• Blackfeet Manpower Universal Application For Public Law 102-477

  • REQUIRED FOR ALL 477 PROGRAMS:

    I understand the questions on this application and the penalty for withholding or giving false information or breaking any of the rules listed in the penalty warning.  I understand and agree to provide documents to prove what I have said.  I understand and agree that the Agency may contact other persons or organizations to obtain necessary verification of any statement on this application.   By signing below, I certify under penalty of perjury, that all my answers are correct and complete to the best of my knowledge, including information about the citizenship of each household member.

    • Tribal TANF, you and your household must be enrolled in the Blackfeet Tribe.  if you or any of your children are not enrolled in the Blackfeet Tribe you may apply with the Office of Public Assistance @ apply.mt.gov.

     

    • General Assistance/TANF are designed to temporarily provide assistance while an eligible individual is looking for work and transitioning to self-sufficiency. General Assistance, is like TANF, is based on individual completing certain number of work hours consist of completing social security requirements, all medical appointments, and meeting all work requirements.  

     

    • All General Assistance and TANF Cases will be closed, suspended or sanctioned if a client does not comply with their employability plan which include: Job Search and completing job applications, attend Job Readiness Training (JRT); Fatherhood/Motherhood is sacred training; HI-SET (GED study and any other requirements set forth in their employability plan.  

     

    • Child Care applicant must provide verification of Blackfeet Enrollment or Blackfeet descendant to be eligible, verification of Work, School, or training schedule or job search hours must be verified.  

     

    • Child Care/ Adult/Youth (WIOA) applications are valid for 90 days following the application date.  The eligibility determination-approval or denial-must be completed within this 90-day period 

     

    • VOC-Rehabilitation applicants: Vocational Rehabilitation to Blackfeet enrolled members who reside on or near the Blackfeet Reservation.  the following documents are required, verification of Tribal enrollment, Residency and Disability Income. 

     

    • WIOA (Adult & Youth): The following documents are required: Enrolled member of a federally recognized Tribe (Certified document of Indian blood and/or Blackfeet descendant; verification of residency and Social Security Number).  

     

    • State Work Activity Program (SWAP) The state work activity program provides case management to all State TANF clients.  We perform an enrollment intake and negotiate a Family Futures contract (Employability plan) for all adults. The following document is required: Referral from State.

     

    • (Wraparound Services): Wraparound services are employment training services that are available to adult non-custodial parent(s) who are referred by (BCSEP) Blackfeet Child Support Enforcement program for the purpose of promoting parental responsibility to meet the financial needs of children and their families. 

     

    • Medicine Bear Shelter: Provides shelter for (adult only), will assist finding resources:  permanent housing, employment & training, etc.

     

    • Veterans Alliance (VETS): Blackfeet Veterans Alliance is here to help Veterans navigate the Veterans Health Administration, Veterans Benefits Administration, as well as assist families with the National Cemetery Administration.  This will also include helping veterans file claims with the aforementioned programs.  This will include filing for any compensation benefits, insurance, pensions and home loans.  

     

    • Reporting requirements:  It’s the responsibility of all financial assistance applicants to report and present appropriate documentary verification of any and all changes that may occur in their income, resources and/or household composition, these changes must be reported within 10 days from the date of the change.  Failure to report changes may result in you having to re-pay benefits and may cause and Intentional program violation (IPV) which will cause you to be ineligible for TANF cash assistance (disqualified) for a specified period of time depending upon number of times he/she has been found to have committed an IPV.
  • Use this application to apply for: Put a check mark in the boxes for the services you are applying
  • Have you received or are receiving any of the services from above within the last 3 months?
  • REFERRAL SERVICES: If you are interested in any of the services that Manpower provides, please place a check mark on the service needed.  Your case manager will refer you to these services and they will contact you by mail as soon as possible.

  • Blackfeet Manpower Universal Application For Public Law 102-477

  • Have you received or are receiving any of the services listed in page 1 within the last 3 months?*

  • 1. TANF/GA applications are valid for 30 days following the application date. The eligibility determination-approval or denial must be completed within this 30 day time period. This time limitations serves to protect the applicant's right to receive benefits in a timely basis.

