FY26 Assistance Application

FY26 Assistance Application
Low Income Home Energy Assistance Program (LIHEAP) Community Services Block Grant (CSBG)
Required Documents
Please attach copies of the following with your application:
• Certificate of Degree of Indian Blood (CDIB) for at least one household member (LIHEAP).
• CDIBs for all Cheyenne and Arapaho tribal members in the household (CSBG).
• Current original utility bill (electric, propane, or gas). Applicant name must match the name on the bill.
• Proof of income for all household members over 18 years of age (check stubs, SSI/SSA/VA award letters, etc.).
• Notarized no-income statements for any adult household member with no income.
Service Request (Check One or More)
Do you reside within the 11 -county service area?
ONLY CSBG CAN ASSIST IN OKLAHOMA COUNTY (Tribal members only).

Head of Household Applicant Information
Date:

MonthDayYear
Date
Phone:

Area CodePhone Number
Full Name (Head of Household):

First NameMiddle NameLast NameSuffix
Date of Birth:

MonthDayYear
Date
Age:
Social Security #:
Home/Service 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

Household Members:

Rows	Name:	DOB:	Age	Sex: M/F	Race/ Ethnicity	SSN	Tribal Affiliation	Elderly (E) Handicapped (H) Disabled (D)	Employed? (Y/N)
Member
Member
Member
Member
Member

Household Income - List amount of income earned each month by each adult household member and attach proof of income:

Rows	Name:	Source of Income: employment /SSI/ Disability	Monthly Amount	Proof Attached (Y /N)
Member
Member
Member

No Income Statement (if applicable)
I ______________________________________ currently do not receive any monetary income because.
Client Signature:
Date

MonthDayYear
Date
Notary Public:
Commission #:
My Commission Expires:
SEAL
Applicant Certifications:
Applicant Signature
Date:

MonthDayYear
Date
Electronic Document Uploads

Browse Files

Cancelof
Please Submit Applications and Documents to:

https://cheyenneandarapaho-nsn.gov/

Cheyenne and Arapaho Tribes

Social Services Program

P.O. Box 38

Concho, OK 73022

405-422-7476

Email - socialservices@Cheyenneandarapaho-nsn.gov
Client Feedback Survey (10 Questions)
1. How satisfied are you with the overall LIHEAP assistance you received?
2. How easy was the application process to understand and complete?
3.Were the program staff respectful, helpful, and responsive during your application process?
4. How long did it take from submitting your application to receiving services?
5. Did LIHEAP assistance help reduce your household’s energy burden (for example, preventing disconnection or improving comfort/safety)?
6. What type of energy assistance did you receive?

Other
7. What barriers, if any, did you experience when applying for LIHEAP?

Other
8.How comfortable did you feel working with the Tribal Social Services Program?
9. What additional services or support would you like the LIHEAP program to offer?
10. Would you recommend the Tribal LIHEAP Program to other community members?
Should be Empty: