Application for Assistance

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

Directions for application.

Office Locations

All office locations and email settings will be configured when moved over to tribe site.

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)

Street Address Address Line 2 City State ZIP Code

Physical/Rural/Residential Address(Required)

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?

Chapter you reside in?

Marital Status(Required)

Single – Never Married

Married – Living Together

Married – Separated

Divorced

Widowed

Common Law

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

Hidden

Household Member 2

Full Name

SSN

Tribal Enrollment Number

Date of Birth

Relationship to Applicant

Household Member 2 Part 2

U.S. Citizen

Ethnicity

Gender

Last Grade Completed

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:

Hidden

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?

Hidden

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

Yes

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

Yes

Hidden

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?

Hidden

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

Hidden

7. Has anyone in your household applied for, or is currently receiving income from, any of the following sources?(Required)

Check All that apply.

Child Support Payments

SSB: Retirement, Survivors, Disability

Retirement, Federal, State, Tribal, RR

Royalty Payments (oil, gas, etc.)

Rental/Lease of Property/Land

Per Capita Payments

Unemployment Insurance Comp.

Vacation/Sick/Severance Payments

Lottery/Gambling Winnings

Insurance/Settlement

Worker’s Compensation

Disability Payments

Other

No income from the above sources

List Income Source(s)

Type of Income

Receiving?

Who is the Recipient

Amount Received?

Received how Often? (Monthly, Bi-weekly, Weekly

List Other Income Sources

Type of Other Income

Receiving?

Who is the Recipient

Amount Received?

Received how Often? (Monthly, Bi-weekly, Weekly

Hidden

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

Hidden

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

Yes

List Self-Employed Household Members:

Name

Employer's Name & Address

Date of Employment

Hours per Week

Monthly Gross Income

Hidden

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

Hidden

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:

Hidden

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

Hidden

Child Care Assistance (subsidized) Type:

State Funded

Tribal Funded

Local Funds

Average monthly assistance amount:

Hidden

15. Do you or anyone in your household have:

Medicaid

Medicare

AZ AHCCCS

Other

List Other Medical Coverage:

From which State/County?

State

County

ACKNOWLEDGEMENT / CERTIFICATION SHEET
You must complete an Acknowledgment/Certification Sheet 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 completed form below.

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.