Emergency Assistance Application

Emergency Assistance Application
The Emergency Assistance program offers limited financial support to Yurok Tribal members experiencing household crises. Its purpose is to help stabilize families during urgent times of need, with priority given to households that include elders or children. All Yurok Tribal Elders are eligible regardless of income, while other Tribal members must live on the reservation or within the service area and meet income guidelines at or below 150% of the federal poverty level. Assistance is available to those who have no other resources to meet their emergency needs. Services may include help with food, hygiene, and clothing; emergency fuel or utility payments; rent or mortgage support; car or home repairs; and medical transportation for those needing care outside the service area or far from their residence.
Application Checklist

Tribal VerificationW9 for VendorIncome Verification for all Household Members 18 years and older. (Last 30 days of income, Passport to Services, most recent award letter for Social Security, Retirement, Disability, Unemployment, or Child Support)If Requesting Utilities: All pages of power/propane bills.If Requesting Car or Home Repairs: Provide 2 quotes, or if reimbursement provide receipts for repairs.If Requesting Rent or Mortgage Assistance: Provide bill or written statement, and W9 for landlord.If Requesting Out-of-Area Medical Travel: Provide either receipts or hotel stay for reimbursement, or proof of out-of-area medical appointment.
Tribal Verification

Cancelof
W9 for Vendor

Cancelof
Income Verification for all Household Members 18 years and older. (Last 30 days of income, Passport to Services, most recent award letter for Social Security, Retirement, Disability, Unemployment, or Child Support)

Cancelof
If Requesting Utilities: All pages of power/propane bills.

Cancelof
If Requesting Car or Home Repairs: Provide 2 quotes, or if reimbursement provide receipts for repairs.

Cancelof
If Requesting Rent or Mortgage Assistance: Provide bill or written statement, and W9 for landlord.

Cancelof
If Requesting Out-of-Area Medical Travel: Provide either receipts or hotel stay for reimbursement, or proof of out-of-area medical appointment.

Cancelof

Is there a child 5 yrs or younger in the Household?*

YesNo
Is there a person with a disability in the Household?*

YesNo

Monthly Income (all household members including yourself over 18): *

	Name	Amount
Wages/Employment
TANF/CALWORKS
Social Security/SSI
Unemployment
Veteran Benefits
Pension/Retirement
Other

Total Monthly Amount of Chart Above*
Emergency Assistance (select one only): An emergency is an urgent, sudden, and serious event or an unforeseen change in circumstances that necessitates immediate action to remedy harm or avert imminent danger to life, health, or property; an exigency.*

Emergency Food/Clothing/Hygiene- Assistance with purchasing food, hygiene, and clothing.Emergency Utilities- including fuel and energy bills to offer emergency assistance to tribal members with no other resources to make energy related payments and repairs, emergency health issues, etc.Emergency Housing – Rent/Mortgage Assistance- to combat crisis including emergency rental assistance, intervention with landlords/Housing/Financial Institutions to Tribal members with no other resources at the time to make shelter paymentsEmergency Vehicle/Home Repair- to provide emergency car or home repair to Tribal members with no other resources for such need.Emergency Medical Transportation (outside of area)- to provide emergency medical assistance to Tribal members with no other resources to get to medical facilities outside the Yurok Tribe's service area of Humboldt, Del Norte, and Trinity counties, or 75 miles from residence if within the service area. Assistance also include travel, food, lodging. or medical supplies needed for medical crisis.
Explanation of Emergency: *

Emergency Assistance Acknowledgements & Authorization to Release Information:
I understand that I will be required to provide verification of emergency situation, including, but not limited to; Utility bills, rental/mortgage documentation, Past Due/Shut Off Notice, Eviction Notice, Cost Estimates for repairs, W-9 for Vendors, etc.
I understand that receipts MUST be submitted to the Client Services Dept. within 5 business days of using vouchers if requested by staff.
I am the only person in my household who has applied for Emergency Assistance.
I understand my application will remain active for ten (10) days in order to give me the opportunity to collect the documentation needed. After ten (10) days, the application will be inactive and I will need to re-apply again if assistance is still needed.
I hereby release the Yurok Tribe and its agents and employees from any/ all liabilities, responsibilities, damages and claims which might result from release of information authorized above.
I authorize Client Services Department, a department of the Yurok Tribe, and the organizations and/or individuals indicated below by to release and receive information concerning my case and/or the case of my dependent(s) named above in direct relation to service provided under as indicated in this application, including the reporting agency. I have been informed of the type of information to be requested and released.
Applicant Signature*

Clear
Date of Signature*

MonthDayYear
Date
Co-Applicant Signature

Clear
Please verify that you are human*
Date of Co-Applicant Signature

MonthDayYear
Date
Should be Empty:

	Name	Relationship	DOB	Age	Tribal Roll #
1
2
3
4
5
6
7
8
9
10

Emergency Assistance Application

Emergency Assistance Acknowledgements & Authorization to Release Information: