Hope Program

Application for Assistance
Applicant Name*

First NameLast Name
Application Date

MonthDayYear
Date
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
SSN*
CDIB*
Phone Number*

Area CodePhone Number
All applicants must complete an interview with a caseworker before determination of assistance can be made. All assistance requires processing time. Applications are active for 10 business days. Determination of assistance is conducted on a case by case basis that includes documentation and assessment information.

If unable to be seen in-office, applicant may request a telephone interview. It is the client’s responsibility to call and schedule the telephone interview.

Documentation must be provided.
Briefly explain your crisis:
Unexpected, unplanned, or unforeseen incident:*
What type of assistance are you seeking today? (Please check all that apply)*

FoodUtilityRentFuneralTransit Bus PassMed ICU/Prescriptions
Complete your current sources of income (Click the + sign to add additional income):*
Are you a Veteran of the United States Military?

YesNo
Current housing situation*

HomelessLeaseRentOwnTempOther
Highest level of education?*

High SchoolGEDSome collegeBachelors/MastersDid not graduate from high school
I certify that information I have provided is true to the best of my knowledge. I understand this information will be usedto determine my eligibility for assistance with the HOPE Program and my signature allows tribal programs to share myinformation to determine eligibility. If you request a stop payment on your services after the check has been issued andmailed out, you will be suspended from the HOPE program for one year.*

Clear
Tribal Member Signature
List ALL individuals currently living in your household, regardless of tribal affiliation or ethnicity. PLEASE LIST YOURSELF FIRST AND CLICK THE + SIGN TO ADD OTHER MEMBERS.*
Today's Date

MonthDayYear
Date
Code of Conduct Agreement

To ensure a cooperative, safe, and courteous environment, a Code of Conduct will be enforced by the Cheyenne and Arapaho HOPE Program. HOPE is focused on providing the client with caring and respectful service, making every
attempt to avoid any physical or emotional damage to either clients or staff. Please adhere to the following standards.

• Any inappropriate use of language is disrespectful or will not be tolerated.

• Threatening/intimidating remarks about the staff to other clients are also disrespectful and will not be
tolerated.

• Inappropriate behavior such as throwing objects, violent physical contact with others in the office, or
raising a voice in anger or contempt will not be tolerated.

• The staff will use respectful and professional behaviors with a client and anticipate the same behavior
from the client.

HOPE understands the difficulties of going through a crisis and will make every effort to make the application
process go quickly and smoothly. Please exhibit patience and understanding with the extensive application
process and be informed there are consequences for any inappropriate behavior
Supporting Documentation
Please attach necessary documentation described below. If any bill or lease provided is not in your name, you will need to fill out and also attach the Residence Verification Form, which is found by clicking here.
For Rental Assistance: Please provide a copy of your signed lease agree and late/eviction notice

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For Utility Assistance: Please provide a copy of your late/disconnect notice and a full bill.

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Acknowledgement of Two Time Assistance Form
If you have not done so already please download the Acknowledgement of Two Time Assistance form here: www.cheyenneandarapaho-nsn.gov/files/acknowledgement-of-two-time-assistance

This requires your caseworkers signature. Upload the completed form below.
Acknowledgement of Two Time Assistance Form

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I, {applicantName}, have read and understand the Code of Conduct of the Cheyenne and Arapaho Tribes HOPE Program. By signing this agreement, I agree to adhere to the Code of Conduct and understand that if I breach the terms of the agreement, I will be placed on immediate suspension from the HOPE Program until my suspension is lifted.

Clear
Today's Date

MonthDayYear
Date
AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby authorize you to release any information from any medical facility, institutions, the Social Security Administration, any local, State, or Federal Law Enforcement Agency, or any other agency. I understand that his information is to be held confidential by all parties.
Name*

First NameLast Name
Social Security Number*
Date of Birth*

MonthDayYear
Date
The information is to be released from:
Name of Agency
ATTN:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Information to be released includes:*
This authorization will terminate one year from the date of my signature. It is further understood that I may revoke this authorization any time by written request except to the extent that action has been taken in reliance theron.
Today's Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Application for Assistance

Briefly explain your crisis:

Supporting Documentation

Acknowledgement of Two Time Assistance Form

AUTHORIZATION FOR RELEASE OF INFORMATION