Kickapoo Tribe of Oklahoma

Tribal code

Ask Donna

What actually matters in this document.

Text

Social Services Department

PO BOX 70

McLoud. OK 74851

(405) 964-4227

Email: socialservices@okkt.net

INTERVIEW DATE: ____________________

APPLICATION FOR FINANCIAL ASSISTANCE AND SOCIAL SERVICES INSTRUCTIONS

Any individual or family may apply for Kickapoo Tribe of Oklahoma Financial Assistance and Social Services by completing the

application process with the assistance of the Social Services worker and providing the following required information: proof of

tribal membership; proof of residency; proof of income and resources. Failing to provide this information may result in denial

of Financial Assistance and Social Services.

DIRECTIONS FOR COMPLETING “APPLICATION FOR FINANCIAL ASSISTANCE AND SOCIAL SERVICES” FORM

Please fill in your NAME/TRIBE/PHYSICAL ADDRESS/PHONE NUMBER/MAILING ADDRESS (if different from physical address)

or provide directions on how to get to your home. Please also respond to the two questions.

Section I: FAMILY PROFILE OF HEAD OF HOUSEHOLD MEMBERS APPLYING

Under Family Profile, fill in the following information to the best of your ability. First, start with yourself. Please fill in your

name (Last, First, Middle), Date of Birth (mm/dd/yyyy), Sex (M/F), your marital status, the highest education level received,

Social Security Number, and finally your Tribal Enrollment Number. Next, complete the names of the total members of the

household starting with your spouse and then children in descending order of age. For each member list the birth date, sex, and

relation to the head of household, marital status, highest education received, Social Security Number, and Tribal Enrollment

number. If you are living in a household with more than one (1) family, list the family members that fall under your household.

Section II: TYPES OF FINANCIAL ASSISTANCE AND SOCIAL SERVICES

Put a check mark in the boxes for the services you are applying. This will assist your Social Services worker in determining

which portions of the application you will need to complete.

Section III: EARNED & UNEARNED INCOME

All income, including earned and unearned income, for yourself and any other person in your household, is to be listed on the

application. You are required to provide proof of income.

Earned Income

is cash or any in-kind payment earned in the form of wages, salary, commissions, or profit by an employee or self-employed

individual. This includes one-time payments for ongoing activities such as sale of crops or sale of art-work. Self-employed

individuals must report profits from business enterprises (gross receipts minus business expenses included in the production of

goods or services). Business expenses do not include depreciation, personal transportation costs, capital equipment purchases

or principal payments on loans for capital assets or durable goods. (25 CFR §20.308)

Unearned Income

includes but is not limited to; interest, royalties, gaming income or other per capita distribution not excluded by federal statue,

rental property, cash contributions such as child support or alimony, gaming winnings, retirement benefits, annuities, veteran’s

disability, unemployment benefits, and tax refunds. Other types of unearned income include financial assistance from

government agencies, income from sale of trust land or other real or personal property set aside for investment in trust land

that has not been reinvested in trust land or a sale of a primary residence that has not been reinvested in a primary residence at

the end of one year from the date the income was received, and in-kind contributions providing free shelter up to the 25% of the

amount for shelter included in the state standard. (25 CFR §20.309).

Under Section II and Section III please complete questions 1-4 to the very best of your ability based on the information provided

above. If you are unsure of the question please ask your Social Services worker for assistance or clarification.

Section IV: STATEMENT OF COOPERATION

The Statement of Cooperation is a confirmation of your understanding of the provisions of the Federal Law governing fraud, and

you agree to supply information regarding resources and income and to notify the agency of any change in your living situation.

Also you must sign the Release of Information authorizing the Social Services Program to obtain and/or exchange information

necessary to establish eligibility for Financial Assistance and Social Services.

IF YOU NEED CLARIFICATION OR HAVE ANY QUESTIONS, PLEASE ASK YOUR SOCIAL SERVICES WORKER

CHECKLIST

Copies of all CDIB cards, Driver’s License, Social Security cards, Birth Certificates:

a. Copy of court custody/divorce decree for the children of single parent applying

b. Copy of court guardianship if applicant is not the natural parent

Provide documentation to complete Emergency request (reports, estimates).

