Please complete the following form. The completed form will be emailed to the email you have specified. Please upload the form in your TANF application or in the upload portal.

Please contact XXXXX for questions or concerns regarding this process.

• I understand the questions on this form.
• I understand any facts I have given, including benefit income facts, will be matched with local, state and federal
records (Employees, Social Security, TANF and other applicable agencies).
• I understand all facts entered on this form, including benefit and income information are subject to verification and
review by tribal personnel. Giving false /misleading facts and /or failing to report information may affect eligibility or
benefits for Cash Assistance /Services.
• I understand my case may be selected for additional review to ensure my eligibility was accurately determined and
I must cooperate fully with tribal personnel in any temporary investigations or reviews, including quality review.
• I understand the Chippewa Cree Tribal TANF Program is a temporary assistance program.
• I understand, as a condition of receiving assistance, parents are required to participate in a work participation
program.
• I understand I will be required to develop an individual improvement plan (“IIP”) with the Chippewa Cree Tribal
TANF case managers.
• I understand I have the right to full and complete confidentially of all information pertaining to my application or
verification.
• I understand I have the right to an appeal if dissatisfied with any adverse action, sanction or denial of benefits
affecting my application or ongoing TANF case.
• I understand my family may not receive duplicative assistance from a state or other Tribal TANF program.
• I understand in order to comply with TANF regulations, clients are required to undergo drug testing.