TANF Application – Eaglesun Systems

Important Application Information:

This TANF application has been separated into online questions and documents to upload. The documents to upload have been separated into documents that must be printed and other signature documents that can be filled out online.

Please print and collect the following checklist and documents provided here:

Click here to download the TANF Application Checklist. This has a list of the required documents.

These documents must be printed, filled out by the appropriate parties and uploaded in the document upload portal or emailed to XXX@officeemail.com. For questions regarding this process call XXX-XXX-XXXX.

Employment Verification
Residency Verification
School Enrollment Verification

An email address is required to submit online applications. Please contact the office if you need assistance in setting up an email address.

Office Location(Required)

Actual office locations for routing will be configured when moved to tribe site.

Total number of household members applying for Cash Assistance on this application:

Head of Household Last Name(Required)

Head of Household First Name(Required)

Head of Household Middle Name

Social Security #(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Maiden Name (if any)

Also Known As

Is this your permanent address?(Required)

Yes

Homeless

Home Address

Street Address City State County Zip Code

Mailing Address (if different)

Street Address City State ZIP Code

Home or Primary Phone #(Required)

Please list 999-999-9999 if you do not have an phone. It is required to submit online applications.

Email(Required)

Please call XXX-XXX-XXX, if you do not have an email address. We will help you set up an email address. It is required to submit online applications.

Work Phone #

Message Phone #

Is anyone applying for:

Cash Assistance

Non-Needy Relative

Child Only

Has anyone applied for or received aid or benefits?

If so, please indicate which ones.

TANF

Medical

Food Stamps

List Aid Received

If so, please indicate whether the aid came from:

State Assistance or Tribal TANF Program

Date Received

Name Used

Program Name or County

Please indicate your tribal affiliation:

Member of Federally Recognized Tribe:

Do you reside on a Reservation?(Required)

If yes, list Reservation name.

Yes

Reservation Name:

Is anyone Pregnant?(Required)

If yes, list due date.

Yes

Pregnancy Due Date

MM slash DD slash YYYY

How much income did everyone, including the child(ren) receive or will receive, in the month of this application?

Who received income

Amount of income received

How much is your rent or mortgage each month?(Required)

How much are your utilities that are not included in your rent?(Required)

Is there a personal emergency?(Required)

Yes

Emergency Type:

Domestic Violence

Other threats to health or safety

Other health or safety threat:

Adult 1 Information

Applicant Last Name(Required)

Applicant First Name(Required)

Applicant Middle Name

Disabled?(Required)

Yes

Social Security #(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age

Gender(Required)

Male

Female

Race(Required)

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status(Required)

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant(Required)

Head of Household

Spouse

Parent

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Unrelated Adult

Tribe

Tribal Enrollment #

Prior TANF Client(Required)

Yes

Non-Custodial Parent(Required)

Yes

Prior Cash Assistance from another TANF program?(Required)

Yes

Hidden

Start Cast Assistance Section Break

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Hidden

End Cast Assistance Section Break

Receiving Unemployment(Required)

Yes

Hidden

Start Unemployment Section Break

Unemployment Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Unemployment Section Break

Receiving Disability(Required)

Yes

Hidden

Start Disability Section Break

Disability Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Disability Section Break

Currently on Probation?(Required)

Yes

Hidden

Start Currently on Probation Section Break

Currently on Probation Information

Name of Officer

County

Offense

Amount of time

Activity

Hidden

End Currently on Probation Section Break

Cash Resource?(Required)

Cash on hand.

Yes

Hidden

Start Cash Resource Section Break

Cash Resource Information

Resource

Amount

Start Date

End Date

Date Last Received

Hidden

End Cash Resource Section Break

Other Income?(Required)

Other income includes: Training, Education, TANF, State Benefits, Worker’s Comp, Child/spouse support, Social Security, Veterans Admin, Military Pension, Government Agency, Gifts, Contributions, Rental Property, Winnings, Other, Trust Fund

Yes

Hidden

Start Other Income 1 Section Break

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Hidden

End Other Income 3 Section Break

Government Assistance?(Required)

Yes

Hidden

Start Government Assistance Section Break

Government Assistance Information

Assistance Type

Monthly Amount

Start Date

End Date

Date Last Received

Hidden

End Government Assistance Section Break

Pays Child Support?(Required)

Yes

Hidden

Start Pays Child Support Section Break

Pays Child Support Information

Paid to

Paid for

Amount

Court Ordered

Hidden

End Pays Child Support Section Break

Education

Highest Education Level?(Required)

01-11 Grade level completed in primary/secondary school including secondary level vocational school or adult high school

High School Diploma, GED or National External Diploma Program

Awarded Associate Degree

Awarded Bachelor’s Degree

Awarded Graduate degree (Master’s or higher)

Other credentials (degree, certificate, diploma, etc.).

No formal education

I attended school through what grade:

What year did you last attend school?

Employment

List Employer(Required)

Current or Last Employer Name

Employment Start Date

Employment End Date

Title

Reason no longer employed

Vehicle Information

Year

Make

Model

Class

License Plate

Estimated Value

Amount owed

Have you ever been convicted of a drug related felony in the past 10 years?(Required)

Yes

If yes, please explain:

In the past 6 months, have you ever been charged with a drug related felony?(Required)

Yes

If yes, please explain:

Atestiment(Required)

I understand that as recipient of CCTTP benefits, I am required to complete substance abuse testing. Random testing will be conducted, following initial testing, and a positive test will require me to participate in substance abuse assessment and possibly attend counseling sessions or enroll in a rehabilitation program. CCTTP will continue Tribal TANF assitance to my family through a voucher system, or deny, reduce, or terminate benefits to ensure my compliance.

Atestiment(Required)

I herby grant permission to CCTTP to investigate and verify the above information provided by me to determine eligibility for CCTTP.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature Name

First Last

Date

MM slash DD slash YYYY

Adult 2 Information

Applicant Last Name

Applicant First Name

Applicant Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Head of Household

Spouse

Parent

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Unrelated Adult

Tribe

Tribal Enrollment #

Prior TANF Client

Yes

Non-Custodial Parent

Yes

Prior Cash Assistance from another TANF program?

Yes

Hidden

Start Cast Assistance Section Break

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Hidden

End Cast Assistance Section Break

Receiving Unemployment

Yes

Hidden

Start Unemployment Section Break

Unemployment Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Unemployment Section Break

Receiving Disability

Yes

Hidden

Start Disability Section Break

Disability Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Disability Section Break

Currently on Probation?

Yes

Hidden

Start Currently on Probation Section Break

Currently on Probation Information

Name of Officer

County

Offense

Amount of time

Activity

Hidden

End Currently on Probation Section Break

Cash Resource?

Cash on hand.

Yes

Hidden

Start Cash Resource Section Break

Cash Resource Information

Resource

Amount

Start Date

End Date

Date Last Received

Hidden

End Cash Resource Section Break

Other Income?

Yes

Hidden

Start Other Income 1 Section Break

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Hidden

End Other Income 3 Section Break

Government Assistance?

Yes

Hidden

Start Government Assistance Section Break

Government Assistance Information

Assistance Type

Monthly Amount

Start Date

End Date

Date Last Received

Hidden

End Government Assistance Section Break

Pays Child Support?

Yes

Hidden

Start Pays Child Support Section Break

Pays Child Support Information

Paid to

Paid for

Amount

Court Ordered

Hidden

End Pays Child Support Section Break

Education

Highest Education Level?

01-11 Grade level completed in primary/secondary school including secondary level vocational school or adult high school

High School Diploma, GED or National External Diploma Program

Awarded Associate Degree

Awarded Bachelor’s Degree

Awarded Graduate degree (Master’s or higher)

Other credentials (degree, certificate, diploma, etc.).

No formal education

I attended school through what grade:

What year did you last attend school?

Employment

List Employer

Current or Last Employer Name

Employment Start Date

Employment End Date

Title

Reason no longer employed

Vehicle Information

Year

Make

Model

Class

License Plate

Estimated Value

Amount owed

Have you ever been convicted of a drug related felony in the past 10 years?

Yes

If yes, please explain:

In the past 6 months, have you ever been charged with a drug related felony?

Yes

If yes, please explain:

Atestiment

I herby grant permission to CCTTP to investigate and verify the above information provided by me to determine eligibility for CCTTP.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature Name

First Last

Date

MM slash DD slash YYYY

Child 1 Information

Last Name(Required)

First Name(Required)

Middle Name

Disabled?(Required)

Yes

Social Security #(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age

Gender(Required)

Male

Female

Race(Required)

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status(Required)

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant(Required)

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

Prior TANF Client(Required)

Yes

Hidden

Section Break

Pregnant?(Required)

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 2 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 3 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 4 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 5 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 6 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Fillable Forms

Declaration of Understanding Form
You must complete an Declaration of Understanding Form and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and upload the form below.

Client Affirmation Form
You must complete an Client Affirmation and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and upload the form below.

Release of Information Form
You must complete an Release of Information Form and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and upload the form below.

Verification of Monetary Distribution
Form You must complete an Verification of Monetary Distribution Form and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and upload the form below.

Your Rights and Responsibilities Form
You must complete an Your Rights and Responsibilities Form and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and upload the form below.