Proof of income (Earned and Unearned)

Apply for Food Stamps or Commodities (Must submit letter from DHS/or Commodity Program, if already receiving,

need copy of award letter and card)

Proof of residency (Copy of current Utility bill in your name or post marked mail received within the last 30days. **NO

JUNK MAIL** if you are living with someone else will need a copy of their bill).

Other:___________________________________________________________________________________________________________________________________

_______________

Date

______________________________________

Signature of Applicant #1

_______________

Date

______________________________________

Social Services Worker Signature

_______________

Date

___________________________________

Signature of Applicant #2 (if applicable)

Kickapoo Tribe of

Oklahoma

Social Services

Department

Date of Application: ____________________________

Date of Interview:

____________________________

Decision:

Approved; Date: _____________________

Denied; Date: ________________:

APPLICATION for

FINANCIAL ASSISTANCE and SOCIAL

SERVICES

_________

Initials

_________

Initials

Reason for Denial:

APPLICANT FILL OUT FORM

Name: ___________________________________________________________________________ Tribe/Enrollment Number:____________________________________

Email: _________________________________________________________

Phone Number: ________________________________________________

Mailing Address: ___________________________________________________________________________________________________________________________________

Physical Address: _________________________________________________________________ Cell/ MSG Number: _________________________________________

Provide directions on how to get to your home:________________________________________________________________________________________________

1. Reason for applying for Financial Assistance and Social Services?

2. What type of income have you been living on for the last three (3) months?

Section I: FAMILY PROFILE OF HEAD OF HOUSEHOLD MEMBERS APPLYING (25 CFR §20.308)

Marital

Status

(Married,

Highest

Relation to Single,

Sex

Grade/

Head of Widowed,

(M/F)

Degree

Household Divorced,

Completed

Common

Law,

Separated)

Social

Security

Number

Tribal

Enrollment

Number

Verified

Year

Day

Members of Household

(Last, First, Middle)

Month

Date of Birth

Verified

Fill in all required blanks for everyone who lives with you, either permanently or temporarily. You must list yourself first, then your

spouse and children, then other adults and children. Place an asterisk (*) to the left of each person not included in payment.

SELF

Section II: TYPES OF FINANCIAL ASSISTANCE AND SOCIAL SERVICES (Check type of Assistance or Services applying for)

General Assistance

Burial Assistance

Emergency Assistance

Information & Referral Only

Section III. EARNED INCOME & UNEARNED INCOME (25 CFR §20.308-§20.310)

Is anyone in the household currently working or have they worked in the past 30 days

Yes

If yes, identify Household Member(s) who are working and their earnings:

Household Member # 1 _____________________________________ Amount $: _____________

Household Member # 2 _____________________________________ Amount $: _____________

Household Member # 3 _____________________________________ Amount $: _____________

Do you expect to receive or are receiving any of the following listed below:

Yes

(If yes, put a check mark in the box in front of all unearned income (not from employment) received by any household members, (see box

below; use additional space for further explanation.)

Earned Income

Unearned Income

Wages/ Salary

Amount: $

Supplemental Security Income (SSI)

Amount: $

Alimony/ Child Support

Amount: $

TANF

Amount: $

Gifts/ Contributions

Amount: $

Food Stamps

Amount: $

Income Tax Refund (Federal/State)

Amount: $

Commodities

Insurance Settlement (Auto Accident, etc.)

Amount: $

Foster Care Payments

Interest/ Dividends (Bank Accounts)

Other (list):

Lease Income (list)

Amount: $

Other (list)

(Example: Carl Perkins P.L. 105-332)

Other (list)

(Example: Alaska Native Corporation Dividend

Amount: $

Lottery/ Gaming Income (cash winnings)

Amount: $

Retirement Benefits/ Pensions

Amount: $

Royalties

Amount: $

Tribal Per Capita Payments

Amount: $

Social Security/ Survivor/ Disability Benefits

Amount: $

Unemployment Benefits

Amount: $

Veteran’s Benefits/ Payments

Amount: $

Worker’s Compensation Benefits

Amount: $

Farm/ Ranch Income

Amount: $

Have you applied for any other Emergency Assistance?

Have you applied for other Resources/ Programs?

Amount: $

Explain the Amount Approved and/or Disapproved- need to specify

gross and net earnings. (Social Service Worker Section)

YES

Date: __________________

Section IV. STATEMENT OF COOPERATION

I/We apply for financial assistance/ services for the listed members of my (our) household who are in need.

