Applicant Information

First Name(*)

Provide your first name!

Last Name(*)

Must provide last name!

M.I.

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Maiden Name (other)

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Check if a new applicant

I am a new applicant Invalid Input

I have applied for public assistance before. If yes, where?

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Date last applied

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Gender(*)

MaleFemale Must specify gender!

Date of Birth(*)

/ / Please add your date of birth.

Male over 18, have you applied with Selective Service?

YesNo Invalid Input

Social Security No.(*)

Your social security # is required.

Tribal Enrollment No.(*)

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Family Status(*)

Single IndividualParent in one parent familyParent in two parent family Must define family status!

Number of dependents under 18

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Have you ever been arrested?(*)

YesNo Please specify.

Total Number in Household

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Select which ever applies, if any.

Enrolled CSKTEnrolled In Other TribeFirst Generation DescendantNone Invalid Input

Enrolled Parent Name

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Tribal Affiliation

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Veteran(*)

YesNo Please specify.

Upload Tribal Affiliation

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US Citizen

YesNo Invalid Input

Driver's License(*)

YesNo Please specify.

Driver's License No

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Have Transportation?(*)

YesNo Please specify

Vehicle Insurance?(*)

YesNo Please specify.

Insurance Company

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Provide Proof of Insurance

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Current loans with CSKT?(*)

YesNo Please specify.

Education Status of applicant

Education Level

High SchoolCollege/Vocational School/TechGEDCertificate of AchievementCurrently enrolled/attending schoolCurrent TABE (within last year) Invalid Input

Degree

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Year Received or Graduated

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Major

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Contact Information

Mailing Address:(*)

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City(*)

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Zip Code(*)

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Physical Address

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City

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Zip Code

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Home or Message Phone(*)

Please add a phone number!

Work Phone

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Cell Phone

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Email Address(*)

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Services you are requesting

Check all that apply

Education and TrainingEmploymentGeneral Assistance (GA)Child Care Block Grant (CCBG)Lights, Heat, Energy Assistance Program (LIHEAP)Temporary Assistance to Needy Families (TANF)Dire NeedWorkforce Innovations Opportunity Act (WIOA) *Applicants must enroll in MentoringMentoring (Resume needed) Invalid Input

REQUEST FOR RELEASE OF CONFIDENTIAL INFORMATION

Have you had any of the following loans with the tribal credit office (please mark all that apply)

SHORT TERM MONTHLY PAYMENT LOANREVOLVING LONG TERM LOANEDUCATIONAL LOANBUSINESS LOAN

Please list all occupants of the household residence below: All applicants must fill out

Household Name 7

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Gender

MaleFemale Invalid Input

Date of Birth

Invalid Input

Social Security#

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Enrollment#

Invalid Input

School/Daycare

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Household Name 8

Invalid Input

Gender

MaleFemale Invalid Input

Date of Birth

Invalid Input

Social Security#

Invalid Input

Enrollment#

Invalid Input

School/Daycare

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Household Name 9

Invalid Input

Gender

MaleFemale Invalid Input

Date of Birth

Invalid Input

Social Security#

Invalid Input

Enrollment#

Invalid Input

School/Daycare

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Household Name 10

Invalid Input

Gender

MaleFemale Invalid Input

Date of Birth

Invalid Input

Enrollment#

Invalid Input

School/Daycare

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Social Security#

Invalid Input

Household Name 11

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Gender

MaleFemale Invalid Input

Date of Birth

Invalid Input

Enrollment#

Invalid Input

School/Daycare

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Social Security#

Invalid Input

If more than 6 household members please specify names, gender, DOB, Social Security, Enrollment # and Schools/Daycares

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Comments:

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Work Innovations Opportunity Act (WIOA) Applicants ONLY

Background checks will be completed if placed with children/elderly

Have you ever participated in WIOA before? If yes answer (A)-(E)

YesNo Invalid Input

(A) Sponsoring Organization

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(B) City

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(C) State:

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(E) From Date

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(D) Program Activities

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(E) To Date

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List other experience and/or voluntary work:

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Types of work preferred:

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Employment History

Hourly Wage $

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Have you worked in the last 13 weeks?

YesNo Invalid Input

In the last 12 months?

YesNo Invalid Input

Are you working part-time, but seeking full-time?

YesNo Invalid Input

Describe all jobs held, starting with the most recent position: (include Military jobs)

Employer

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Full/Part-Time

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Position/Title 1

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Start/End Dates

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Hr. per week

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Rate of Pay

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Address of Employer:

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Employer1 Phone:

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Duties:

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Reason for Leaving

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Employer 2

Invalid Input

Full/Part-Time

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Position/Title 2

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Start/End Dates

Invalid Input

Hr. per week

Invalid Input

Rate of Pay

Invalid Input

Address of Employer:

Invalid Input

Employer2 Phone:

Invalid Input

Duties:

Invalid Input

Reason for leaving:

Invalid Input

Employer 3

Invalid Input

Full/Part-Time

Invalid Input

Position/Title 3

Invalid Input

Start/End Dates

Invalid Input

Hr. per week

Invalid Input

Rate of Pay

Invalid Input

Address of Employer:

Invalid Input

Employer3 Phone:

Invalid Input

Duties:

Invalid Input

Reason for leaving:

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CHILD CARE BLOCK APPLICANTS (CCBG) ONLY

(Must be working, enrolled in formal training, attending school FT or PT job) (Three months only for job searching)

Employer:

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Hours:

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Work Schedule:

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Spouse/Co-Applicant:

Invalid Input

Spouse Address & Phone #

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Spouse/Co-Applicant Employer:

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Work Phone:

Invalid Input

If you have more members in your household please list their information here ( Name, DOB, Tribe/ID, Relationship, Gender (M/F) and Occupation.

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Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

FemaleMale Invalid Input

Occupation

Invalid Input

Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

MaleFemale Invalid Input

Occupation

Invalid Input

Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

MaleFemale Invalid Input

Occupation

Invalid Input

Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

MaleFemale Invalid Input

Occupation

Invalid Input

Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

MaleFemale Invalid Input

Occupation

Invalid Input

Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

MaleFemale Invalid Input

Occupation

Invalid Input

Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

MaleFemale Invalid Input

Occupation

Invalid Input

Name

Invalid Input

Date of Birth

Invalid Input

Tribe/ID

Invalid Input

Relationship

Invalid Input

M/F

MaleFemale Invalid Input

Occupation

Invalid Input

Children I need CCBG For

Invalid Input

Monthly (submit documentation)

Applicant

Wages/Salary $

Invalid Input

Child Support $

Invalid Input

Social Security

Invalid Input

Self-Employment $:

Invalid Input

Public Assistance $

Invalid Input

Financial Aid $

Invalid Input

Other

Invalid Input

Other - Describe

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Spouse/Co-Applicant

Wages/Salary $

Invalid Input

Child Support $

Invalid Input

Social Security $

Invalid Input

Self-Employment

Invalid Input

Public Assistance

Invalid Input

Educ. Financial Aid

Invalid Input

Other

Invalid Input

Other- Describe

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Total $

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+ Total $

Invalid Input

= $ Total Monthly Income

Invalid Input

Please upload any documents pertaining to you and your spouses wages i.e., wages/salary, child support, social security, self-employment, public assistance, educational (financial aid) or other financial information here. to add multiple files click the 'Add More Files' button.

(submit documentation)

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Upload Work Verification:

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WORK VERIFICATION CCBG Applicants ONLY

ALL PERSONS 18 YEARS & OLDER MUST COMPLETE A FORM

**DO NOT LEAVE ANY BLANK SPACES**

Before starting this application please follow these steps:

1) Download the WORK VERIFICATION file here.

2) Have your supervisor fill it out.

3)Upload it at the end of this form or email to: dhrd-help@cskt.org

CCBG Applicants ONLY Upload filled out Work Verification from Employer

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2021 POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES AND THE DISTRICT OF COLUMBIA

(This is used to determine whether the applicant(s) meet the income guidelines for service. Please list your household members and Poverty Guidelines amount.)

ALL applicants must fill out.

List persons in family/household

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Poverty Guidelines (annual income)$

Invalid Input

$12,880

Invalid Input

$17,420

Invalid Input

$21,960

Invalid Input

$26,500

Invalid Input

$31,040

Invalid Input

$35,160

Invalid Input

$40,120

Invalid Input

$44,660

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FAMILY INCOME AND AVAILABLE FUNDS

All applicants must fill out

Family Income and Available Funds—List ALL sources of income that you have received during the last 30 days and current available funds. You must provide copies of pay stub(s) if worked, for the last 30 days as verification of income. Add amounts and comments in the text boxes for each line item that pertains to your family income.

Applicant’s net salary $

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Spouse net salary $

Invalid Input

General Assistance $

Invalid Input

Housing Assistance $

Invalid Input

Child Support and alimony $

Invalid Input

Social Security $

Invalid Input

TANF/SNAP $

Invalid Input

Veteran’s Benefits $

Invalid Input

Unemployment Insurance Benefits $

Invalid Input

Medicare/
Medicaid $

Invalid Input

Checking Account $

Invalid Input

Savings Account $

Invalid Input

Student Loans/grants/
Scholarship(s) $

Invalid Input

Cash out retirement/
Pension $

Invalid Input

Foster Care Payments $

Invalid Input

Workers Comp $

Invalid Input

Other $

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Total Household Income for the last six (6) months: $

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By checking these boxes I/We certify that all information provided on all sections of this application is true and correct to the best of my/our knowledge.