    2. General Rule: Individuals who are applying for TANF or GA are required to be interviewed face­to-face. That interview can be conducted in the BTT /GA offices. Exceptions: Currently due to COVID-19 office closure to the public telephone interviews are available.

    3. Child Care/ Adult/Youth (WIOA) applications are valid for 90 days following the application date. The eligibility determination-approval or denial-must be completed within this 90 day period Interview: After your application is filled it can be turned into the Manpower office to the receptionist and they will give you an appointment once the application is date stamped. Your eligibility will not be determined until the application is completed and all required verifications have been turned in, this applies to all programs.

    4. Child Care applicant must provide verification of Blackfeet Enrollment or Blackfeet descendant to be eligible. Verification of Work, School, and training or job search must be verified. Self­employment, if an applicant is self-employed, their taxes from the prior year will be taken into account for eligibility purposes.

    5. General Assistance is designed to temporarily shelter assistance while an eligible individual is looking for work and transitioning to self-sufficiency.

    6. General Assistance, is like TANF, is based on individual completing certain number of work hours consist of completing social security requirements, all medical appointments, and meeting all hearting requirements.

    7. All General Assistance and TANF Cases will be closed/suspended/sanctioned if a client does not complete the work hours (Job Search, completed job applications, required referral to: Job Readiness Training (JRT); Fatherhood/Motherhood is sacred training; HI-SET (GED study and any other requirements set forth in their employability plan.

    8. Reporting requirements: It is your responsibility of all financial assistance applicants to report! and present appropriate documentary verification of any and all changes that may occur in their income or living arrangements. For TANF clients are required to report within 10 days from the date of the change, as for GA you are required to report any changes that might affect your eligibility immediately to your case manager whenever there is a change in household composition, income (earned/unearned), resources, etc.

  • Blackfeet Manpower Universal Application For Public Law 102-477

    APPLICATION FOR SERVICES

  • Fill in all required blanks for each adult who lives with you, either permanently or temporarily.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you live within the boundaries of the reservation?*
  • Are you Homeless?*
  • Are you pregnant?*
  • Date of Birth:*
     - -
  • Gender:*
  • Marital Status:*
  • Highest level of education:*
  • Are you a Veteran?*
  • For Male applicants 18 to 25, did you register with the Selective Services System?*

  • To be eligible for the 477 services, you must register online at www.sss.gov or at the local post office.

  • Add another person who lives with you, either permanently or temporarily?:

  • Fill in all required blanks for everyone who lives with you, either permanently or temporarily.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you live within the boundaries of the reservation?*
  • Are you Homeless?*
  • Are you pregnant?*
  • Date of Birth:*
     - -
  • Gender:*
  • Marital Status:*
  • Highest level of education:*
  • Are you a Veteran?*
  • For Male applicants 18 to 25, did you register with the Selective Services System?*

  • To be eligible for the 477 services, you must register online at www.sss.gov or at the local post office.

  • Add another person who lives with you, either permanently or temporarily?:

  • Fill in all required blanks for everyone who lives with you, either permanently or temporarily.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you live within the boundaries of the reservation?*
  • Are you Homeless?*
  • Are you pregnant?*
  • Date of Birth:*
     - -
  • Gender:*
  • Marital Status:*
  • Highest level of education:*
  • Are you a Veteran?*
  • For Male applicants 18 to 25, did you register with the Selective Services System?*

  • To be eligible for the 477 services, you must register online at www.sss.gov or at the local post office.

  • Add another person who lives with you, either permanently or temporarily?:

  • Fill in all required blanks for everyone who lives with you, either permanently or temporarily.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you live within the boundaries of the reservation?*
  • Are you Homeless?*
  • Are you pregnant?*
  • Date of Birth:*
     - -
  • Gender:*
  • Marital Status:*
  • Highest level of education:*
  • Are you a Veteran?*
  • For Male applicants 18 to 25, did you register with the Selective Services System?*

  • To be eligible for the 477 services, you must register online at www.sss.gov or at the local post office.

