TOR Sober Living Application

Sober Living Assistance Application

1950 S. Shepard El Reno, OK 73036 TOR@cheyenneandarapaho-nsn.gov (405)295-1769
Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Enrolled Cheyenne and Arapaho Tribal Member?

YesNo
CDIB Number
Are you employed?

YesNo
Monthly Income:
Other Income
Are you Currently in Treatment?

YesNo
Recovery Housing Facility Name*
Facility Contact Name
Phone
Have you received recovery housing assistance from TOR before?

YesNo
If so when
Are you currently involved in any 12-Step Recovery Programs? Check all that apply

I'm currently attending AA meetingsI'm currently attending NA MeetingsI attend both AA and NA MeetingsI'm currently attending Wellbriety meetingsI have attended meetings in the past but do not find it helpfulI have never attended 12 step meetings
SobrietyClean Date

MonthDayYear
Date
/ certify that my answers are true and complete to the best of my knowledge. If this application leads to receiving assistance, I understand that false or misleading information in my application may result in not receiving any assistance in the future.
Signature

Clear
Date

MonthDayYear
Date
Recovery housing assistance is available to Cheyenne and Arapaho Tribal Members in Oklahoma that are residing in OKARR certified Recovery Housing Facilities. Recovery Housing assistance is limited to two payments of up to $500 in a calendar year per client.

Payment will be made directly to Recovery Housing Facility. To ensure timely processing of payment please attach all required documentation.
Proof of Recovery Housing Residence*

Cancelof
Proof of OKARR Certification for Recovery Housing Facility

Cancelof
Recovery Housing Facility W-9 for Payment Processing

Cancelof
Your Agreement between recovery Housing Facility stating monthly rent amount*

Cancelof
Copy of CDIB*

Cancelof
Should be Empty: