Social Services General Assistance Program

Program Description:

The Cheyenne and Arapaho Tribes provide assistance to federally recognized American Indian and Alaskan Native Tribal members in the following ways:

General Assistance:

Cash assistance to meet essential needs of food,clothing, shelter, and utilities. Additionally, each General Assistance recipient must work with a social services worker to develop a signed and agreed upon Individual Self-Sufficiency Plan (ISP) to meet the goal of employment. The plan must outline specific steps individuals will take to increase their independence. Eligibility will be reviewed on either a three-month or six-month basis, or whenever there is change in status affecting eligibility. Recipients must immediately inform their Social Services Caseworker of such changes. If a client refuses employment or quits a job under the agreement of their ISP, he/she will be sanctioned and made ineligible for services for a minimum of 60 days, not to exceed a period of 90 days.

General Program Requirements:

Individuals must meet all of the following eligibility criteria:

1. Be enrolled member of a federally-recognized American Indian/Alaskan Native tribe,

2. Prove their inability to meet the essential need of food, clothing, shelter, and utilities,

3. Reside in an 11 county approved service area (Blaine, Beckham, Canadian, Custer, Dewey, Kingfisher, Roger Mills, Washita, Major, Woodward , or Ellis)

4. Apply concurrently for all the other federal, state, tribal, county,and local programs for which he/ she may be eligible, and

5. Shall not be receiving any comparable assistance.

Items to Copy & Upload (Required)

1. Verification of residence (Rent receipt, and utility bill OR written statement from homeowner)

2. Verification of tribal enrollment (CDIB Tribal membership card)

3. Statement verifying whether or not employment benefits are being received

4 . Verification of any and all income

5. Verification of a submitted/pending application or denial letter to TANF or SSI if eligible

6. Physicians statement verifying inability to work and anticipated amount of time (if claiming temporary disability- physician will have to fax documentation to (405) 422-8218, please do not upload into this form)

Privacy Act Statement

25 CFR Part 20 and 25 U.S.C. 13 authorize the collection of this information. The information is confidential and is never disclosed without written clearance and consent of the applicant. The primary use of this information is to determine eligibility for financial assistance and services from the Bureau of Indian Affairs (BIA) Child Welfare, Burial, and Disaster programs. Additional disclosures of the information may be to other BIA or tribal officials in the conduct of their official duties pertaining to the application for financial assistance or services, or in the conduct of program review and to the Office of the Inspector General or the General Accounting Office when conducting an audit of BIA programs, or local law enforcement agency when the agency aware of violation or possible violation of civil or criminal law, and to the General Services Administration in connection with it responsibility for records management. This information will be entered into the BIA, Social Services system of records which can be obtained upon request from Chief, Division of Social Services, 1849 C Street, NW, MS-4513-MIB, Washington, DC 20240. No record contained therein may be disclosed by any means of communication to any person, or to another agency, except pursuant to a request by, or with prior written consent of the individual to whom the record pertains. Executive Order 9397 authorizes the collection of your Social Security number. Furnishing the information is voluntary but failure to do so may result in disapproval of your application. If the BIA uses the information furnished on this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes.

Paperwork Reduction Act Statement

The information is being collected to determine applicant eligibility for financial assistance and services to provide Bureau of Indian Affairs (BIA) managers with information for program planning, reporting and utilization. Response to this collection is required to obtain a benefit(s) required in 25 CRF 20. A Federal Agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Public reporting for this form is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining data, and completing the form. Direct comments regarding the burden estimate or any other aspect of this form to: Office of Regulatory Affairs & Collaborative Action – Indian Affairs, Information Collection Clearance Officer, 1849 C Street, NW, MS-4141, Washington, DC 20240.

Client Signature *

Clear

Today's Date

Date

“Whoever, in any matter with jurisdiction of any Department or Agency of the United States, knowingly and willingly falsifies, conceals, or covers up by trick, scheme, or devises a material fact, or makes any false, fictitious, or fraudulent statement or representations or makes or uses any false writing or document, knowing the same to contain false, fictitious, or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five (5) years or both. “

I (We), have read, or heard or have had interpreted to me (us) the preceding provisions of law and understand them. I (We), agree to supply all necessary information about my (our) household, employment and to notify the Agency when my (our) situation changes. I (We), also authorize the Bureau of Indian Affairs to obtain information necessary to establish my (our) eligibility for General Assistance.

“ALL APPLICANTS SHALL BE NOTIFIED IN WRITING, BY MAIL, OR GIVEN IN HAND, REGARDING THE DECISION AND ACTIONS ON THEIR APPLICATION, INCLUDING THE AMOUNT OF THE GRANT, IF APPROVED”

Applicant Signature *

Clear

Today's Date

Date

Spouse Signature

Clear

Today's Date

Date

Name *

First Name Last Name

Tribe *

AKA (also known as:)

Email *

example@example.com

Phone Number *

Area Code Phone Number

Cell/MSG Number *

Area Code Phone Number

Mailing Address *

Street Address

Street Address Line 2

City

Postal / Zip Code

Physical Address *

Street Address

Street Address Line 2

City

Postal / Zip Code

Provide directions on how to get to your home *

1. Reason for applying for General Assistance? *

2. What type of income have you been living on for the last three (3) months? *

Fill in all required blanks for everyone who lives with you, either permanently or temporarily. You must list yourself first, then your spouse and other adults and children. Be sure to check the requested box for each individual not included in the payment.