Check here (Applicant)Check here (Co Applicant) Invalid Input

Client/DHRD AGREEMENT

Applicant’s Responsibilities

I understand that:

The answer(s) I give on this form will be used to help determine my eligibility for any assistance applied for through DHRD. (GA, LIHEAP, TANF, WIOA, Mentoring, CCBG).
The amount of my grant depends on the number of eligible people in my household. If I report that an eligible person has left or had income, which makes him/her ineligible, the amount of my grant is subject to change.
The amount of my grant also depends on the amount of income received by me and others covered by my grant. If the income I report is more than the grant allowance, I will be denied for the month.
I am required to sign a Release of Confidential Information Form in order to assist my worker in establishing my eligibility.
I am aware of the Tribal, Federal, State of Montana laws that provide for a fine and/or imprisonment of any person(s) who attempt to receive, or receives assistance to which he/she is not entitled.
DHRD has the right to cross-reference this application with other requests for assistance, to verify household members, claimed income, place of residence, etc.
DHRD may deny assistance based on the information provided on DHRD applications until the applicant provides additional information.

FEDERAL LAW GOVERNING FRAUD

I UNDERSTAND THAT BY SUBMITTING:

Whoever, in any matter within the jurisdiction of any Department or Agency of the United States, knowingly and willfully, conceals or covers up by any trick, scheme or device, a material fact, or makes false, fictitious, or fraudulent statements or representation or makes any false writing or document, knowing the same to contain any false, fictitious statement or entry, shall be fined not more than $10,000 or imprisoned not more than 5 years or both.

I/We agree by submitting this online form to supply all necessary information about my/our resources and income and to notify DHRD when my/our situation changes. I/We authorize DHRD to obtain information necessary to establish my/our eligibility for assistance from the appropriate Agencies and that this information shall be kept CONFIDENTIAL. I/We further agree that this information may be released for the purposes of investigation of fraud.

NO INCOME DECLARATION

Received any income for the last three (3) month(s) of:

Current Month Income

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Last Month Income

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Month before that Income $

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The reason that I/We have had no income for the months listed above is as follows:

Rent/Mortgage

Invalid Input

Food $

Invalid Input

Child Care $

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Utilities $

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Other

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By checking this box

I/We declare by checking the box on this statement line that the information provided on this form is true and correct to the best of my/our knowledge. I understand that because The PL102-477 Program(s) are federally funded and the penalty for providing false information shall not be more than $10,000 dollars and/or not more than five (5) years imprisonment. Invalid Input

INDIVIDUAL SELF-SUFFICIENCY PLAN (ISP)

I understand that the purpose of this Individual Self-Sufficiency Plan (SP) is to meet the goals of employment through specific action steps. I am aware that I am required to follow the steps developed in the (ISP). I understand that I must participate in work activities and/or other activities and referrals developed in this plan that will promote my self-sufficiency and failure to do so may constitute suspension from the Public Assistance Program for a period of 60 days, but not more than 90 days.

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Are you currently employed?

YesNo Invalid Input

If yes, where?

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How long?

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Highest grade completed

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Date Graduated

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Date received GED or Certificate of Achievement

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Date last attended school

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What are your short-term employment goal(s) to get off General Assistance?

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What are your long-term goal(s) to get off Public Assistance?

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STEPS NEEDED TO ACHIEVE SELF-SUFFICIENCY

START DATE

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GOAL #2

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WHO WILL COMPLETE

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DATE TO ACHIEVE

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Steps1

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Steps2

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Steps 3

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Applicant Information

Education Status of applicant

Contact Information

Services you are requesting

REQUEST FOR RELEASE OF CONFIDENTIAL INFORMATION

Please list all occupants of the household residence below: All applicants must fill out

Work Innovations Opportunity Act (WIOA) Applicants ONLY

Employment History

Describe all jobs held, starting with the most recent position: (include Military jobs)

GENERAL ASSISTANCE (GA) APPLICANTS ONLY (Applicants must take/pass a drug test)

Monthly (submit documentation)

Please upload any documents pertaining to you and your spouses wages i.e., wages/salary, child support, social security, self-employment, public assistance, educational (financial aid) or other financial information here. to add multiple files click the 'Add More Files' button.

ATTN: Before starting this application please make sure

you have the LANDLORD/SHELTER STATEMENT

NO INCOME DECLARATION

Received any income for the last three (3) month(s) of:

The reason that I/We have had no income for the months listed above is as follows:

INDIVIDUAL SELF-SUFFICIENCY PLAN (ISP)

CONSENT FOR RELEASE OF INFORMATION

Confederated Salish and Kootenai Tribes

APPLY FOR DHRD SERVICES ONLINE NOW!