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Andrew Moser, Assistant Secretary - page 5 / 8

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ELIGIBILITY CRITERIA

ACCEPTABLE DOCUMENTATION (Only one of the following is required

INDIVIDUAL/FAMILY

INCOME (youth program only)

NOTE: Documentation should

be provided for applicable

income source.

Alimony Agreement

Applicant Statement

Award Letter from Veterans Administration

Bank Statements (Direct Deposit)

Compensation Award Letter

Court Award Letter

Employer Statement/Contact

Farm or Business Financial Records

Housing Authority Verification

Pay Stubs

Pension Statement

Public Assistance Records

Quarterly Estimated Tax for Self Employed Persons (Schedule C)

Social Security Benefits

Unemployment Insurance Documents and/or Printout

INDIVIDUAL STATUS/

FAMILY SIZE

Applicant Statement

Birth Certificate

Decree of Court

Disabled (See Individuals with Disabilities)

Divorce Decree

INDIVIDUAL STATUS/

FAMILY SIZE, cont.

Landlord Statement

Lease

Marriage Certificate

Medical Card

Most Recent Tax Return supported by IRS Documents (e.g. Form

Letter 1722 - See Appendix A)

Public Assistance/Social Service Agency Records

Public Housing Authority (If Resident of or on Waiting List)

Written Statement from a Publicly Supported 24 Hour Care Facility

or Institution (e.g. Mental, Prison)

FOOD STAMPS

NOTE: The listed items of

documentation are acceptable

for any individual listed on the

grant.

Current Authorization to obtain Food Stamps

Current Food Stamp Receipt

Food Stamp Card with Current Date

Letter from Food Stamp Disbursing Agency

Postmarked Food Stamp Mailer with Applicable Name and Address

Public Assistance Records/Printout

HOMELESS

Applicant Statement

Written Statement from an Individual Providing Temporary Residence

Written Statement from Shelter

Written Statement from Social Service Agency

SUPPORTED FOSTER CHILD

Court Contact

Court Documentation

Medical Card

Verification of Payments made on Behalf of the Child

Written Statement from State/Local Agency

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