I/We have received a copy of and have had explained to us, and understand the provisions of Federal Law governing fraud.

Under 18 U.S.C. §1001, the Federal Law concerning fraud states: “Whoever, in any matter within the jurisdiction of any department or agency

of the United States, knowingly and willfully falsifies, conceals, or covers up by any trick, scheme, or devise a material fact, or makes or uses

any false writing or documents, knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than

$10,000 or imprisoned not more than five years or both.”

I (We) agree to supply information regarding resources and income and to notify the agency of any changes in my (our) situation. Release of

Information: Human Services is authorized to obtain/exchange information necessary to establish eligibility for assistance. I (We) have read,

or had explained to me/us, the provision of our protection under the Paperwork Reduction Act and the Privacy Act.

Please check & initial:

Read, Understood & Signed the Fraud Statement: ________

Read, Understood & Signed the Paperwork Reduction Act: ______

Read, Understood & Signed Release of Information & Privacy Act/FOIA: _______

_______________

Date

______________________________________

Signature of Applicant #1

_______________

Date

______________________________________

Social Services Worker Signature

_______________

Date

___________________________________

Signature of Applicant #2

OFFICE USE ONLY

BUDGET CALCULATION (25 CFR §20.311-§20.313):

Household Size:

Adults: __________ Children: _________

TOTAL HOUSEHOLD SIZE: __________

1. Monthly State Standard

$ ____________

State Standard:

2. Monthly Deductions

$ ____________

Deductions:

3. Monthly Earned Income

$ ____________

Earned Income:

4. Monthly Unearned Income

$ ____________

Unearned Income:

5. Monthly Liquid Assets* Available

$ ____________

Liquid Assets*:

6. Total Monthly Income

$ ____________

What are your monthly expenses?

7. Total Monthly Countable

Income

$ ____________

Shelter/ Rent: $ _____________

Utilities: $ _____________

Food: $ _____________

Clothing: $ _____________

8. APPROVED AMOUNT

$ ____________

TOTAL MONTHLY EXPENSES: $ _____________

Additional Comments or Notes

Application Approved

Date of Approval

Application Disapproved

Date of Disapproval

Social Services Worker Signature

Date of Signature

Not applicable

E. Emergency Assistance

(25 C.F.R. §20.329 - §20.330)

Name of Applicant/Recipient: _____________________________________________________________________________________

Tribe: _______________________________________ Tribal Enrollment #: __________________________ Agency: ________________________________

Nature of Emergency:

Amount of Assistance: $ ____________________________

Application for Assistance:

Yes No N/A

--- Household Application – Dated & Signed

--- Timely Approval Notice Provided

--- Timely Denial Notice Provided

--- Hearing Rights Provided

--- Fraud Statement Provided

Eligibility Factors:

Yes No N/A

--- Enrolled Member of a Federally Recognized Indian Tribe or Alaska Native Village

--- Reside in Kickapoo Tribe Jurisdiction

--- Does not Have Insurance

--- Application to Other Resource (e.g., Red Cross)

--- Proof of Loss (e.g., Police Report, Fire Report or Other)

--- Verification of Income

Payments:

Yes No N/A

--- Household Payment Does Not Exceed Current BIA Rate for Essential & Non-Medical Need

--- Authorized Payment is Based on Itemized Loss- Loss related to Essential Needs

Additional Comments or Notes

Application Approved

__________________

Date of Approval

Application Disapproved

__________________

Date of Disapproval

_________________________________________

Social Services Worker Signature

_____________________

Date of Signature

Not applicable

G. INFORMATION & REFERRAL ONLY (FOR OFFICE USE ONLY)

NARRATIVE

(Blue or Black ink Only)

Kickapoo Tribe of Oklahoma

Social Services Department

PRIVACY ACT STATEMENT

25 CFR Part 20 and 25 U.S.C. 13 authorize the collection of this information. The information is confidential and is never

disclosed without written clearance and consent of the applicant. The primary use of this information is to determine eligibility

for financial assistance and services for the Bureau of Indian Affairs (BIA) Welfare Assistance through the Kickapoo Tribe of

