FY24 Assistance Application

LIHEAP assists Native Americans within the service area with assistance towards utility bills. (Gas, electric, propane, wood) If there are a surplus of funds from the cooling and heating season left individual AC window units and portable heater units will be purchased. This service is not guaranteed.

CSBG assists Cheyenne and Arapaho tribal members with temporary emergency assistance with utilities that have been disconnected and need to be restored. CSBG also assists with emergency food and emergency gas cards for major medical appointments.

In order to qualify for the LIHEAP/LIHWAP program, at least one (1) household member must be a member of a federally recognized American Indian or Alaska Native tribe. In order to qualify for CSBG program all members of the household must be enrolled or eligible for enrollment Cheyenne and Arapaho tribal members. All households must provide complete documentation so that the caseworker may determine the applicant’s eligibility.

Please see the following page for a complete checklist of the required documents that are needed to process an application. It is the applicant’s responsibility to provide all necessary documents.

Must Select Service Applicant is applying for:*

ELECTRIC/PROPANE/GAS UTILITY ASSISTANCE (LIHEAP)WEATHERIZATION (PORTABLE HEATER , OR AC UNIT) (LIHEAP)EMERGENCY UTILITY SERVICES (DISCONNECT/TURNED OFF) (CSBG)EMERGENCY FOOD CARDS (CSBG)EMERGENCY MEDICAL GAS CARDS (CSBG)

Do you reside within the 11 county service areas?*

YesNO

ONLY CSBG CAN ASSIST IN OKLAHOMA COUNTY

REQUIRED DOCUMENTS:

· CDIB for at least one (1) member of the household (LIHEAP/LIHWAP)
CDIBs for all C&A members (CSBG)
Current, Original Utility Bill* (Water, Electric, Propane, or Gas)
Proof of Income for all Household Members over Eighteen (18) Years of Age**

*Applicants Name must match the name on the utility bill

**Check stubs, and SSI/SSA/VA award letters must be included in the proof of income.

All no-income statements must be signed in front of notary.

In order to expedite your application process, please provide all necessary documents.

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 caseworker if you need assistance filling out an application or if you have any questions.

*Applicant Must Be Head of Household*

Date:*

Date

Full Name:*

First NameMiddle NameLast NameSuffix

Birth Date:*

Date

Age:*

Social Security #:*

Home/Service Address:*

Street Address

Street Address Line 2

City

Postal / Zip Code

Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone:*

Area CodePhone Number

Email:

example@example.com

List All Household Members:

	Name:	DOB:	Age	Social Security#:	Tribe:	Elderly, Handicapped, Or Disabled?	Employed?
Member
Member
Member
Member
Member

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. List amount of income earned each month:

	Name:	Hourly Wage	Payment Schedule:	Other:
Member
Member
Member

Please list any other assistance that you receive.

	Source of Assistance:	Award Amount:	Payment Schedule:
Member
Member

Please attach award letters for benefits received to your completed application.

Please list any additional income on an additional page and attach any check stubs.
Other assistance (SSI, Disability, etc.) can be accounted for on page 5.
If household members over eighteen (18) years of age are not receiving income, please fill out a "No Income Statement" and upload.

Browse Files

**No Income Statement Download Here**

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 LIHEAP services could be suspended.I understand that my application will notbe processed until all required documentation is submitted.I understand that my application will take up to 3 work days to process or up to two (2) weeks for vendor checks to be processed by A.P. department.I authorize the Cheyenne & Arapaho Tribes’Department of Social Services to acquire any information that is necessary to complete my application.I understandthe Cheyenne & Arapaho Tribes’ Social Service Program is not responsible for damage or repair to heater/ac units and/or fans.

Applicant is applying for:

ELECTRIC/PROPANE/GAS UTILITY ASSISTANCE (LIHEAP)WEATHERIZATION (portable heater, or ac unit) (LIHEAP)EMERGENCY UTILITY SERVICES (DISCONNECT/TURNED OFF) (CSBG)EMERGENCY FOOD CARDS (CSBG)EMERGENCY MEDICAL GAS CARDS (CSBG)

If you have read, understand, and agree to the terms above, please sign below:

Client Signature*

Date*

Date

Please Submit or Request Applications and Documents to:

https://cheyenneandarapaho-nsn.gov/

Cheyenne and Arapaho Tribes

Social Services Program

P.O. Box 38

Concho, OK 73022

405-422-7476

Email - socialservices@Cheyenneandarapaho-nsn.gov

Fax –

405-422-8218

Have you used LIHEAP in the past?*

YesNo

Would you or your family be interested in attending events focused on DIY weatherizing of your home?*

YesNo

Would you liketo see more educational information on reducing energy costs?*

YesNo

Would you be interested in attending budgeting classes?*

YesNo

In which age category do you belong?*

18-2930-4950-5960 years or older

How many are in your household size?*

1-32-55 or more

What are some ideas you would like to see with the LIHEAP program?*

Other Comments/Ideas: *