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)(Required)

Street Address Address Line 2 City State Zip Code

This field is hidden when viewing the form

Geocoder

Physical/Rural/Residential Address(Required)

Map: drag the marker pin or click to drop it on your physical home location or use the Locate Me button below

Get my current location

Coordinates (from map marker above)

Address (from map marker above)

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?

In which Border Town do you reside?

Marital Status(Required)

Single – Never Married

Married – Living Together

Married – Separated

Divorced

Widowed

Primary Language(s) Spoken(Required)

English

Navajo

Both

Other

Other Primary Language Spoken:

Is anyone in your household a Veteran?(Required)

Yes

Who is a Veteran?

1. Household Members: List all individuals living in your home.

Applicant: your own information

Applicant Full Name

Applicant's SSN

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is your Tribal Affiliation

What is your ethnicity?

Are you currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Household Member 2

Who else lives in your home?

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 3

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 4

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 5

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 6

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 7

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 8

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 9

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 10

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 11

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 12

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 13

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

Would you like to add an additional household member?

Yes

Household Member 14

Household Member Info

Full Name

SSN (ex: 123-45-6789)

Tribal Enrollment Number

Date of Birth (ex: 03/21/1982)

Relationship to Applicant

U.S. Citizen

Yes

Gender

Male

Female

Last Grade Completed

Ethnicity

What is this household member's tribal affiliation?

What is this household member's ethnicity?

Is this household member currently in school (including k-12, university, college, or trade school)?(Required)

Yes

School Name and Address

Attending Full or Part Time?

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?

Who?

From (ex: 03/2020):

To (ex: 12/2020):

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

From which State/Tribe?

What Program?

Who?

When? (ex: 08/2023)

This field is hidden when viewing the form

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

Yes

Who is on probation or parole?

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

Yes

This field is hidden when viewing the form

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?

This field is hidden when viewing the form

6. Is any child or adult in your household attending school (including k-12, university, college, or trade school)?(Required)

Yes

List School Attendance (if more than one, please use the + at the end of the row for additional students)

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

Source of Income?

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

This field is hidden when viewing the form

11. Do you, or anyone in your household, receive funds using peer-to-peer payments (Venmo, Cash App, 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

Upload as much of the required documentation as you can.

Whatever is not uploaded will need to be brought to the intake meeting.

Drop files here or

Max. file size: 40 MB.

Acknowledgements and Certifications

Please read the information below, initial each section to acknowledge you understand the information provided in the section, and then sign the application.

For two-parent applications, both parents must initial.

Customer Responsibility Parent 1 Initial(Required)

Customer Responsibility Parent 2 Initial

Personal Responsibility Plan Parent 1 Initial(Required)

Personal Responsibility Plan Parent 2 Initial

WPH Requirements Parent 1 Initial(Required)

WPH Requirements Parent 2 Initial

Fair Hearing Rights Parent 1 Initial(Required)

Fair Hearing Rights Parent 2 Initial

Confidentiality Parent 1 Initial(Required)

Confidentiality Parent 2 Initial

Release of Information Parent 1 Initial(Required)

Release of Information Parent 2 Initial

Fraud Penalties Parent 1 Initial(Required)

Fraud Penalties Parent 2 Initial

Payment Errors Parent 1 Initial(Required)

Payment Errors Parent 2 Initial

For two-parent applications, both must print their full names and both must sign.

Applicant Print Name(Required)

First Middle Last

Date(Required)

Co-parent Print Name

First Middle Last

Date

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

1. Household Members: List all individuals living in your home.

Household Member 2

Household Member 3

Household Member 4

Household Member 5

Household Member 6

Household Member 7

Household Member 8

Household Member 9

Household Member 10

Household Member 11

Household Member 12

Household Member 13

Household Member 14

File Upload

Acknowledgements and Certifications

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