IMPORTANT REMINDER: This form must be submitted by January 13, 2025

PURPOSE: Program benefits that meet IRS general welfare guidelines are exempt from federal income tax under Internal Revenue Code Section 139E. This form is intended to help the Tribe ensure that benefits are used solely for eligible purposes and to set limits for future years based on actual member needs.

INSTRUCTIONS: Complete all sections of this form with only those amounts that you actually spent during the benefit year for you, your spouse/partner or dependents in each of the listed categories. Include expenses paid with General Welfare Assistance dollars and excess expenses, if any, that you paid for out of pocket. However, do not include amounts that are paid on your behalf or reimbursed to you through federal, state or other tribal programs. Refer to Instructions for 2024 Annual Substantiation Form for special definitions including dependents and household members.

NOTE: The total amount allocated to General Assistance is set by the Tribal Council and may not be set by individual members. However, the Tribe will use your responses to substantiate General Assistance at the current year level and as a survey to set new levels for next year. So it is very important to list all eligible expenses, even if they exceed your annual benefit level.

NOTE: All members of the household must be identified in order to claim allowance for living expenses or vehicle assistance.

Living Allowance:

NOTE: These benefits may be claimed only for individuals identified in the family household section of this form above.

For purposes of our program, living expenses include:

• Food, household supplies (not claimed elsewhere), laundry and cleaning supplies, stationery supplies, postage, delivery services, and needed household products and supplies.

• Clothing, footwear, material, patterns and supplies for making clothes, alterations and repairs, clothing rental, clothing storage, dry cleaning and sent- out laundry.

• Necessary personal care products and services, products for the hair, oral hygiene products, shaving needs, cosmetics and bath products, electric personal care appliances, and other personal care products.
  

Vehicle Allowance:

NOTE: You may claim only one necessary use vehicle for each licensed driver identified in the family household section of this form above.

Additional Limitations: A necessary use vehicle for purposes of this program is a vehicle (not lavish or extravagant) needed for essential general welfare purposes, including school, work, medical or other essential travel needs. You may not include costs for vehicles purchased with funds from the Minor General Welfare Account or a car not needed for general welfare purposes.

Category of Safe Harbor Expenses:

Housing Expenses (for Principal residence only):

NOTE: Do not include benefits paid through the Redding Rancheria home equity or other assistance program. The expenses listed on this form should be excess out-of-pocket TOTAL ANNUAL expenses only.

NOTE: You cannot deduct mortgage interest on your individual tax return if your mortgage is paid with General Assistance dollars.

NOTE: Do not include amounts financed through other tribal programs, tribal housing programs or reimbursed through tax credits.

Category of Safe Harbor Expenses:

Transportation Costs(Other than Personal Vehicles):

NOTE: Exclude travel that is reimbursed by your employer or under any other program. Exclude any travel costs that appear in other sections of this form, such as your own vehicle(s).

Medical Related Expenses:

NOTE: Exclude payments covered by Redding Rancheria medical programs, IHS, PRC, or other programs that cover your medical expenses. The expenses listed on this form should be excess out-of-pocket expenses only.

Note: Marijuana is not an eligible expense for General Assistance pending future guidance from IRS.

Catergory of Safe Harbor Expenses:

Education Related Expenses:

NOTE: Exclude payments covered by the Redding Rancheria education assistance programs, grants, scholarships, or other programs that cover your education expenses. The expenses listed on this form should be excess out-of-pocket expenses only.

Catergory of Safe Harbor Expenses:

Education Related Expenses(Continued):

NOTE: Exclude payments covered by the Redding Rancheria education assistance programs, grants, scholarships, or other programs that cover your education expenses. The expenses listed on this form should be excess out-of-pocket expenses only.

Other:

Category of Safe Harbor Expenses:

Total 2024 Safe Harbor Expenses and Certification:

I hereby certify under penalty of perjury that the amounts set forth herein are true and correct General Welfare expenses incurred on behalf of myself, spouse/partner and eligible dependent family members for Calendar Year 2021, as per instructions to this form, to the best of my knowledge. I understand that I am responsible to maintain receipts and records to substantiate reported expenditures, and that the Redding Rancheria assumes no responsibility for any future taxation associated with disallowance of expenses by a taxing agency.