TANF Application

TANF Application
Yurok Tribal Households with eligible children residing within the YTTP Service Area of Humboldt and Del Norte Counties may be eligible for services. Service Area excludes other reservations or rancheria territories. Other Federally Recognized Tribal Households residing within the Yurok Tribal Reservation boundaries may be eligible for services.

If you have been convicted of a felony drug or domestic violence charge within the past two years and have not completed a treatment program you will not be eligible to receive Tribal TANF assistance. If you have completed a certified treatment program you must provide proof of completion.
Name*

First NameLast Name
REQUIRED VERIFICATION DOCUMENTATION The following verifications are required when you apply for assistance:
Tribal Verification

Cancelof
Valid California Driver License or California Identification Card

Cancelof
Certified Birth Certificates

Cancelof
Social Security Cards

Cancelof
Proof of Income (Earned Income/Unemployment/Disability/SSI)

Cancelof
Proof of Residency (Current Utility Statement)

Cancelof
Immunization Records

Cancelof
Proof of Pregnancy

Cancelof
Automobile Registration / Proof of Insurance

Cancelof
Current Bank Statement

Cancelof
Current Student Enrollment and Attendance Record(s)

Cancelof
Custody/Guardianship

Cancelof
High School Diploma or GED

Cancelof
Other

Cancelof
YOU HAVE THE RIGHT TO APPEAL

The Yurok Tribal TANF Program has an interest in assuring its Program is administered, implemented and enforced non-discriminatorily and consistent with basic principles of justice and fairness. To that end, all applicants, or recipients of services and financial assistance, have the right to appeal all decisions made by the program that affects services or assistance provided to the applicant or recipient. You may submit your request for a hearing before the Program Manager or designee. The request must be in writing and must be made within 10 working days from the date the Notice of Action. (NOA) The request must be signed and dated.

Application for Initial Services12-Month Re-certificationUpdate
Applicant is Applying for:*

Cash AssistanceDiversion ServicesEmployment Services
Previous TANF Client:*

YesNo
Full Name*

First NameLast Name
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
SS#*
Tribal Affiliation:*

Yurok Tribal TANF Program - Application for Assistance

List ALL household members who WILL be utilizing Program services *

	Full Name (First, MI, Last Name)	Social Security Number	DOB	Age	Relationship	Sex	Marital Status	Education (Last grade Completed):
1
2
3
4
5
6
7
8
9
10
11
12

List ALL household members who WILL NOT be utilizing Program services *

	Full Name (First, MI, Last Name)	Social Security Number	DOB	Age	Relationship	Sex	Marital Status	Education (Last grade Completed):
1
2
3
4
5
6
7
8
9
10
11
12

FEDERAL LAW GOVERNING FRAUD:
"Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals, or covers up any trick, scheme, or device, a material fact, or makes any false fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned more than five years or both. "Fraud in the Yurok Tribal TANF Program will lead to a negative and immediate termination from the Program.

I (we) have read, or heard, or have had interpreted to me (us) the proceeding provisions of law and understand them. I (we) agree to supply all necessary information about my (our) situation changes. I (we) also authorize the Yurok Tribal TANF Program to obtain information to establish my (our) eligibility for assistance. By my (our) signature, I (we) verify that all the above information reported on this application and oral information given is true and correct to the best of my (our) knowledge.
Signature of Applicant:*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Signature of Spouse/Partner of Applicant OR Parent of a Minor Applicant:

Powered by Jotform SignClear
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

	Full Name	Source	Type	Amount	Date Last Received	Still Receiving?
1
2
3
4
5
6
7
8
9
10

	Employer's Name & Address	Area Code & Phone Number	Supervisor's Name	Type of Work	Dates of Employment	Reason for Leaving
1
2
3
4
5
6
7
8
9
10

TANF Application

REQUIRED VERIFICATION DOCUMENTATION The following verifications are required when you apply for assistance:

YOU HAVE THE RIGHT TO APPEAL

Yurok Tribal TANF Program - Application for Assistance

List ALL household Income & Benefits received in the LAST SIX-MONTHS

FEDERAL LAW GOVERNING FRAUD: