Non-Recurring Short-Term Benefits (NRSTB) Application

Non-Recurring Short-Term Benefits (NRSTB) Application
The TANF program administered by the Yurok Tribe, referred to as the Yurok Tribal TANF Program (YTTP), provides limited emergency assistance to eligible needy Native American families with child(ren) and caretakers/relatives caring for Native American child(ren) for episodes of need during natural disasters, pandemics, and state of emergency declarations. YTTP requires this application and supplemental documents to determine your family’s eligibility for emergency services.

NRSTB has a lifetime cap of $5,000 per household and is only for non-recurring episodes of emergency. We keep all information private and secure, as required by law. You have the right to appeal your decision and the review will be completed within 10 business days.
• Custody of minor children (under the age of 18)
• Expectant Native parent(s) may be eligible in the 3rd
• trimester of pregnancy.
• Have not already received NRSTB funds from Yurok Tribal TANF Program, other tribes, or agencies.
• Household income is less than 300% FPL (Net income).
• U.S. Citizen or eligible alien status
• Physically reside in Humboldt or Del Norte County except for Hoopa Valley (commonly known as the Hoopa square), at least one member of household is enrolled Yurok. Enrollment in other federally recognized tribal households’ enrollment is allowable if living on the Yurok reservation.

NRSTB Acknowledgement
Dear NRSTB Applicant:

The TANF program administered by the Yurok Tribe, referred to as the Yurok Tribal TANF Program (YTTP), provides limited emergency assistance to eligible needy Native American families with child(ren) and caretakers/relatives caring for Native American child(ren) for episodes of need during natural disasters, pandemics, and state of emergency declarations. YTTP requires this application and supplemental documents to determine the eligibility of your family for emergency services.
NRSTB has a cap of $5,000 per household and is only for non-recurring episodes of emergency pending availability of funds.

NRSTB is for a singular crisis episode for families to avoid reliance for ongoing expenses through government funded programs. It is the applicant’s responsibility to demonstrate a need. Payments will be provided directly to the applicants chosen vendor(s) with completed W-9 and quote/receipts to address emergency crisis. Payments will not be made directly to the applicant unless under extraordinary circumstances and approved by the TANF Manager.

NRSTB applications will be notified by TANF staff regarding all payments. It is imperative that NRSTB applications do not contact the Yurok Tribe Fiscal Department. We keep all information private and secure, as required by law. You have the right to appeal your decision within 10 business days of receipt of denial letter through written correspondence. Upon receipt of the appeal, the TANF Manager has 10 business days to respond to your appeal through written correspondence.
I, Name* acknowledge under penalty of perjury, under the laws of the United State of America and the State of California, I swear and affirm that the information provided on this application is true, correct, and complete. I will undergo a sanction and be required to return any benefits received if my information is not true. Sanctions may include administrative, civil, or criminal actions against me, including prosecution.
Signature*

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Date*

MonthDayYear
Date

NRSTB Application

Section I- Contact Information
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Section II: Family Unit- Please provide information for all household members.

18+ Years Household Members*

	Full Name	DOB	Tribal Affiliation	Relationship to Applicant
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Children in a shared custody must be in applicants’ residence at least 51% of the time. *

	Full Name	DOB	Tribal Affiliation	Relationship to Applicant
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Section III- Household Income-

Please tell us about the household current income and employment situation for all adults (18+), including paid internships, paid work experience programs, tips, etc.; include no income verification form if there is no earned income. Include other sources of income you are currently receiving, including financial aid, TANF, CalFresh, CalWORKs, SSDI, EDD, SSI, EDD, Per Capita Payments, Child Support, Social Security, Retirement, Survivor’s Benefits etc.

	Name of Person With Income	Employer and/or Benefits Type	Amount Received Monthly	Will this end within the next 30 days? (Yes/No)
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Section IV- Demonstration of Need- Please provide a description with supportive documentation to confirm your need in crisis.
I, Full Name* am requesting $ Amount*
I am applying for one of the following NRSTB purposes (pick one):*

State of EmergencyNatural DisasterPandemicOther
Description of crisis/need:

Applicant Checklist

To process your application as efficiently as possible, please utilize this application checklist to ensure you have all documents required when submitting your application.
Upload for All Household Members:
Valid Photo Identification (adults, 18+ only)

Cancelof
Birth Certificates

Cancelof
Tribal ID’s or Verification from Enrollment; If any household member is enrolled with a different tribal entity, verification of enrollment must be provided.

Cancelof
Social Security Cards

Cancelof
Proof of Physical Residency (Utility bill, rent, or mortgage with applicant’s name and address on it)

Cancelof
Previous month of Income/No Income Verification

Cancelof
W-9 for Vendors

Cancelof
Receipts of purchases & invoices. If purchases have not been made yet, quotes are accepted with receipts returned within 10 business days.

Cancelof
Child Custodial Guardianship (if applicable)

Cancelof
3rdd Trimester Pregnancy Confirmation (if applicable)

Cancelof
Signature*

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Non-Recurring Short-Term Benefits (NRSTB) Application

NRSTB Acknowledgement

NRSTB Application

Section II: Family Unit- Please provide information for all household members.

Section III- Household Income-

Section IV- Demonstration of Need- Please provide a description with supportive documentation to confirm your need in crisis.

Applicant Checklist

Upload for All Household Members: