Application for TANF-Child Only Non-Needy

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

TANF SERVICES
TANF Services are available for eligible families who have had children placed with them or for which they are otherwise acting as a caregiver. Cash grants are issued monthly to assist with the basic needs of the children in the family unit.
ELIGIBILITY CRITERIA
You must meet the following requirements to be eligible for Tribal Government TANF Services:
1) If living within the boundaries of the Tribal Indian Reservation, there must be an enrolled member of a federally recognized tribe living in the family unit.
2) If living outside the boundaries of the Tribal Indian Reservation but in Tribal X County or Tribal Y County, there must be an enrolled member of the Tribal Nation living in the family unit.
3) Child/ren’s income must not exceed the income limitations based on size of family unit.

Family Unit Size	Monthly Income Limit	Family Unit Size	Monthly Income Limit
1	$800	6	$1,800
2	$1,000	7	$2,000
3	$1,200	8	$2,200
4	$1,300	9	$2,400
5	$1,600	10	$2,600

4) Must be a citizen on the United States or a certified Legal Alien Resident.

To avoid delay in determining eligibility, the following items must be submitted:

A Certificate of Indian Blood (CIB) for at least one person in the family unit; and

Proof of school enrollment for each child that is six years of age or older.

Placement papers from a placement agency; or

A notarized statement from the custodial parents that gives you custody and the right to acquire benefits; or

A Statement of Adult Acting in Loco Parentis .

Head of Household

First Name(Required)

Middle Name(Required)

Last Name(Required)

Suffix (Jr, SR, II)

Alternate Names

Gender(Required)

Male

Female

Date of Birth(Required)

Social Security #(Required)

US Citizen?(Required)

Yes

Tribal Affilation(Required)

Enrollment #(Required)

Disabled?(Required)

Yes

Pregnant?(Required)

Yes

If Pregnant, Due Date

Physical Address(Required)

Street Address City State ZIP Code

Mailing Address(Required)

Street Address City State ZIP Code

Phone Number(Required)

Email Address(Required)

Marital Status(Required)

Single, Never Married

Married

Seperated

Divorced

Widowed

Highest Education Level Completed(Required)

Less than High School Diploma or GED

High School Diploma or GED

Associates Degree

Bachelor’s Degree

Graduate/Master’s Degree

Other Credentials (Ex. CDL, Vocational Certifications, etc.)

Do you have a Spouse or Significant Other?(Required)

Yes

Spouse/Significant Other

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Alternate Names

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Pregnant?

Yes

If Pregnant, Due Date

Phone Number

Email Address

Marital Status

Single, Never Married

Married

Seperated

Divorced

Widowed

Highest Education Level Completed

Less than High School Diploma or GED

High School Diploma or GED

Associates Degree

Bachelor’s Degree

Graduate/Master’s Degree

Other Credentials (Ex. CDL, Vocational Certifications, etc.)

Child #1

First Name(Required)

Middle Name(Required)

Last Name(Required)

Suffix (Jr, SR, II)(Required)

Relationship To Household(Required)

Gender(Required)

Male

Female

Date of Birth(Required)

Social Security #(Required)

US Citizen?(Required)

Yes

Tribal Affiliation(Required)

Enrollment #(Required)

Disabled?(Required)

Yes

Teen Parent(Required)

Yes

Pregnant?(Required)

Yes

If Pregnant, Due Date

Father's Name(Required)

Father's Status(Required)

In Home

Absent from Home

Deceased

Mother's Name(Required)

Mother's Status(Required)

In Home

Absent from Home

Deceased

Current Grade Level(Required)

School Attending(Required)

Do you have additional children to add?(Required)

Yes

Child #2

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

School Attending

Do you have additional children to add?

Yes

Child #3

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

School Attending

Do you have additional children to add?

Yes

Child #4

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

School Attending

Do you have additional children to add?

Yes

Child #5

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

School Attending

Do you have additional children to add?

Yes

Child #6

First Name

Middle Name

Last Name

Suffix (Jr, SR, II)

Relationship To Household

Gender

Male

Female

Date of Birth

Social Security #

US Citizen?

Yes

Tribal Affiliation

Enrollment #

Disabled?

Yes

Teen Parent

Yes

Pregnant?

Yes

If Pregnant, Due Date

Father's Name

Father's Status

In Home

Absent from Home

Deceased

Mother's Name

Mother's Status

In Home

Absent from Home

Deceased

Current Grade Level

School Attending

Resources and Income Information

Do any of the children in the family unit have resources?(Required)

If Yes, complete below.