  • Add another person who lives with you, either permanently or temporarily?:

  • Fill in all required blanks for everyone who lives with you, either permanently or temporarily.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Do you live within the boundaries of the reservation?*
  • Are you Homeless?*
  • Are you pregnant?*
  • Date of Birth:*
     - -
  • Gender:*
  • Marital Status:*
  • Highest level of education:*
  • Are you a Veteran?*
  • For Male applicants 18 to 25, did you register with the Selective Services System?*

  • To be eligible for the 477 services, you must register online at www.sss.gov or at the local post office.

  • Blackfeet Manpower Universal Application For Public Law 102-477

    APPLICATION FOR SERVICES
  • Rows
  • Are you applying for child care?:*

  • If you are applying for child care assistance complete Child information below:

  • Children eligible for program benefits (under the age of 13)

  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Any children not eligible for program benefits (age 13 or older)*

  • Children not eligible for program benefits (age 13 or older)

  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Add Another?:
  • Date of Birth*
     - -
  • Any children living in the household with physical or mental handicap?:*

  • Children living in the household with Physical or Mental Handicap list below:

  • Add Another?:
  • Add Another?:
  • Add Another?:
  • Add Another?:

  • Blackfeet Manpower Universal Application For Public Law 102-477

    INCOME
  • Is anyone in the household currently working or have they worked in the last 4 months? If yes, please list persons who are working or have worked.*

  • If yes, please list persons who are working or have worked.

  • EMPLOYMENT-EARNED INCOME

    IF YES, complete for each household member. If this applies to you, start with yourself first. If a household member has more than one job, list each jobs separately. Employment must be verified by your employer before this application can be processed. If you have copies of your paycheck stubs within the last 30 days, attach them to the application. If you do not have any information about your employment, you will be asked to provide it at a later date and Tribal TANF caseworker can help you get it. It is very important that you report all income so that you avoid having to repay any benefits received incorrectly.

  • Format: (000) 000-0000.
  • Add Another Employed Member of your household
  • Format: (000) 000-0000.
  • Add Another Employed Member of your household
  • Format: (000) 000-0000.
  • Add Another Employed Member of your household
  • Format: (000) 000-0000.
  • Add Another Employed Member of your household
  • Format: (000) 000-0000.
  • Add Another Employed Member of your household
  • Format: (000) 000-0000.

  • Self Employment

  • Do you or anyone in your household operate your own business or are self-employed? (For example, Babysitting, etc.,*

  • If yes, complete and attach the self-employment ledger. Your caseworker can provide you with a copy of the self-employment ledger. 

  • Blackfeet Manpower Universal Application For Public Law 102-477

    OTHER INCOME
  • Do you or anyone in your household currently receive other income, or have received other income in the last 30 days?*

  • If yes, complete below for each household member. If this applies to you, start with yourself first. Other income must be verified to process your application. If you have any of the below, attach it to your application. If you don't have this information, you will be asked to provide it at a later date and the Tribal TANF worker will help you get it. 

  • Other income type:*
  • Add Another:
  • Other income type:*
  • Add Another:
  • Other income type:*
  • Add Another:
  • Other income type:*
  • Add Another:
  • Other income type:*
  • Add Another:
  • Other income type:*

  • Blackfeet Manpower Universal Application For Public Law 102-477

    RESOURCES: For all household members

  • Resources

  • Do you or anyone in your household have checking accounts, savings accounts, certificates of deposit, stocks, savings bonds, trusts or and other investments?*

  • If yes, complete for each household member. If this applies to you, start with yourself first. Resources (i.e. checking account) must be verified to process your application. If you have this information, attach it to this application.

  • If this is a joint account, do you contribute?*
  • Add Another:
  • If this is a joint account, do you contribute?*
  • Add Another:
  • If this is a joint account, do you contribute?*
  • Add Another:
  • If this is a joint account, do you contribute?*
  • Add Another:
  • If this is a joint account, do you contribute?*
  • Add Another:
  • If this is a joint account, do you contribute?*