Oklahoma, Burial and Disaster Assistance Programs. Additional disclosures of this information may be to other BIA or tribal

officials in the conduct of their official duties pertaining to the application for financial assistance or services, or in the conduct

of program review and to the Office of Inspector General or the General Accounting Office when conducting an audit of Kickapoo

Tribe Social Services Programs, or local Law Enforcement agency when the agency becomes aware of violation or possible

violation of civil or criminal law, and to the General Services Administration in connection with its responsibility for records

management. This information will be entered into the BIA and Kickapoo Tribe Social Services Database, Financial Assistance

and Social Services, which can be obtained upon request from the Social Services Department to authorized requesters. No

record contained therein may be disclosed by any means of communication to any person, or to another agency, except

pursuant to a written request by, or with prior written consent of the individual to whom the records pertains. Executive Order

9397 authorizes the collection of your Social Security number. Furnishing the information is voluntary but failure to do so may

result in disapproval of your application. If the Kickapoo Tribe Social Services uses the information furnished on this form for

purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes.

Under the Privacy Act, Kickapoo Social Services may not give out information you give the social service worker except that

Social Services may share the information with other Federal, State, and Tribal offices and programs who have some

responsibility with the social services for which you are applying. The information can also be given to those agencies when you

ask them for a job or some other benefit and for law enforcement purposes. This can be done without your consent. For any

other person or program wanting information from your case file, you must first give your written consent or release of

information form signed by you. You have the right to know what information is in your case record and you can ask to see it. If

you believe some information in your case file is inaccurate, ask your caseworker about how to change the information in the

case record.

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 by any trick, scheme, or devise a material fact, or makes or uses any false writing or documents,

knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or

imprisoned not more than five years or both.

DECISION

When you file an application for social services, you have a right to a written decision within 30 days. In some cases, it may take

30 days. If you disagree with the decision, you may have a review of the decision by caseworker, Director and/or Executive

Director. You also may file an appeal and have a hearing. An applicant or recipient must pursue the appeal process applicable to

the Kickapoo Tribe of Oklahoma appeal policy and procedures. The regulations for Human Services are in Title 25, Code of

Federal Regulations, Part 20.

The amount of grant assistance you may receive or authorize to be expended is based on State Standards of Public Assistance

and/or the rates established by the Assistant Secretary - Indian Affairs, minus your income and available resources. The

information you give must be accurate. If your circumstances change, you must report this immediately to your Social Services

Caseworker. By doing so, your Social Services worker can give you proper assistance you are eligible to receive.

Within the limits of its authority, the Social Services Office wants to help you. Ask your Social Services worker to explain more

fully any of this information. If you give inaccurate information and receive assistance to which you are not entitled, you will be

required to pay it back.

Kickapoo Tribe of Oklahoma

Social Services Department

ELIGIBILITY

INDIAN BLOOD (25 CFR §20.100)

Applicant must (1) be a member of a federally recognized Indian Tribe, or (2) in the Alaska service area only, any person who

meets the definition of “Native” as defined under 43 U.S.C. 1602(b): “a citizen of the United States and one-fourth degree or more

Alaska Indian.” It includes, in the absence of proof a minimum blood quantum, any citizen of the United States who is regarded

as an Alaska Native by the Native village or Native group of which he claims to be a member and whose father or mother is (or, if

deceased, was) regarded as native by a village or group.

RESIDENCY (25 CFR §20.100 & §20.300)

To be eligible for assistance or services, an applicant must reside in a Kickapoo Tribe Jurisdiction.

ELIGIBILITY FOR OTHER SERVICES

Applicant must not be receiving or eligible to receive County/State Public Welfare or Social Security Income. An individual

and/or Spouse must not be receiving little to no income, an individual or family who is presumed to be eligible for these

programs may, after providing evidence of having applied for those benefits, be granted General Assistance (GA), pending

approval of such application. Also, all clients applying for GA who are eligible for assistance from other programs such as Social

Security, Unemployment Benefits, Worker’s Compensation, Veteran Benefits, Retirement, etc., will be required to seek and show

that they have applied for that assistance. The BIA Financial Assistance and Social Services programs are a secondary resource

and cannot be used to supplant or supplement other programs.

