COVID-19 Coronavirus Food Card Assistance Application

COVID-19 Coronavirus Food Card Assistance Application

Cheyenne and Arapaho Tribes HOPE Program
Head of Household Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number*

Area CodePhone Number
C&A Tribal Roll #*
SSN (last four digits)*
Application Date

MonthDayYear
Date
Spouse/Companion Name (if applicable)

First NameLast Name
Date of Birth

MonthDayYear
Date
Phone Number

Area CodePhone Number
C&A Tribal Roll #
SSN (last four digits)
Mailing Address/PO Box*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Have you previously/recently been assisted for food assistance through HOPE for COVID-19*

YesNo
ELIGIBILITY REQUIREMENTS (please check all that apply)*

Elder caring for school age childrenLoss of job/income due to COVID-19Substantial loss of income i.e. tip position due to COVID-19Unemployed and caring for school age childrenMeets HOPE income guidelines and has not been assisted by HOPE since March 20th
INCOME CRITERIA HAS TEMPORARILY BEEN INCREASED TO ASSIST MORE TRIBAL MEMBERS DURING THIS NATIONAL PANDEMIC
(1 person)--$25,755 (2)--$31,755 (3)--$37,755 (4)--$43,755 (5)--$49,755 (6)--$55,755 (7)--$61,755 (8)--$67,755
OTHER HOUSEHOLD MEMBERS

Eligibility is based on the number of Cheyenne and Arapaho tribal members in the home
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.
By my signature below, I attest that the information provided above is true and correct. I understand that if I purposely falsify this document in order to receive funds, I will jeopardize future services with the Cheyenne and Arapaho Tribes and/or the HOPE Program. I also understand that cards will be sent by certified mail to the address I have provided and will not be reissued if they are not received at the address on this application. I also understand cards issued and signed for by me or a member of my household will not be replaced if lost or stolen.*

Tribal Member Signature
Today's Date

MonthDayYear
Date
FOR OFFICE USE ONLY ---- TRACKING #
Date application received

MonthDayYear
Date
Approved or denied?

ApprovedDenied
Reason
Certified Mail Tracking #
PASTE CERTIFIED MAIL STICKER HERE
Should be Empty:

COVID-19 Coronavirus Food Card Assistance Application

OTHER HOUSEHOLD MEMBERS