Yes

Resources

A resource is anything that is own or is being bought that can be sold, traded, or converted into cash or money held by others. A resource does not include personal property such as furniture or clothing. Example of resources are: Annuities, Checking, Land, Savings Accounts, Bonds, College Funds, Life Insurance, Savings Bonds, Buildings, Condominiums, Money Market Accounts, Stocks, Cash, Houses, Mutual Funds, Time Shares, CD Accounts, IIM Accounts, Sales Contracts, Trusts.

Resource

Who Owns

Location

Value

Primary Vehicle

Please list the primary vehicle that is used to transport the children in the family unit. If you do not have a vehicle, please leave blank.

Year

Make (Ford)

Model (Escort)

Income Statement

Do you receive any form of income for the children in the family unit?(Required)

If yes, complete the Unearned Income section. If no, please read the following statement and initial afterwards. Both Head of Household and Significant Other must initial.

Yes

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

Head of Household Initials:

At this time, I/we attest that I/we receive no form of unearned income for the children in the family unit.

Spouse Initials:

At this time, I/we attest that I/we receive no form of unearned income for the children in the family unit.

Unearned Income

Do you receive any form of unearned income for the child in the family unit?

Yes

Unearned Income

Examples of unearned income are: Alaska Shareholder Dividends, Gifts or Prizes, Rental/Lease Income, Annuities, IIM Accounts, Sale of Property/Timber, Child Support, Inheritance, Settlements, Dividends, Military Allotments, Social Security – Dependent Benefits, Food Stamps, Out of State TANF, Social Security – Survivor Benefits, Foster Care Payments, Per Capita, Supplemental Security Income – SSI, Tribal Lease Payments.

Who Received Income

Income Type

Amount

Frequency Received

Date Received

Hidden

Section Break

Child Support Income Statement

Have you or your significant other received child support payment(s) directly from a non-custodial parent in the last 30 days?(Required)

If yes, list the date and amount of the payments that you have received. If no, please read the following statement and initial afterwards. Both Head of Household and Significant Other must initial.

Yes

Date Received

Amount Received

Head of Household Initials:

At this time, I/we attest that I/we have not received any child support payments directly from a non-custodial parent in the last 30 days.

Spouse Initials:

At this time, I/we attest that I/we have not received any child support payments directly from a non-custodial parent in the last 30 days.

Statement of Residency

Head of Household(Required)

First Last

Significant Other

First Last

Residing Address(Required)

Street Address Address Line 2 City State ZIP Code

I/we have resided at this address for:

WEEKS

I/we have resided at this address for:

MONTHS

I/we have resided at this address for:

YEARS

I/we make rent/lease/mortgage payments to:

Payment Recipient

I/we make rent/lease/mortgage payments in the amount of:

Payment Amount

Head of Household Initials:

Spouse Initials:

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.

Head of Household Signature(Required)

I/we have read (or had explained to me/us) and understand the information in this application. I/we declare under penalty of perjury, that information I/we gave in this application is true, correct and complete to the best of my/our knowledge. I/we understand that if I/we incorrectly receive a Tribal TANF cash grant, because I/we have made a willful false statement or because I/we have willfully failed to report information required by the Tribal TANF Program, I/we will be required to repay the amount received.

Significant Other Signature

Date of Signature(Required)

Date of Signature

Child Support Referral Information

Please complete the Child Support Referral and Assignment. It will be emailed back to you upon completion. Attach with all other supporting documents at the end of the application. Please know that incomplete referrals and assignments will delay the processing time for a determination of eligibility. Information is required on the custodial parent(s), non-custodial parent(s) and children. If children do not have the same mother and father, a separate referral must be completed.

Required Child Support Referral

You must complete this required form and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this application.

Required Child Support Assignment

Required Statement of Adult Acting in Loco Parentis

Required Release of Information

Required Payment Form

Required W9 -9 Release of Taxpayer Information

You must complete an IRS W9 form and attach it to this application. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed W9 will be emailed to you and can then be attached to this application.

Optional Authorization Agreement for Direct Deposit

Depending on the payment form choice you chose, this form made be required. Click HERE to open the form in a new tab. Fill out the form completely, sign and submit. The completed form will be emailed to you and can then be attached to this application.

File Upload(Required)

Drop files here or

Max. file size: 40 MB, Max. files: 20.

File Upload

For additional files to upload.

Drop files here or

Max. file size: 40 MB, Max. files: 20.

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

Head of Household

Spouse/Significant Other

Child #1

Child #2

Child #3

Child #4

Child #5

Child #6

Resources and Income Information

Primary Vehicle

Income Statement

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

Unearned Income

Section Break

Child Support Income Statement

Statement of Residency

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.

Child Support Referral Information

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