POLICY ON EMPLOYMENT: ACCEPTANCE OF AVAILABLE EMPLOYMENT (25 CFR §20.314)

An applicant must actively seek employment including the use of available state, tribal, county, local or Bureau-funded

employment services, which they are able and qualified to perform. This means that a recipient, prior to and after applying for

GA, must continue to actively seek employment. An applicant or recipient of GA who is determined employable must also accept

local and seasonable employment when it is available. According to 25 CFR §20.316, the recipient must demonstrate that they

are actively seeking employment by providing the Human Services worker with evidence of job search activities as required in

the Individual Service Plan (ISP) and if they do not seek available local and seasonal employment or quit a job without good

cause, they cannot receive GA for a period of at least 60 days but not more than 90 after they refuse or quit a job.

Applicants must report all current and expected employment and income. Those claiming temporary or permanent disability

are required to present documented medical verification of such disability.

REPORTING REQUIREMENTS

It is the responsibility of all Financial Assistance applicants to report and present appropriate documentary verification of all

changes that may occur in their income or living arrangements. Failure to do so may constitute fraud and be subject to

prosecution and/or repayment of disbursements. Each of the following must be reported as they occur:

▪

A move from one residence to another

Changes in contact information

Addition to or reduction in household members

Payments received from employment and/or any other income source

Changes or adjustments in housing or Utility Costs

A move from within the Kickapoo jurisdiction

IMPORTANT: Once you have finished reading the Notification to the Client you must sign and date Page 4 of the

Application and check that you have read and understand all provisions of the Privacy Act/FOIA, the Fraud Statement,

the Paperwork Reduction Act, and sign the Release of Information Statement.

RELEASE OF INFORMATION

You grant and authorize the exchange of information between the Kickapoo Tribe of Oklahoma/ Tribal Human Services Program

and the following agencies/programs:

Tribal/State Employment Offices

Tribal/State Alcohol & Drug Programs

Tribal/State Social Services Programs

Tribal/State Housing Programs

Social Security Administration

Veteran’s Administration

Tribal/State Education Programs

Tribal/State Federal Probation Programs

Tribal/State/Federal Courts

Tribal/State Child Protection Services

Tribal/State Medical Services

Tribal/State Mental Health Services

Tribal Enterprises

Tribal/State Voc-Rehab Programs

Alaska Native Corporations

Indian Health Services

State/County Fiduciary Trust Offices

Other (specify): _________________________________________

Any information exchanged will pertain to your eligibility to receive Financial Assistance and Social Service benefits or referral

to other programs that would benefit you. By signing on the statement of cooperation (Page 3 of the Application) you agree and

understand any information obtained will be kept confidential and will be used only for the purposes directly connected with

providing benefits or services on your behalf. You further agree and understand that any information obtained may be released

to proper governmental agency, court, or law enforcement agencies for purposes of legal and investigative action concerning

fraud.

This Release of Information will remain in effect for one (1) year from date of signature or until you request to rescind

authorization.

I authorize the Social Services Program to obtain and/or exchange information necessary to establish eligibility for Financial

Assistance and Social Services. I have been informed that any person knowingly, willfully, and fraudulently provides false information

for the purpose of obtaining benefits which he/she is ineligible to receive, may be fully subject to prosecution by the Kickapoo Tribe of

Oklahoma. I have read or had explained to me and understand/agree with the policies, procedures and requirements that govern the

Tribal Living Assistance program.

___________________________________________________

Name of Applicant (Print)

_______________

Date

_________________________________________________

Signature of Applicant

Kickapoo Tribe of Oklahoma

Social Services Department

Federal General Assistance Program

PHONE: (405) 964-4227

EMAIL: socialservices@okkt.net

PO BOX 70

MCLOUD, OK 74851

STATEMENT OF RESIDENCE

To Whom it May Concern

I hereby certify that the information provided is true and correct to the best of my knowledge. I understand that the provided information’s is

subject to verification and that if I am found to have provided false or fraudulent information, I may be subject to prosecution under the law.

Additionally, the person (s) identified in this statement of residence, will NOT be considered, or claimed part of my household for the current

year for tax purposes.

I provided that a place of residence, room, and board only, to the person (s) listed:

Person (s) residing at the address below

Name (First, Last)

Address

Name (First, Last)

City

State

Signature of person providing residence to names listed above

Zip

Date

(Notary Stamp Here)

Name of Notary:

Commission Expires:

Date:

County

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.