Application for TANF- Diversion Services

DIVERSION SERVICES
TANF Services are available for eligible families who have had children placed with them or for which they are otherwise acting as a Diversion Services are available to families who are otherwise eligible for TANF. Diversions consist of a one-time payment of $2,000 and are limited to one per year and up to ten per lifetime. Those that receive Diversion Services cannot apply for a monthly cash grant until after the first day of the month, three months from the date that the Diversion Services closed.
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 Indian Nation living in the family unit.
3) Income limitations are based on 300% of the Federal Poverty Level for the year in which the application is received.

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

Social Security Card for each adult and child in the family unit.

State Certified Birth Certificates for each adult and child in the family unit.

Verification of all household income, both earned and unearned, for the previous 60 days.

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

Custody Order or Parenting Plan that shows the children are in the home at least 51% of the time. This is only required if a parent is out of the home.

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 you or anyone in the household have any resources?(Required)

If Yes, complete below.

Yes

Resources

A resource is anything that you own or are buying 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: Cash, Checking Accounts, Savings Accounts, CDs, Money Market Accounts, Savings Bonds Bonds, Mutual Funds, Stocks, Annuities, Trusts, IRA, 401K, Retirement Fund, Houses, Condominium, Land, Sales Contracts, Buildings. Life Estate Life Insurance Burial Funds, Prepaid College Funds Time Shares Business Equipment Farm Equipment Livestock

Resource

Who Owns

Location

Value

Vehicles

Do you or anyone in the household own a licensed or unlicensed vehicle (car, truck, motorcycle, boat, recreational vehicle or any other type of vehicle?(Required)

If Yes, complete below.

Yes

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)

Owed $

Payment $

Value $

Income Statement

Have you, or anyone in the household, received any form of earned or unearned income in the last 60 days?(Required)

If yes, complete the following Section Earned Income and Section Unearned Income, as it applies. If no, please read the following statement and initial afterwards. Both Head of Household and Significant Other must initial.

Yes

Head of Household Initials

I/we attest that I/we have not receive any form of earned or unearned income in the last 60 days.

Significant Other Initials:

I/we attest that I/we have not receive any form of earned or unearned income in the last 60 days.

Earned Income

Do you or anyone in the household have income from work?

If yes, complete the following information.

Yes

Earned Income

Who earns this income?

Employer’s Name

Employer’s Phone Number

Start Date

Gross Amount (Before Taxes) $

Pay Frequency (Week, Two Weeks, Month)

Is this job self-employment (Yes, No)

Unearned Income

Do you or anyone in the household have any unearned income?

If Yes, Complete below.

Yes

Unearned Income

Examples of unearned income are: Alimony, Medical Assistance, Social Security – Dependent Benefits, Annuities, Military Allotments, Social Security – Survivor Benefits, Casino Winnings, Out of State TANF, Subsidized Housing, Child Support, Per Capita, Supplemental Security Income (SSI), Dividends, Railroad Retirement, Tribal Lease Payments, Food Stamps, Rental/Lease Income, Unemployment Benefits, Foster Care Payments, Sale of Property or Timber, Veteran’s Benefits (VA), General Assistance (GA), Settlements, Worker’s Compensation Benefits, Gift or Prizes, Social Security –Disability, Inheritance, Social Security –Retirement

Whose Income

Income Type

Amount $

Frequency Received

Date Received

Statement of Residency

Head of Household(Required)

I/We

First Last

Significant Other

I/We

First Last

Residing Address(Required)

Live at:

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:

Statement of Child Custody

A dependent child is considered a member of the household if they spend 51% of their time during the calendar month in the household.

Do all of the children listed in this application currently live with you at least 51% of the time?(Required)

If no, please know that you cannot apply with children who do not meet this requirement.

Yes

Head of Household Initials:(Required)

I/we attest that all of the children listed in this application currently live with me/us at least 51% of the time.

Spouse Initials:

I/we attest that all of the children listed in this application currently live with me/us at least 51% of the time.

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

Required Release of Information

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 Crisis Statement

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)

Upload required files.

Drop files here or

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