FDPIR Tribal Leaders, Managers, Staff (State/Local/ Tribal Government)

OMB NUMBER: 0584-XXXX

EXPIRATION DATE: XX-XX-20XX

ATTACHMENT B1a: CASE RECORD REVIEW

BURDEN DISCLOSURE STATEMENT

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0584-XXXX. The time required to complete this information collection is estimated to average 2 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Case Record Number (this will include a Tribal-specific code followed by a 4-digit number -0001,-0002, etc.)

Information about the Household

Household size [1-16 persons]

Certification status [New, Recertified]

Information on each household member (including HOH)

• The head of household (HOH) is defined as the person in the household that has primary responsibility and/or obligation for the financial support of others in the household.

• Relationship to HOH [self, spouse/partner, son, daughter, grandchild, sibling, foster child, etc.]

• DOB [mm/dd/yyyy] [Will be recalculated to indicate Age]

SNAP

• Whether currently receiving receive SNAP (Y/N)

• Whether recently applied for SNAP (Y/N)

• Whether HOH or anyone in household has ever been disqualified from SNAP(Y/N)

Income (Earned and unearned) ^{1 2}

• Income source 1 and amount

• Income source 2 and amount

• Income source 3 and amount

• Income source 4 and amount

• Total of earned income sources

Self-employment income (Y/N)

• Number of household members self-employed

• Type of Business

• Occupation

• Primary source of income (Y/N)

Student status (Y/N)

• Receipt of educational grants, scholarships, or loans (Y/N)

• Amount

• Time period

• Type (Pell Grant, Student Loan, BIA, Scholarship, Other)

• Amount used for tuition and fees

Resources

• Cash

• Checking/savings accounts

• Stocks, bonds, certificate of deposit, other

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Wages, social security, SSI, TANF, general/public assistance, foster care payments, unemployment or worker’s compensation, child support, alimony, pensions, Veteran’s benefits, per capita payments from gambling enterprises, work/training allowances, etc.).

2 Frequently Asked Questions on FDIPR Household Eligibility (Rev. 8/5/2010): Based on treaties and other legal documents (including court judgments), laws have been enacted to specify that certain funds are to be excluded as income and/or a resource in determining eligibility for any Federal or federally assisted means-tested program. This list is posted on the FDPIR website at: http://www.fns.usda.gov/fdd/programs/fdpir/fdpir_guidance.htm .

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