File Upload(Required)

Please be sure to upload the following required documents: Medicaid Verification, SNAP Verification, Birth Certificates, Social Security Cards, Identification (tribal ID, DL), School, Rent

Drop files here or

Max. file size: 40 MB.

Office Location(Required)

Actual office locations for routing will be configured when moved to tribe site.

Total number of household members applying for Cash Assistance on this application:

Head of Household Last Name(Required)

Head of Household First Name(Required)

Head of Household Middle Name

Social Security #(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Maiden Name (if any)

Also Known As

Is this your permanent address?(Required)

Yes

Homeless

Home Address

Street Address City State County Zip Code

Mailing Address (if different)

Street Address City State ZIP Code

Home or Primary Phone #(Required)

Please list 999-999-9999 if you do not have an phone. It is required to submit online applications.

Email(Required)

Please call XXX-XXX-XXX, if you do not have an email address. We will help you set up an email address. It is required to submit online applications.

Work Phone #

Message Phone #

Is anyone applying for:

Cash Assistance

Non-Needy Relative

Child Only

Has anyone applied for or received aid or benefits?

If so, please indicate which ones.

TANF

Medical

Food Stamps

List Aid Received

If so, please indicate whether the aid came from:

State Assistance or Tribal TANF Program

Date Received

Name Used

Program Name or County

Please indicate your tribal affiliation:

Member of Federally Recognized Tribe:

Do you reside on a Reservation?(Required)

If yes, list Reservation name.

Yes

Reservation Name:

Is anyone Pregnant?(Required)

If yes, list due date.

Yes

Pregnancy Due Date

MM slash DD slash YYYY

How much income did everyone, including the child(ren) receive or will receive, in the month of this application?

Who received income

Amount of income received

How much is your rent or mortgage each month?(Required)

How much are your utilities that are not included in your rent?(Required)

Is there a personal emergency?(Required)

Yes

Emergency Type:

Domestic Violence

Other threats to health or safety

Other health or safety threat:

Adult 1 Information

Applicant Last Name(Required)

Applicant First Name(Required)

Applicant Middle Name

Disabled?(Required)

Yes

Social Security #(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age

Gender(Required)

Male

Female

Race(Required)

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status(Required)

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant(Required)

Head of Household

Spouse

Parent

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Unrelated Adult

Tribe

Tribal Enrollment #

Prior TANF Client(Required)

Yes

Non-Custodial Parent(Required)

Yes

Prior Cash Assistance from another TANF program?(Required)

Yes

Hidden

Start Cast Assistance Section Break

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Hidden

End Cast Assistance Section Break

Receiving Unemployment(Required)

Yes

Hidden

Start Unemployment Section Break

Unemployment Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Unemployment Section Break

Receiving Disability(Required)

Yes

Hidden

Start Disability Section Break

Disability Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Disability Section Break

Currently on Probation?(Required)

Yes

Hidden

Start Currently on Probation Section Break

Currently on Probation Information

Name of Officer

County

Offense

Amount of time

Activity

Hidden

End Currently on Probation Section Break

Cash Resource?(Required)

Cash on hand.

Yes

Hidden

Start Cash Resource Section Break

Cash Resource Information

Resource

Amount

Start Date

End Date

Date Last Received

Hidden

End Cash Resource Section Break

Other Income?(Required)

Yes

Hidden

Start Other Income 1 Section Break

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Hidden

End Other Income 3 Section Break

Government Assistance?(Required)

Yes

Hidden

Start Government Assistance Section Break

Government Assistance Information

Assistance Type

Monthly Amount

Start Date

End Date

Date Last Received

Hidden

End Government Assistance Section Break

Pays Child Support?(Required)

Yes

Hidden

Start Pays Child Support Section Break

Pays Child Support Information

Paid to

Paid for

Amount

Court Ordered

Hidden

End Pays Child Support Section Break

Education

Highest Education Level?(Required)

01-11 Grade level completed in primary/secondary school including secondary level vocational school or adult high school

High School Diploma, GED or National External Diploma Program

Awarded Associate Degree

Awarded Bachelor’s Degree

Awarded Graduate degree (Master’s or higher)

Other credentials (degree, certificate, diploma, etc.).

No formal education

I attended school through what grade:

What year did you last attend school?

Employment

List Employer(Required)

Current or Last Employer Name

Employment Start Date

Employment End Date

Title

Reason no longer employed

Vehicle Information

Year

Make

Model

Class

License Plate

Estimated Value

Amount owed

Have you ever been convicted of a drug related felony in the past 10 years?(Required)

Yes

If yes, please explain:

In the past 6 months, have you ever been charged with a drug related felony?(Required)

Yes

If yes, please explain:

Atestiment(Required)

I herby grant permission to CCTTP to investigate and verify the above information provided by me to determine eligibility for CCTTP.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature Name

First Last

Date

MM slash DD slash YYYY

Adult 2 Information

Applicant Last Name

Applicant First Name

Applicant Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Head of Household

Spouse

Parent

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Unrelated Adult

Tribe

Tribal Enrollment #

Prior TANF Client

Yes

Non-Custodial Parent

Yes

Prior Cash Assistance from another TANF program?

