General Assistance

General Assistance
Application Checklist :
A checklist must accompany each application sent in. Be sure to complete all of the necessary information in order for your application to be processed. Your application will remain active for ten (10) days in order to give you the opportunity to collect the documentation needed. After ten (10) days, the application will be inactive. Please use the checklist below and complete the application as thoroughly as possible so a delay in the application process will not occur.
Tribal Verification

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A Valid State I.D.

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Social Security Card

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Proof of Handicap or Disability

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Enrollment in Program or other appropriate verification to qualify for the program (based on attached unemployable definitions)

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Income Verification for all Household Members (18 years and older)

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Denial from County General Relief Office and any other appropriate denials (TANF, Social Security, County Aid, etc.)

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Social Security Administration verification along with application

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*NOTIFICATION TO CLIENT*
In order to be eligible for General Assistance (GA), you must be unemployable. You must apply for services from the state or county before you may receive Yurok General Assistance. We may be able to assist during the interim period if you can provide documentation that you have an application pending with another program. You cannot already be receiving supplemental Social Security Income (SSI) or Temporary Assistance to Needy Families (TANF).

If denied from another program, you must prove it was for good cause or we cannot assist you. To qualify for GA, the Social Service staff must first get information about you and your household, which includes all income. We are required by law to check with other agencies to ensure services are not being duplicated. A home visit may be necessary to verify residency.
All applicants must currently live in the designated tribal service area of Humboldt and Del Norte Counties and have been a resident for at least 3 months.
You may be required to verify disabilities if it prevents you from seeking work. A signed Physician’s statement is necessary. It should also state the length of time you will be unable to work.

The amount you may receive for GA is based on State standards of public assistance less your income and resources. The information you give must be accurate. If your circumstances change, you must report it to the Social Services Department within ten (10) days. If there are no changes, you must have a re-determination within ninety (90) days. If you are granted, a written notice will be sent to you. A date for re-evaluation will also be included. If you fail to respond by that date, you must re-apply for services.

When you file an application for GA you have a right to a written decision within thirty (30) days. If you disagree with the decision, you have the right to file an appeal within ten (10) days. The penalty for knowingly and willfully concealing or giving false information may result in being denied assistance for one year plus paying back all funds received. This program will continue until funding is depleted or the fiscal year ends.

	$ Amount
AFDC
SSI
Social Security
Wages
Unemployment Benefits
Veterans Benefits
Other

	$ Amount
Rent
Utilities
Food

Certification:

By signing this document I am certifying that all information provided orally and on this form are true and correct to best of my knowledge. I acknowledge that such information is subject to verification and that falsifying of this information shall be grounds for denial, sanction for one year and reimbursement of any and all funds received from this program.
Signature*

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Date*

MonthDayYear
Date
*PLEASE DESCRIBE YOUR SITUATION**
Please list your permanent address below:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature*

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*AUTHORIZATION TO RELEASE INFORMATION*
IFull Name* hereby authorize Yurok Social Services, a department of the Yurok Tribe, and the organizations and/or individuals indicated below by my initials to release and receive information concerning my case and/or the case of my dependent(s) named below. I have been informed of the type of information to be requested and released.
Initial* Department of Health and/or Social Services of blank* County.
Initial United Indian Health Service and/or the following clinics and health programs: blank
Initial Juvenile and/or Dependency Court of blank County.
Initial The following school (s) blank
Initial Otherblank
Initial My dependents who are covered by this release are:blank
InitialI hereby release the Yurok Tribe and its agents and employees from any/all liabilities, responsibilities, damage and claims which might result from release of information authorized above.
InitialI understand that the above consents are subject to revocation by me at any time, expect to the extent that action has been taken in reliance on this consent prior to revocation.
Social Security Number (SS#)*
Date of Birth (DOB)*

MonthDayYear
Date
Date*

MonthDayYear
Date
Signature*

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	Name	Relationship	DOB	Tribal Affiliation	Enrolled Member (Yes or No)	Social Security #
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General Assistance

Application Checklist :

*NOTIFICATION TO CLIENT*

All applicants must currently live in the designated tribal service area of Humboldt and Del Norte Counties and have been a resident for at least 3 months.

Certification:

Please list your permanent address below:

*AUTHORIZATION TO RELEASE INFORMATION*

NOTIFICATION TO CLIENT

AUTHORIZATION TO RELEASE INFORMATION