Transitional Services Recertification - Quinault Indian Nation

Transitional Services consist of support services that are tied to employment and training for a period of up to one year and up to $2,000.

To remain eligible for Transitional Services, participants must submit a completed Transitional Services Recertification and verification of all earned and unearned income for the last 30 days. Recertification must be completed every 90 days or later based upon when services are requested.

To remain eligible, all criteria must be met to include the income being within 300% of federal poverty guidelines.

If you would prefer to download and print this form to submit by email or in person, please click here. To submit by email to TANF@quinault.org.

Important

An email address is required for this form to be HIPAA compliant. If you do not have an email address, please call the office for assistance in setting up an email address.

Head of House First Name(Required)

Head of House Middle Name

Head of House Last Name(Required)

Head of House Suffix (Jr, SR, II)

Phone Number(Required)

Email Address(Required)

Physical Address(Required)

Street Address City State ZIP Code

Mailing Address

Street Address City State ZIP Code

Did any adult or minor parent earn money from employment?(Required)

If Yes, complete below. Attach proof.

Yes

Earned Income

Include tips, vacation pay or income in-kind (ex: earned housing). List gross amounts, before deductions for each payday. If self-employed and you claim actual expenses, please complete a Self-Employment Income Form.

Who Received Income

Employer Name

Gross Amount

Date Received __/__/____

Hours Worked

Optional Self-Employment Income Form

If you are self Employed, this form is required. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this form.

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Has any person in the family unit left the household?(Required)

If Yes, complete below.

Yes

Household Changes

Name of Person

Date Left

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Has any person entered the household?(Required)

If Yes, complete below.

Yes

Household Changes

Name of Person

Date Entered

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Has a child or children in your family unit been placed into another person’s care/custody?(Required)

If Yes, complete below.

Yes

Child Care or Custody Changes

Name of Child

Date of Placement __/__/____

Placement Agency

New Caregiver Name

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Has anyone in the family unit relinquished from his/her tribe or has anyone enrolled into another tribe?(Required)

If Yes, complete below.

Yes

Tribal Enrollment Changes

Who Relinquished

Date of Relinquishment __/__/____

New Tribal Enrollment

Date of Enrollment

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Did anyone in the household receive money or benefits, to include in-kind contributions?(Required)

If Yes, complete below.

Yes

Unearned Income

Include child/spousal support, interest or dividends, gambling/lottery winnings, insurance or legal settlements, strike benefits, cash, gifts, loans, scholarships, tax refunds, any government benefits (ex: social security, SSI, SSP, unemployment, worker’s comp, retirement), rental income, rental assistance, free housing/utilities/clothing/food, per capita, foster care, adoption support or anything else.

Who Received Income

Source of Income

Gross Amount

Date Received __/__/____

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Is anyone in the household receiving food benefits from DSHS?(Required)

If Yes, complete below.

Yes

Food Benefits

Who Received

Date Received __/__/____

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Is there any person that is a fugitive felon or who is not in compliance with any court ordered parole or probation?(Required)

If Yes, complete below.

Yes

Name of Fugitive not in Compliance

Name of Person

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File Upload

Upload supporting documents here.

Drop files here or

Max. file size: 40 MB, Max. files: 20.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Head of Household Signature(Required)

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.

Spouse Signature

Head of Household Signature Date(Required)

Spouse Signature Date