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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 and cooperating with DSR staff, including, if necessary, investigations.
(Required)
I certify I understand.
For Two-Parent applications, both Parents must initial.
Customer Responsibility Parent 1 Initial
(Required)
Customer Responsibility Parent 2 Initial
Customer Responsibility 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 to the third party.
(Required)
I certify I understand.
Confidentiality Parent 1 Initial
(Required)
Confidentiality Parent 2 Initial
Confidentiality Parent 2 Initial
DECISION NOT APPEALABLE – I understand the decision made regarding my eligibility for Diversion Benefits cannot be appealed. I also understand that if I am not eligible for Diversion Benefits, I have the right to apply for DSR Monthly Assistance.
(Required)
I certify I understand.
Decision Not Applicable Parent 1 Initial
(Required)
Decision Not Applicable Parent 2 Initial
Decision Not Applicable Parent 2 Initial
RELEASE OF INFORMATION – I authorize DSR to contact any other agency to obtain information necessary to determine my 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)
I certify I understand.
Release of Information Parent 1 Initial
(Required)
Release of Information Parent 2 Initial
Release of Information Parent 2 Initial
FRAUD PENALTIES – I understand if I intentionally provided false information, or withhold information, in order to make my family eligible for DSR Diversion Benefits, which my family would otherwise be ineligible to receive, I and, if applicable, the other parent may be disqualified from receiving DSR assistance and benefits. In addition, I may be subject to criminal penalties under applicable tribal, state or federal laws.
(Required)
I certify I understand.
Fraud Penalties Parent 1 Initial
(Required)
Fraud Penalties Parent 2 Initial
Fraud Penalties Parent 2 Initial
Head of Household's Signature
(Required)
Print Name
(Required)
First
Middle
Last
Date
(Required)
MM slash DD slash YYYY
Spouse’s Signature (Two-Parent Application)
Print Name
First
Middle
Last
Date
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.
Password
(Required)
The completed PDF form will be emailed to you please provide an email address below.
Email
(Required)
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