Fillable Assistance Application (The Chickasaw Nation)

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Assistance Application (The Chickasaw Nation)

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Page 1 of 4 Form no. 04748 CS-SS Rev. 6/2019
Assistance Application
====================================================================================
Area offices: Addresses and contact information:
Ada 231 Seabrook Road / Post Office Box 1548 / Ada, Oklahoma 74820
(580) 436-7256 / FAX (580) 436-2109
Ardmore 949 Locust / Ardmore, Oklahoma 73401
(580) 226-4821 / FAX (580) 226-6732
Duncan 1819 West Plato Road / Duncan, Oklahoma 73533
(580) 470-2131 / FAX (580) 470-2129
Pauls Valley 20118 South Indian Meridian Road / Pauls Valley, Oklahoma 73075
(405) 207-9883 / FAX (405) 207-9876
Purcell 1430 Hardcastle Boulevard / Purcell, Oklahoma 73080
(405) 527-4973 / FAX (405) 527-8058
Sulphur 4970 West Highway 7 / Post Office Box 538 / Sulphur, Oklahoma 73086
(580) 622-2888 / FAX (580) 622-7102
Tishomingo 815 East 6
th
Street / Post Office Box 192 / Tishomingo, Oklahoma 73460
(580) 371-9512 / FAX (580) 371-3845
Oklahoma City 4001 North Lincoln / Oklahoma City, Oklahoma 73105-5206
(405) 767-8971 / Toll Free 1-866-466-1481 / FAX (405) 767-8968
====================================================================================
Dear Applicant:
Once your completed application is received, it will be reviewed for eligibility. If you are eligible for this program
and there are funds available, payment will be made to the vendor and you will be notified. If your application
shows that you are not eligible for assistance, you will be notified.
To apply for this program, the following documentation is required:
Proof of tribal citizenship
A copy of the applicant’s Social Security card
Age 18 and over will provide documentation of income
If no income, a non-income statement will be completed for every person in the household over 18 years of
age
Copy of utility bill
Copy of veteran’s card (if applicable)
Bill Anoatubby
Governor
Department of Community Services / Social Services Division
Page 2 of 4 Form no. 04748 CS-SS Rev. 6/2019
Assistance Application
APPLICANT INFORMATION:
First name:
Middle name:
Last name:
Maiden name:
Mailing address:
City:
State:
Physical address:
City:
State:
Home phone:
Cell phone:
Message phone:
Social Security number:
Birth date:
Age:
Gender:
Email:
Marital status: □ Single □ Married □ Separated □ Divorced □ Widowed
Tribal affiliation: ___________________________________________
EDUCATION:
High school:
□ High school graduate
□ High school equivalency
□ Dropout
College:
□ Enrolled in college
□ College graduate
Vocational training:
□ Enrolled in vocational training
□ Vocational training graduate
Type of degree:
Type of certification:
EMPLOYMENT STATUS:
What is your current employment status?
□ Unemployed □ Self-employed □ Other: _______________
□ Employed full-time □ Employed part-time
If you are currently unemployed, check all the items below that apply to you:
□ Seeking work □ Student □ Other: ______________
□ Seeking training □ Disabled
HOUSEHOLD INFORMATION:
PLEASE LIST EVERYONE WHO LIVES IN THE HOUSE
Name
First, middle,
last, suffix
Relationship
to applicant
Gender
Age
Birth date
Social Security
number
Department of Community Services / Social Services Division
Bill Anoatubby
Governor
Page 3 of 4 Form no. 04748 CS-SS Rev. 6/2019
VETERAN STATUS:
□ Veteran
Veteran Verification Documents:
□ DD214 or NGB22
□ State issued driver’s license with veteran logo
□ Retired Military Identification card
□ VA (Veterans Affairs) Identification card
□ VA benefits letter or other documents
HOUSEHOLD MONTHLY INCOME:
Sources of income amount: Received? Who receives? Monthly
Employment income □ Yes □ No ____________ __________
Social Security □ Yes □ No _____________ _________
Supplemental Security Income (SSI) □ Yes □ No _____________ _________
TANF □ Yes □ No _____________ _________
Alimony □ Yes □ No _____________ _________
Veteran’s benefits □ Yes □ No _____________ _________
Retirement or pension □ Yes □ No _____________ _________
Unemployment compensation □ Yes □ No ______________ _________
Other: __________________ □ Yes □ No ______________ _________
Age: 18 and over will provide documentation of income, regardless of status.
Is any member of your household unable to work? □ Yes □ No
If yes, list name(s) and why:
________________________________________________________
Questions:
Yes No
□ □ Do you have a valid driver’s license?
□ □ Do you have your own reliable transportation?
□ □ Have you ever been convicted of a felony?
□ □ Have you ever been convicted of a DWI or DUI?
If yes, when? ___________________________
□ □ Are you currently under treatment for alcohol/substance abuse?
□ □ Do you have any physical or mental limitations?
__________________________________________________________________
Page 4 of 4 Form no. 04748 CS-SS Rev. 6/2019
WRITTEN STATEMENT
(All requested information is needed before eligibility can be determined)
Describe the type of services you need. Explain what your current circumstances are and give
reasons surrounding your needs. Include all information to help us assist you better.
APPLICANT’S STATEMENT OF AGREEMENT AND UNDERSTANDING:
I declare that the information given in this application is true and correct, and that I shall cooperate in
any quality control audit or review regarding my application. I hereby authorize the Chickasaw
Nation to perform any necessary investigation regarding my initial eligibility and/or my continuing
eligibility in the program. I authorize any exchange or release of information between departments
within the Chickasaw Nation and with any outside agencies. If my request for assistance is denied at
any time, despite meeting eligibility requirements, I shall have the right to appeal the decision in
writing through the area office where my application was processed. If I do not provide a written
request for appeal within (30) days from the date of the denial. I waive my right to any further
hearing or relief.
_________________________________________ ___________________________
Applicant’s signature Date
_________________________________________ ___________________________
Legal guardian’s signature (if applicable) Date
_________________________________________ ___________________________
Resource specialist’s signature Date
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Assistance Application (The Chickasaw Nation)

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Completed 31 January 2021

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