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Tribal Agency Name
Food Distribution Program
Address
City, Alaska Zip

TRIBAL
AGENCY LOGO

NOTICE OF ADVERSE ACTION OF INELIGIBILITY OR
REDUCTION IN FOOD DISTRIBUTION BENEFITS
CASE:
DATE:
NAME:
ADDRESS:
CITY:
Dear:
This letter is to inform you that there has been a change affecting your household’s Food
Distribution Program on Indian Reservations (FDPIR) benefits. Your benefits will discontinue
effective (date):
. The reason(s) for this action is listed below:
 State of Alaska records indicate a member of your household (name/names):
is/are receiving State of Alaska Supplemental Nutrition Assistance
Program benefits (Food Stamps). Dual participation in both FDPIR and SNAP within the
same month is prohibited.
 A reported change in household income has made your household ineligible due to exceeding
FDPIR’s household income limits, and/or loss of the Shelter/Utility/Fuel Deduction.
 A reported change in permanent residence has made your household ineligible due to not
meeting (your tr