Skip to content

PLEASE READ THE INFORMATION BELOW, INITIAL EACH SECTION TO ACKNOWLEDGE YOU UNDERSTAND THE INFORMATION PROVIDED IN THE SECTION AND SIGN THE APPLICATION (For Two-Parent applications, both Parents must sign)

CUSTOMER RESPONSIBILITY: I understand and acknowledge I am responsible for providing complete and accurate information, reporting all the changes that may affect my eligibility for DSR assistance within five (5) business days after the change occurs, and cooperating with DSR staff, including, if necessary, investigations.(Required)
For two-Parent applications, both Parents must initial.
Customer Responsibility Parent 2 Initial
PERSONAL RESPONSIBILITY PLAN: I understand I am required to develop a “Personal Responsibility Plan” (PRP) within thirty (30) days after approval for DSR assistance, comply with the provisions outlined in my PRP, and review my PRP with my assigned DSR staff at least once every four (4) months.(Required)
Personal Responsibility Plan Parent 2 Initial
WORK PARTICIPATION HOURS (WPH) REQUIREMENTS: I understand adults included in a DSR assistance benefit group are required to participate in authorized work activities for a minimum number of hours each month. I understand that, if I am required to meet WPH requirements and do not meet the minimum hours, I will be subject to penalty. The types of work activities that are countable and the minimum number of hours I must participate have been explained to me.(Required)
Work Participation Hours Requirements Parent 2 Initial
FAIR HEARING RIGHTS: I understand if I do not agree with a decision made on my application or assistance case, I have a right to appeal the decision by submitting a Request for Appeal Hearing within twenty (20) business days from the postmark date on the notice.(Required)
Fair Hearing Rights Parent 2 Initial
CONFIDENTIALITY: I understand information obtained to determine my eligibility is confidential and, in compliance with the Navajo Nation Privacy and Access to Information Act, may not be released to a third party, unless I sign a Notarized Release of Information form authorizing the release of information I have provided to the third party.(Required)
Confidentiality Parent 2 Initial
RELEASE OF INFORMATION: I authorize DSR to contact any other agency to obtain information necessary to determine my benefit group’s eligibility for DSR assistance/benefits. I also authorize DSR to access my information stored in the DSR data base to verify information I have provided and to prevent duplication of assistance.(Required)
Release of Information Parent 2 Initial
FRAUD PENALTIES: I understand if I intentionally provide false information, or withhold information, in order to make my benefit group eligible for DSR assistance or benefits we would otherwise be ineligible to receive, I and all members of my benefit group may be disqualified from receiving DSR assistance and benefits and required to repay any payments I was not eligible to receive. In addition, I may be subject to criminal penalties under applicable tribal, state, or federal laws.(Required)
Fraud Penalties Parent 2 Initial
PAYMENT ERRORS: I understand a payment error will occur if I receive a monthly assistance payment that is more or less than I am eligible to receive. If I receive a payment for more or less than I was eligible to receive, I will immediately report this to the DSR. I understand I will be responsible for repaying the amount I was not eligible to receive.(Required)
Payment Errors Parent 2 Initial

Print Name(Required)
MM slash DD slash YYYY
Print Name
MM slash DD slash YYYY

In order to protect your private information the completed PDF form will be encrypted with a password. Please type a memorable password below.

The completed PDF form will be emailed to you please provide an email address below.