  • Property Owned

  • Do you or anyone in your household own a car, truck, motorcycle, or recreational vehicle?*
  • Do you own it with someone else?:*
  • Can you use it?:*
  • Add Another:
  • Do you or anyone in your household own a car, truck, motorcycle, or recreational vehicle?*
  • Do you own it with someone else?:*
  • Can you use it?:*
  • Add Another:
  • Do you or anyone in your household own a car, truck, motorcycle, or recreational vehicle?*
  • Do you own it with someone else?:*
  • Can you use it?:*
  • Add Another:
  • Do you or anyone in your household own a car, truck, motorcycle, or recreational vehicle?*
  • Do you own it with someone else?:*
  • Can you use it?:*
  • Add Another:
  • Do you or anyone in your household own a car, truck, motorcycle, or recreational vehicle?*
  • Do you own it with someone else?:*
  • Can you use it?:*
  • Add Another:
  • Do you or anyone in your household own a car, truck, motorcycle, or recreational vehicle?*
  • Do you own it with someone else?:*
  • Can you use it?:*

  • Blackfeet Manpower Universal Application For Public Law 102-477

    AUTHORIZED REPRESENTATIVE
  • I want someone over age 18 to apply for benefits or act on my behalf, called an "Authorized Representative"*

  • If yes, please download this form and upload it with your application or drop it off at the manpower office. 

  • Authorized Representative's Date of Birth
     - -
  • Format: (000) 000-0000.
  • Check one

  • Declarations 

    List all household members and answer “yes” for anyone tried as an adult or who had a trial scheduled. If the question does not apply, answer “No”. Start with yourself first.

  • Have you or any member of your household ever been convicted of fraudulently receiving duplicate TANF Cash benefits in any State after 9/22/96*
  • Have you fled to avoid prosecution, custody, or jail for a crime that is a Felony?*
  • Are you violating a condition of probation or parole?*
  • Have you been convicted in a Federal or State court of a Felony committed after August 22, 1996 related to illegal possession, use, or distribution of a controlled substance?*
  • Add Another:
  • Have you or any member of your household ever been convicted of fraudulently receiving duplicate TANF Cash benefits in any State after 9/22/96*
  • Have you fled to avoid prosecution, custody, or jail for a crime that is a Felony?*
  • Are you violating a condition of probation or parole?*
  • Have you been convicted in a Federal or State court of a Felony committed after August 22, 1996 related to illegal possession, use, or distribution of a controlled substance?*
  • Add Another:
  • Have you or any member of your household ever been convicted of fraudulently receiving duplicate TANF Cash benefits in any State after 9/22/96*
  • Have you fled to avoid prosecution, custody, or jail for a crime that is a Felony?*
  • Are you violating a condition of probation or parole?*
  • Have you been convicted in a Federal or State court of a Felony committed after August 22, 1996 related to illegal possession, use, or distribution of a controlled substance?*
  • Add Another:
  • Have you or any member of your household ever been convicted of fraudulently receiving duplicate TANF Cash benefits in any State after 9/22/96*
  • Have you fled to avoid prosecution, custody, or jail for a crime that is a Felony?*
  • Are you violating a condition of probation or parole?*
  • Have you been convicted in a Federal or State court of a Felony committed after August 22, 1996 related to illegal possession, use, or distribution of a controlled substance?*
  • Add Another:
  • Have you or any member of your household ever been convicted of fraudulently receiving duplicate TANF Cash benefits in any State after 9/22/96*
  • Have you fled to avoid prosecution, custody, or jail for a crime that is a Felony?*
  • Are you violating a condition of probation or parole?*
  • Have you been convicted in a Federal or State court of a Felony committed after August 22, 1996 related to illegal possession, use, or distribution of a controlled substance?*

  • Blackfeet Manpower Universal Application For Public Law 102-477

    PENALTIES: TANF/GA CASH ASSISTANCE SERVICES:
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  • REQUIRED FOR ALL 477 PROGRAMS:

    I understand the questions on this application and the penalty for withholding or giving false information or breaking any of the rules listed in the penalty warning.  I understand and agree to provide documents to prove what I have said.  I understand and agree that the Agency may contact other persons or organizations to obtain necessary verification of any statement on this application.   By signing below, I certify under penalty of perjury, that all my answers are correct and complete to the best of my knowledge, including information about the citizenship of each household member.

  • Date*
     - -
  • Add Another Applicant
  • Date*
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  • Add Another Applicant
  • Date*
     - -
  • Add Another Applicant
  • Date*
     - -
  • Add Another Applicant
  • Date*
     - -
  • Should be Empty: