Page 1 of 12
Background checks will be completed if placed with children/elderly
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)
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: email@example.com
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
filled out by your landlord and ready to upload.
You can DOWNLOAD the Shelter Statement
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.
FAMILY INCOME AND AVAILABLE FUNDS
All applicants must fill out
I understand that:
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.
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.
SELF-SUFFICIENCY ACTIVITY PLAN AND GOALS
ACTION STEPS TO ACHIEVE GOAL
STEPS NEEDED TO ACHIEVE SELF-SUFFICIENCY
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.
Tribal Personnel/Payroll Office: (Drug Test results, payroll data, etc.), etc.
Early Childhood Services – ECS – Participation in services (CHIP information, Address, Household Composition)
Tribal Health Department – THD
Tribal Education Department – TED (educational awards, grades, referrals), etc.
Salish Kootenai College/ALC/ABE Programs – (Schedule, Test results, Student verification of attendance, Credit Loan, Grants), etc.
Montana State Offices of Public Assistance – (Flathead, Lake, Missoula, Sanders County)
Landlord/Mortgage institutions/Fuel vendor (i.e. Salish Kootenai Housing Authority, Ronan Housing Authority, Eagle
Bank, Mission Valley Power), (Rent amount, household heating/cooling vendor, household compositions, lease
compliance, residency), etc.
Public Schools – (verify attendance of minor children in general school and at IEP sessions)
Tribal Police – (CPS referrals and outstanding warrants.), etc.
Probation Adult/Juvenile – (Truancy, Community services and other requirements)
Tribal Court – Community Services and Court Orders, etc.
Division of Lands – (verify Land Lease), etc.
Tribal Prosecutors / Tribal Defenders (CPS, Court Orders, Truancy, Families at Risk Staffing), etc.
MT Healthy Kids Insurance Program (CHIP) – Eligibility Status & Employee Health Insurance Information
Tribal Enrollment & Per Capita statement
social Security Administration, MT Disability Bureau, Veteran’s Administration – Verify income
Social Service, Child/Adult Protective Service, Foster Care, Second Circle, GA, Trust Management
EMPLOYER NAME ADDRESS PHONE
Chemical Dependency (City, State and/or Tribal Programs for compliance with IFP/Service Treatment Agreement)
State TANF Programs (to get the number of months for the Federal Time Clock)
Bureau of Indian Affairs (Individual Indian Monies IIM Account ) verification
CSKT Individual Indians Monies Account need current balance for
Child Support Enforcement Division Case #
Potential employers found by DHRD TANF-WIOA list
I understand that the information received by the DHRD Programs will be kept confidential, used for professional purposes only in terms of facilitating services received by me and my family, and will not be released to other outside programs/agencies, unless prior authorization by me, in writing, is obtained. I understand that I may cancel this Consent for Release of Information, in writing at any time.
Check here to sign and date
Witness check here to sign and date
THIS RELEASE OR REQUEST OF INFORMATION HAS BEEN REVOKED BY:
36122 2nd St. N.Pablo, MT 59855
Copyright © 2016 Confederated Salish and Kootenai Tribes. All Rights Reserved.
Phone: (406) 675-2700 | Email: firstname.lastname@example.org | www.csktdhrd.org