Wait List Application Form For Eligibility For Alaska'S Commodity Supplemental Food Program (Csfp) printable pdf download

Wait List Application Form For Eligibility For Alaska'S Commodity Supplemental Food Program (Csfp)

(APPENDIX C)

WAIT LIST APPLICATION

for Eligibility for

Alaska’s Commodity Supplemental Food Program

(CSFP)

Copper River Native Association

CSFP Partner Agency:

(ONE APPLICATION PER PERSON)

The Applicant’s eligibility for CSFP is based upon the following statements. A

APPLICANT:

separate application is required for each Applicant.

Please print and complete all information

Name of Applicant: ________________________________________ Birth Date: _______/_______/__________

(Last)

(First)

(Middle)

YYYY

Mailing

Address: _____________________________________________________________, AK Zip_________________

Street or PO Box

Apt #

City

Total household income before deductions: $

per

month,

year.

How many people in your household?

Did anyone in your household receive the latest AK Permanent Fund Dividend?

Yes

No.

If yes, how many?____________________

If yes, did you include this amount in your total household income listed above?

Yes

Note: Your PFD or other garnished income is considered income even though it is garnished and needs

to be added into your total household income.

I have read the wait list letter informing me of my status and the procedure of notification when my name

has risen to the top of the CSFP wait list.

Applicant’s Signature ________________________________________________date_______________

I certify I spoke with this individual by phone and the above client wishes to be added to the wait list.

Site Representative’s Signature

____________________________________date______________

CSFP Agency Use Only: If an application is signed by someone other than the applicant. CSFP regulations require CSFP

agencies to see Power of Attorney paperwork. Power of Attorney paperwork reviewed by the Certifying Official?

yes

Certifying Official’s Initials_______

Wait List Application Form For Eligibility For Alaska'S Commodity Supplemental Food Program (Csfp)

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