOtherParticipant SignatureBy signing this request, I attest that all of the information that I have provided is true and correct to the best of my knowledge. I also acknowledge that processing time may take up to fourteen business days. Reset signature Signature locked. Reset to sign again