Applicant Name *

First Name Last Name

Birthdate *

Date

Sex *

Male Female

Relationship *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Is there anyone else in the household not added to this application? *

Yes No

Household Member Name *

First Name Last Name

Included in payment? *

Yes No

Birthdate *

Date

Sex *

Male Female

Relationship (Spouse, Son, Daughter, etc.) *

Social Security Number *

Tribal Enrollment *

Client Name *

First Name Last Name

Age *

Family Status *

Single Married (legal or common law) Divorced Separated Widowed

Spouse Name

First Name Last Name

Maiden Name

First Name Last Name

Number of Children *

Number of Children not in Home *

Number of Adults in Home *

Current Living Situation *

Own Home Rent Staying w/someone Section 8 Homeless

Do you have an IIM Account? *

Yes No

Does your Spouse have an IIM Account?

Yes No

Date Applicant Last Employed

Date

Type of Job

Highest Completed Grade *

Training or College? *

What does Spouse plan to do now? *

How have you been making it since your last job/support/provider? *

How has your situation changed for you to need assistance at this time? *

What is your greatest need at this time? (i.e. utility bill, rent, medicine) *

How do you plan to improve your situation? *

Additional Comments

Is anyone in the household currently working or have they worked in the past 30 days? *

Yes No

Identify Household Member(s) who are working and their earnings:

Name *

First Name Last Name

Amount: *

Name

First Name Last Name

Amount:

Name

First Name Last Name

Amount:

Do you or any household members receive or expect to receive any earned or unearned income? (i.e. wages, alimony/child support, gifts/contributions, tax refund, insurance settlement, interest/dividends, lease income, lottery/gaming income, retirement benefits, royalties, Tribal per capita payments, SSI, unemployment, worker's compensation, farm/ranch income, TANF, food stamps, foster care payments) *

Yes No

Earned Income

	Amount	Additional Comments
Wages/Salary
Alimony/Child Support
Gifts/Contributions
Income Tax Refund (Federal/State)
Insurance Settlement (Auto accident, etc.)
Interest/Dividends (Bank accounts)
Lease Income (list in comments)
Lottery/Gaming Income (Cash winnings)
Retirement Benefits/Pensions
Royalties
Tribal per capita payments
Social Security (Survivor/Disability benefits)
Unemployment Benefits
Veteran's Benefits
Worker's Compensation Benefits
Farm/Ranch Income
Total

Unearned Income

	Amount	Additional Comments
Supplemental Security Income (SSI)
TANF
Food Stamps (Specify if commodities in Additional Comments)
Foster Care Payments
Other (i.e. Alaska Native Corporation Dividends) (List in Additional Comments)
Other (i.e. Alaska Native Corporation Dividends) (List in Additional Comments)
Total

Have you applied for TANF? *

Yes No

Have you been terminated from TANF in the past 90 days? *

Yes No

Are you eligible to reapply for TANF? *

Yes No

Have you applied for other resources/programs? *

Yes No

When did you apply for other resources/programs?

Date

I (We) apply for financial assistance/services for the listed members of my (our) household who are in need. I/We have received a copy of and have had explained to us, and understand the provisions of Federal Law governing fraud. Under 18 U.S.C. §1001, the Federal Law concerning fraud states: “Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or devise a material fact, or makes or uses any false writing or document and knowing to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years or both. I (We) agree to supply information regarding resources and income and to notify the agency of any changes in my (our ) situation. Release of information for services is authorized to obtain/exchange information necessary to establish eligibility for assistance. I (We) have read, or had explained to me (us), this for our protection under the Paperwork Reduction Act and the Privacy Act.

Please check: *

Date

Signature

Clear

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. The information will be used to prove my identity and moral standing in my respective community for the purposes of placement AND/OR adoption of foster children. I understand that his information is to be held confidential by all parties.

Name *

First Name Last Name

Social Security Number *

Date of Birth *

Date

The information is to be released from:

Name of Agency *

ATTN: *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

The information is to be released to:

Name of Agency *

ATTN:

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

The purpose of this information is: *

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.

Date *

Date

Signature *

Clear

These additional forms are required to be completed. Complete these forms and attach them below. They will be attached to your application for processing.

https://cheyenneandarapaho-nsn.gov/wp-content/uploads/2020/05/GENERAL-ASSISTANCE-JOTFORM-SECONDARY-FORMS-05-04-20-1.pdf

Secondary Forms (REQUIRED) Submissions without these documents will delay processing *

Browse Files

CDIB for at least one (1) member of the household: *

Browse Files

Current, Original Utility Bill (Electric, Propane, or Gas) *

Browse Files

Proof of Income for all Household Members over Eighteen (18) Years of Age* *

Browse Files

*Applicants Name must match the name on the utility bill

*Check stubs, SSI/SSA/VA award letters, TANF award letters, unemployment benefit statements, child support award letters, & an annual IIM account summary must be included in the proof of income.

Social Services Program

General Assistance Application

Privacy Act Statement & Paperwork Reduction Act Statement

Federal Law Governing Fraud

Social Services of the Cheyenne and Arapaho Tribes APPLICATION for General Assistance

Section 1: FAMILY PROFILE OF HEAD OF HOUSEHOLD MEMBERS APPLYING (25 CFR §20.308) Family Profile

Client Background Summary

Section III. EARNED INCOME & UNEARNED INCOME (25 CFR §20.308-§20.310)

Section IV. STATEMENT OF COOPERATION

AUTHORIZATION FOR RELEASE OF INFORMATION

GENERAL ASSISTANCE ADDITIONAL SECONDARY FORMS

REQUIRED DOCUMENTS