CSBG

Social Services Program

Serving the Counties of Beckham, Blaine, Canadian, Custer, Dewey, Ellis, Kingfisher, Major, Roger Mills, Washita, Woodward, and Oklahoma County.
Applicant is applying for:
Have you received Emergency Food Assistance or Utility Assistance within the past 90 days?
When?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Do you reside within the service areas listed above?
Is your utility services currently disconnected?
Are you receiving food stamps or commodities?
REQUIRED DOCUMENTS
CDIB for at least one (1) member of the household:

Browse Files

Cancelof
Current, Original Utility Bill (Electric, Propane, or Gas) or Proof of Residency

Browse Files

Cancelof
Proof of Income for all Household Members over Eighteen (18) Years of Age* or Attach a Notarized No Income Statement

Browse Files

Cancelof
*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.

All no-income statements must be signed in front of notary. Download and print the form by clicking here.
Please Read Carefully:

The amount of assistance that you receive is determined based on the information that you provide below. Please make sure that all information is accurate and up-to-date. The application must be fully completed, signed, and turned in with all necessary documents to the Cheyenne & Arapaho Tribes Social Services office. Processing will be done in a timely manner and all applicants will receive notice of approval or denial. Please contact the CSBG Caseworker if you need assistance filling out an application or if you have any questions.
Applicant

***Must Be Head of Household***
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Social Security Number
Email
example@example.com
Home/Service Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
List All Household Members

(Not Including Self)
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Social Security Number
Relation
Employed?
Elderly, Handicapped, or Disabled?
Is there anyone else in the household not added to this application?
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Social Security Number
Relation
Employed?
Elderly, Handicapped, or Disabled?
Is there anyone else in the household not added to this application?
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Social Security Number
Relation
Employed?
Elderly, Handicapped, or Disabled?
Is there anyone else in the household not added to this application?
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Social Security Number
Relation
Employed?
Elderly, Handicapped, or Disabled?
Is there anyone else in the household not added to this application?
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Relation
Employed?
Elderly, Handicapped, or Disabled?
Household Income

Please provide a complete, accurate list of income for all members of your household.
All household members over eighteen (18) years of age must provide proof of income
Head of Household
Other Household Members (click the + to add additional household income):
Please list any assistance that you receive (click the + to add multiple sources):
*Please attach any award letters above in the income section for benefits received*
RELEASE OF INFORMATION
Download Here

This Request and Authorization to Release Information is required to be submitted to the Cheyenne & Arapaho Tribes Food Distribution Program to substantiate income, benefits, or other areas included in this submission.

It is required for inclusion in your personal file, to verify eligibility in the program.
PLEASE READ CAREFULLY

By signing below, I agree to the following terms:
I certify that the information on this application is true and correct to the best of my knowledge. If I provide fraudulent information, my eligibility for future CSBG Emergency Food and Utility services could be suspended.
I understand that my application will not be processed until all required documentation is submitted.
I understand that my application will take up to a week to process or up to two (2) weeks for vendor checks to be processed.
I authorize the Cheyenne & Arapaho Tribes’ Department of Social Services to acquire any information that is necessary to complete my application.
I understand the Cheyenne & Arapaho Tribes’ Social Service Program is not responsible for damage or repair to heater/ac units and/or fans.
Comments?
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If you have read, understand, and agree to the terms above, please sign below
Mailing Address (if different from above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Should be Empty:

Social Services Program

REQUIRED DOCUMENTS

All no-income statements must be signed in front of notary. Download and print the form by clicking here.

Please Read Carefully:

Applicant

List All Household Members

Household Income

RELEASE OF INFORMATION

PLEASE READ CAREFULLY