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Applicant Information

 

Provide your first name!

Must provide last name!

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Must specify gender!

/ / Please add your date of birth.

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Your social security # is required.

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Must provide marital status!

Must define family status!

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Please specify.

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Please specify.

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Please specify.

Education Status of applicant

 

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Contact Information

 

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Please add a phone number!

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Services you are requesting

 

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REQUEST FOR RELEASE OF CONFIDENTIAL INFORMATION

 

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

 

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Work Innovations Opportunity Act (WIOA) Applicants ONLY

Background checks will be completed if placed with children/elderly

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Employment History

 

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

 

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

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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)

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Monthly (submit documentation) 

Applicant

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Spouse/Co-Applicant

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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.
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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

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LOW INCOME HOME ENERGY ASSISTANCE PROGRAM (LIHEAP)

LIHEAP Applicants only—Fuel season: November 1, 2020—April 30, 2021

* Incomplete applications will not be processed until fully completed

ATTN: Before starting this application please make sure

you have the LANDLORD/SHELTER STATEMENT 

filled out by your landlord and ready to upload. 

You can DOWNLOAD the Shelter Statement

 

Here

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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.

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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.

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Client/DHRD AGREEMENT

 

Applicant’s Responsibilities

 

I understand that:

  1. 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).
  2. 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.
  3. 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.
  4. I am required to sign a Release of Confidential Information Form in order to assist my worker in establishing my eligibility.
  5. 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.
  6. DHRD has the right to cross-reference this application with other requests for assistance, to verify household members, claimed income, place of residence, etc.
  7. 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:

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

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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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SELF-SUFFICIENCY ACTIVITY PLAN AND GOALS

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ACTION STEPS TO ACHIEVE GOAL

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STEPS NEEDED TO ACHIEVE SELF-SUFFICIENCY

 

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CONSENT FOR RELEASE OF INFORMATION  

Confederated Salish and Kootenai Tribes

INTERAGENCY

 

 

I/We, the undersigned are seeking services from the Department of Human Resources Development (DHRD) which includes, but is not limited to the following programs: Child Care Block Grant, TFAP Cash Assistance, Commodities, Dire Need, WIOA, SYEP, LIHEAP, NEW, GA, Indian Elderly Program, Vocational Rehabilitation Program, Child Support Enforcement Program, Intervention Services (CPS, Foster Care, IIM 4-E, 2nd Circle) Transportation/Transit and CSKT Tribal Council.

 

I, authorize the above named programs to share, exchange, give and receive information about my application and contents therein, in an effort to serve me, my family and my children (as declared on my application/applications for assistance).

 

In addition, I/We authorize the following programs/agencies to release and share information to the DHRD Programs in an effort to provide and facilitate assistance to my/our children and myself/ourselves.  Those programs and agencies include but are not limited to the following:

CHECK EACH PLACE YOU GIVE PERMISSION TO RELEASE INFORMATION.

                                                                                                                                                               

 

 

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Mission & Vision Statement

Our Vision: All children will learn, grow and develop to realize their full potential.

Our Mission: A parent as Teachers promotes the optimal early development, learning and health of children by supporting and engaging their parents and caregivers.

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