Yes

Hidden

Start Cast Assistance Section Break

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Agency

County

State

Monthly amount

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Why discontinued

Hidden

End Cast Assistance Section Break

Receiving Unemployment

Yes

Hidden

Start Unemployment Section Break

Unemployment Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Unemployment Section Break

Receiving Disability

Yes

Hidden

Start Disability Section Break

Disability Information

Date Applied

County

State

Monthly amount

Date of Last Check Received

Hidden

End Disability Section Break

Currently on Probation?

Yes

Hidden

Start Currently on Probation Section Break

Currently on Probation Information

Name of Officer

County

Offense

Amount of time

Activity

Hidden

End Currently on Probation Section Break

Cash Resource?

Cash on hand.

Yes

Hidden

Start Cash Resource Section Break

Cash Resource Information

Resource

Amount

Start Date

End Date

Date Last Received

Hidden

End Cash Resource Section Break

Other Income?

Yes

Hidden

Start Other Income 1 Section Break

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Other Income Type

Source

Other Income Information

Frequency

Amount

Start Date

End Date

Date Last Received

Hidden

End Other Income 3 Section Break

Government Assistance?

Yes

Hidden

Start Government Assistance Section Break

Government Assistance Information

Assistance Type

Monthly Amount

Start Date

End Date

Date Last Received

Hidden

End Government Assistance Section Break

Pays Child Support?

Yes

Hidden

Start Pays Child Support Section Break

Pays Child Support Information

Paid to

Paid for

Amount

Court Ordered

Hidden

End Pays Child Support Section Break

Education

Highest Education Level?

01-11 Grade level completed in primary/secondary school including secondary level vocational school or adult high school

High School Diploma, GED or National External Diploma Program

Awarded Associate Degree

Awarded Bachelor’s Degree

Awarded Graduate degree (Master’s or higher)

Other credentials (degree, certificate, diploma, etc.).

No formal education

I attended school through what grade:

What year did you last attend school?

Employment

List Employer

Current or Last Employer Name

Employment Start Date

Employment End Date

Title

Reason no longer employed

Vehicle Information

Year

Make

Model

Class

License Plate

Estimated Value

Amount owed

Have you ever been convicted of a drug related felony in the past 10 years?

Yes

If yes, please explain:

In the past 6 months, have you ever been charged with a drug related felony?

Yes

If yes, please explain:

Atestiment

I herby grant permission to CCTTP to investigate and verify the above information provided by me to determine eligibility for CCTTP.

By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature Name

First Last

Date

MM slash DD slash YYYY

Child 1 Information

Last Name(Required)

First Name(Required)

Middle Name

Disabled?(Required)

Yes

Social Security #(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age

Gender(Required)

Male

Female

Race(Required)

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status(Required)

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant(Required)

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

Prior TANF Client(Required)

Yes

Hidden

Section Break

Pregnant?(Required)

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 2 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 3 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 4 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 5 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Do you have additional children to add?

Yes

Child 6 Information

Last Name

First Name

Middle Name

Disabled?

Yes

Social Security #

Date of Birth

MM slash DD slash YYYY

Age

Gender

Male

Female

Race

Check all that apply

American Indian or Alaska Native

Black or African American

Asian

Native Hawaiian or Other Pacific Islander

Hispanic or Latino

White

Marital Status

Single – Never Married

Married – Living Together

Divorced

Widowed

Relationship to Primary Applicant

Daughter or Son

Stepdaughter or Stepson

Grandchild or great grandchild

Related person (brother, niece, cousin)

Foster Child

Unrelated Child

Tribe

Tribal Enrollment #

TANF Client

Yes

Hidden

Section Break

Pregnant?

Yes

If yes, due date

MM slash DD slash YYYY

Highest Education Completed

Name of School

Mother's Last Name

Mother's First Name

Mother's Middle Name

Mother's Status

Deceased

Absent

Disabled

Unemployed

Father's Last Name

Father's First Name

Father's Middle Name

Father's Status

Deceased

Absent

Disabled

Unemployed

Fillable Forms

File Upload(Required)

Please be sure to upload the following required documents: Medicaid Verification, SNAP Verification, Birth Certificates, Social Security Cards, Identification (tribal ID, DL), School, Rent

Drop files here or

Max. file size: 40 MB.