Application for Assistance

This site is for demonstration of forms.
Do NOT submit personal applications.

Directions for application.

Office Locations

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Last Name(Required)

First Name(Required)

Middle Name

Other Name(s) Used

Home or Primary Phone #(Required)

Secondary Phone

Email(Required)

Mailing Address (Box # or Street Address)(Required)

Street Address Address Line 2 City State Zip Code

Physical/Rural/Residential Address(Required)

Same as Mailing Address

Street Address Address Line 2 City State Zip Code

How long have you lived at your current residence?(Required)

Number of Years

Number of Months

Number of Days

County you reside in(Required)

Do you reside in a:(Required)

Chapter

Border Town

Chapter you reside in?

Border Town you reside in?

Marital Status(Required)

Single – Never Married

Married – Living Together

Married – Separated

Divorced

Widowed

Language(s) Spoken(Required)

English

Navajo

Both

Other

Other Language Spoken:

Is anyone in your household a Veteran?(Required)

Yes

Who is a Veteran?

1. Household Members: List all individuals that you live with.

Household Member 1

Name

SSN

Tribal Enrollment Number

Date of Birth

Relationship to Applicant

Household Member 1 Part 2

U.S. Citizen

Ethnicity

Gender

Last Grade Completed

Would you like to add an additional household member?

Yes

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Household Member 2

Full Name

SSN

Tribal Enrollment Number

Date of Birth

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last grade completed?

Ethnicity

What is your ethnicity?

This field is hidden when viewing the form

2. Have you, or a household member, ever applied for, or received, TANF assistance?(Required)

Yes

List TANF Assistance

From which State/Tribe?

How Long? From:

How Long? To:

3. Have you, or a member of your family, ever been disqualified from TANF, Food Stamps, or other public assistance programs?(Required)

Yes

List Disqualified from Assistance

Who?

When?

What Program?

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4. Are you, or any household member, currently on Probation or Parole?(Required)

Yes

Are you, or the household member complying with the conditions of the Probation or Parole?

Yes

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5. Do you, or any household member, currently have a warrant for your, or their, arrest?(Required)

Yes

List Current Warrant(s) for Arrest

Who?

For What?

Where?

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6. Is anyone in your household attending school (including university, college, or trade school)?(Required)

Yes

List School Attendance

Student's Name

School Name and Address

Last Grade Completed

Attending Full Time or Part Time

7. Has anyone in your household applied for, or is currently receiving income from, any of the following sources? (If more than one recipient per source, please click the + at the end of the row to add another row for their details.)

Child Support Payments?(Required)

Yes, receiving

Pending

Recipient Details for Child Support Payments

Who is the Recipient?

Amount Received?

Received how Often?

SSB: Retirement, Survivors, Disability?(Required)

Yes, receiving

Pending

Recipient Details for SSB: Retirement, Survivors, Disability

Who is the Recipient?

Amount Received?

Received how Often?

Retirement, Federal, State, Tribal, RR?(Required)

Yes, receiving

Pending

Recipient Details for Retirement, Federal, State, Tribal, RR

Who is the Recipient?

Amount Received?

Received how Often?

Royalty Payments (oil, gas, etc.)?(Required)

Yes, receiving

Pending

Recipient Details for Royalty Payments (oil, gas, etc.)

Who is the Recipient?

Amount Received?

Received how Often?

Rental/Lease of Property/Land?(Required)

Yes, receiving

Pending

Recipient Details for Rental/Lease of Property/Land

Who is the Recipient?

Amount Received?

Received how Often?

Per Capita Payments?(Required)

Yes, receiving

Pending

Recipient Details for Per Capita Payments

Who is the Recipient?

Amount Received?

Received how Often?

Unemployment Insurance Comp.?(Required)

Yes, receiving

Pending

Recipient Details for Unemployment Insurance Comp.

Who is the Recipient?

Amount Received?

Received how Often?

Vacation/Sick/Severance Payments?(Required)

Yes, receiving

Pending

Recipient Details for Vacation/Sick/Severance Payments

Who is the Recipient?

Amount Received?

Received how Often?

Lottery/Gambling Winnings?(Required)

Yes, receiving

Pending

Recipient Details for Lottery/Gambling Winnings

Who is the Recipient?

Amount Received?

Received how Often?

Insurance/Settlement?(Required)

Yes, receiving

Pending

Recipient Details for Insurance/Settlement

Who is the Recipient?

Amount Received?

Received how Often?

Worker’s Compensation?(Required)

Yes, receiving

Pending

Recipient Details for Worker’s Compensation

Who is the Recipient?

Amount Received?

Received how Often?

Disability Payments?(Required)

Yes, receiving

Pending

Recipient Details for Disability Payments

Who is the Recipient?

Amount Received?

Received how Often?

Other Income Source?(Required)

Yes, receiving

Pending

Recipient Details for Other Income Source

Who is the Recipient?

Amount Received?

Received how Often?

8. Are you or anyone in your household currently self-employed?(Required)

Yes

List Self-Employed Household Members:

Name

Type of Employment/ Business Name

How Long?

Hours per Week

Monthly Gross Income

Monthly Business Expenses

9. Is anyone in your household currently employed by others?(Required)

Yes

List Self-Employed Household Members:

Name

Employer's Name & Address

Date of Employment

Hours per Week

Monthly Gross Income

10. Do you, or anyone in your household, have a bank account?(Required)

Yes

List Bank Account

Type of Account

Name on Account

Financial Institution

Current Balance

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11. Do you, or anyone in your household, receive funds using peer-to-peer payments (Zelle, Apple Pay, Google Pay, PayPal, etc.)?(Required)

Yes

Who receives the funds?

Who sends the funds?

For what purpose?

12. Does anyone in your family receive SNAP (Food Stamps)?(Required)

Yes

List Snap/Food Stamp Benefits

From which State/County?

Monthly Benefit Amount:

This field is hidden when viewing the form

13. Are you receiving housing assistance (subsidized)?(Required)

Yes- Public Housing/HUD

Yes- Rent Subsidy

14. Are you receiving Child Care assistance (subsidized)?(Required)

Yes

This field is hidden when viewing the form

Child Care Assistance (subsidized) Type:

State Funded

Tribal Funded

Local Funds

Average monthly assistance amount:

This field is hidden when viewing the form

15. Do you or anyone in your household receive medical assistance (Medicaid, Medicare, AZ AHCCCS, or other)?(Required)

Yes

ACKNOWLEDGEMENT / CERTIFICATION
You must complete an Acknowledgment/Certification Form and attach it to this application. The Certification Form will open in a new tab:

Certification Form

Fill out the Certification Form completely
Sign and submit
Check the email you entered in that form
Download the completed form PDF document from your email, saving it to your device
Then upload that form PDF below; if you need help with uploading documents, please see the DSR How-to Page (link will open in a new tab, so you can return to this form without losing your info)

File Upload(Required)

Don’t forget to attach the acknowledgement/certification sheet and other required documents.

Drop files here or

Max. file size: 40 MB.

This site is for demonstration of forms. Do NOT submit personal applications.

1. Household Members: List all individuals that you live with.

Household Member 2

This site is for demonstration of forms.
Do NOT submit personal applications.