Muscogee (Creek) Nation Energy Program Page 1 of 2
HEAD OF HOUSEHOLD:_________________________________________ DATE:__________________________
PHONE:_______________________ DATE OF BIRTH:________________ SSN:___________________________
TRIBE:________________________ ROLL #:______________________ COUNTY:_______________________
PHYSICAL ADDRESS:________________________________________________________________________________
MAILING ADDRESS:________________________________________________________________________________
HOUSEHOLD COMPOSITION (Not including Head of Household):
Roll #
HOUSEHOLD INCOME (for LIHEAP applicants): Please include all household income earned (salaries, odd jobs, etc.) and
unearned (SSI, SS, Unemployment, Child Support, TANF, etc.).
Income is optional for Tribal Energy applications. Tribal Energy applicants may skip to the next section.
How Often?
For Office Use Only:____________________________________________________________________________________________
Jenks Location:
1000 Riverwalk Terr. Ste. 240
Jenks, OK. 74037
Phone: 918-549-2484
Fax: 918-298-4197
Muscogee (Creek) Nation Energy Program Page 2 of 2
Please answer the following questions:
1. Has any member of the household applied for Energy Assistance through DHS or a Tribal Town?
Please Check: NO
YES If yes, date?____________ And which DHS or Tribal Town?_____________________
Does your household receive SNAP benefits?
Please Check: NO
Would you like MCN Social Services Energy Department to receive or give information to designated
friends or family members?
Please Check: NO
YES If yes, please complete the following for identification purposes.
Name:______________________________________ Relation:___________________
Fair Hearing Statement: Once the Case Specialist receives your application, it will be considered pending until all required documents are received or up to 30 days, whichever
comes first. After 30 days, the application will be denied. All required documentation must be received in order for eligibility to be determined. In the event of denial, if the
applicant feels the decision of the Social Services staff is in error, he/she may file a written appeal within 10 days from the date on the letter of denial. The Human Services
Director will review and forward the appeal letter to an Appeals Team for review and a decision will be made within 10 days from receiving the appeal letter. All decisions will
be based according to Tribal and Federal Law, and the program policy and procedures.
Fraud Statement: All information pertinent to services requested is subject to verification. Falsification of this information shall be grounds for denial of application and/or non-
eligibility to receive future assistance. Fraud cases may be forwarded to the MCN Attorney General’s Office if further action is needed.
Privacy Act Statement: The MCN Social Services Department cannot give out applicant’s information; however, Social Services can share the information with other Federal,
State, Tribal Offices, programs and/or businesses who have some responsibility with the services for which the applicant is applying. For any other person or program wanting
information from the applicant’s case file, the applicant must first give his/her consent by completing #4 above.
By signing below, I certify that I understand and acknowledge the following:
I have read this application or had this application read to me and that all information provided by
me, oral and written, is true and accurate.
I have read and understand the Fair Hearing, Fraud, and Privacy Act Statements.
I understand that LIHEAP and Tribal Energy are not emergency programs and that I must continue
to pay my regular utility bill. I further understand “commit to pay letters” will not be sent.
I understand that Social Services reserves the right to forward my application to the office closest
to my physical location.
I understand that applications may take up to 90 days or longer to process.
Head of Household Name (Printed):___________________________________________
Head of Household Signature/Enrolled Tribal Member Signature:_____________________________________
Does any household members receive social security benefits?
□ No □ Disability benefits □ Retirement benefits □ Survivors benefits
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