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the Chickasaw Nation Division of Social Services ELDERLY (The Chickasaw Nation)

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the
Chickasaw Nation
Division of Social Services
ELDERLY ENERGY ASSISTANCE PROGRAM
APPLICATION INFORMATION
For the Chickasaw Nation to determine an applicant’s eligibility to receive elderly energy
assistance, this application will be completed and submitted with the required documentation. The
elder energy assistance program will assist an eligible applicant twice a year, once in the summer
and once in the winter. The applicant will submit a separate application and documentation for each
request for assistance. If you are eligible for this program and funds are available, payment will be made to
the vendor and you will be notified.
An applicant who is determined ineligible for assistance will be notified of ineligibility.
Note: An applicant may or may not be the head of household.
APPLICATION REQUIREMENTS
1. Provide a copy of the Chickasaw Nation citizenship card.
2. Applicant must be 60 years of age or older.
3. Provide a copy of the utility bill.
Completed application can be mailed or sent by fax to:
Area offices: Addresses and contact information:
Ada 231 Seabrook Road / P.O. 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 1911 W. Plato Road / Duncan, Oklahoma 73533
(580) 470-2131 / FAX (580) 470-2129
Oklahoma City 4001 N. Lincoln / Oklahoma City, Oklahoma 73105-5206
(405) 767-8971 / Toll Free 1-866-466-1481 / FAX (405) 767-8968
Pauls Valley 220 N. Chickasaw / Pauls Valley, Oklahoma 73075
(405) 207-9883 / FAX (405) 207-9876
Purcell 1430 Hardcastle Blvd. / Purcell, Oklahoma 73080
(405) 527-4973 / FAX (405) 527-8058
Sulphur 4970 W. Highway 7 / P.O. Box 538 / Sulphur, Oklahoma 73086
(580) 622-2888 / FAX (580) 622-7102
Tishomingo 815 E. 6th Street / P.O. Box 192 / Tishomingo, Oklahoma 73460
(580) 371-9512 / FAX (580) 371-3845
Bill Anoatubby
Governor
Page 1 of 2 Form no. 04748EEAP CS-SS Rev. 12/2017
ELDERLY ENERGY ASSISTANCE PROGRAM
APPLICANT INFORMATION:
First name:
Middle name:
Last name:
Suffix:
Mailing address:
City:
State:
ZIP:
Physical address:
City:
State:
ZIP:
Home phone:
Cell phone:
Message phone:
Social Security number:
Birth date:
Email:
HOUSEHOLD INFORMATION:
PLEASE LIST EVERYONE WHO LIVES IN THE HOUSE
Name
First, middle, last, suffix
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
I declare that the information I have given in this application is true and correct, and that I will cooperate with the
Chickasaw Nation should my application become part of a quality control/audit review. I hereby authorize the Chickasaw
Nation to make any necessary investigations to other social services agencies of my household verification or other
information regarding my eligibility. If my request for assistance is denied despite meeting the eligibility requirement, I
have the right to appeal this decision and will request this in writing to the area office where my application was processed
within 30 days of the date of denial, or waive my rights to a hearing.
Signature of applicant Date
Resource specialist Date
The Chickasaw Nation Social Services Division and the applicant agree to strictly maintain the confidentiality of all information disclosed hereunder, or any amendments
thereto. The parties agree that the information contained in said application will be considered “Confidential Information” and will not be disclosed to third persons, except
upon written consent of the applicant or as otherwise required by law.
Page 2 of 2 Form no. 04748EEAP CS-SS Rev. 12/2017
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Completed 31 January 2021

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