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APPENDIX K

Agency Name:

Agency Address:

STATEMENT OF CONTRIBUTIONS

Date:

I, (name of person making contribution)

do hereby certify that I assist (enter the name of the person being assisted)

with monthly household expenses. Our relationship is (check the appropriate box):

I am a relative I am a friend Other:

The amount of my monthly contribution is $

Or

I assist with the following:

A. Rent ...................................................................... Amount:

B. Food ...................................................................................

C. Utility Bills ..........................................................................

D. Transportation ....................................................................

E. Medical Expenses ................................................................

TOTAL:

I understand that if I knowingly give incomplete , inaccurate , or incorrect information, regarding my assistance with the person named above, I am subject to criminal prosecution under Title 18 of the U.S. Code.

Contributor’s Name:

Address:

City: Zip:

PHONE NUMBER: ( )

Signature of Contributor:

Effective: April 1, 2026