Fillable Application for Services (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Application for Services (Central Council Tlingit and Haida Indian Tribes of Alaska)

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CENTRAL COUNCIL
Tlingit and Haida Indian Tribes of Alaska
Employment and Training Department • Andrew P. Hope Building
320 W Willoughby Avenue, Suite 300 • Juneau, Alaska 99801
Fax Number (877)333-3449
Application for Services
If you need help filling out this form or have any questions, please let us know and
we will do what we can to assist you.
How to Apply for Services
On the following page you will find a group of check boxes for services that are available to
enrolled Tribal Citizens and provided by Central Council Tlingit & Haida Indian Tribes of
Alaska (CCTHITA). Place a checkmark next to the service that you feel will best meet your
needs by clicking in the box to the left of the service. Please be sure to check all the
services that you feel will meet your needs. If you are not sure, don’t worry, this application
is designed to help us determine which service would work best for your specific needs.
What you should do after selecting your desired services
Once you check all the services that you need, enter the information in the “Required
Personal Information” section directly below the checkbox area. This information will be
utilized to begin the intake process for your application. After you have provided all the
information requested, an Eligibility Technician will review the information and determine
if we need anything else from you to help determine your eligibility. Many times this will
require you to fill out a couple more forms, but please be patient. This information is
required to enable us to provide a service that best fits your needs.
How long will it take?
Completed applications are processed in the order in which they are received. The
application provides places for you to identify your unique situation. If a caseworker has not
contacted you within five business days, please call at .
Let’s get started by selecting the services you need and filing out the required
information.
Intake Staff:
Application Date:
Application Complete:
Appointment Date:
If application complete, you should receive a call by no later than
What type of assistance do you need?
(CHECK ALL THAT APPLY)
Food
Finding Work
Classroom Training
Rent
Child Care
Vocational Rehabilitation
Utilities
Child Support
Post-Secondary Education
Oil/Heat
GED Classes
Other:
Transportation
Adult Basic Education
Other:
Burial Assistance
Vocational Training
Other:
Required Personal Information
(If it does not apply to you write N/A in the field)
Name:
(Last, First MI)
Social Security #:
Date of Birth:
Home Address:
City:
State:
Zip Code:
Mailing Address:
(Check Here if Same as Home Address)
City:
State:
Zip Code:
Home Phone:
Cell Phone:
Message Phone:
Marital Status:
Single Married
Separated Divorced
To Which Tribe are you Enrolled?:
Tribal Enrollment #:
Are you able to work?
Yes No
Is anyone in the household pregnant?
Yes No
Household Members
List ALL PERSONS living in the household – if you need more space use additional page
Name:
Relationship:
(see below)
Date
of
Birth:
SSN:
Education:
(see below)
Sex:
(M/F)
Race:
(see below)
US
Citizen:
Yes/No
HoH-Self
Relationship: Child=C, Foster Child=FC, Grandchild=GC, Non-Custodial Parent=NCP, Other related person=R, Partner=P, Stepchild=SC,
Unrelated Adult=UA, Unrelated Child=UC
Education: High School Diploma=HSD, GED=GED, College Undergraduate=CU, College Graduate=CG, Vocational Training=VT
Race: Alaska Native=AN, American Indian=AI, White=WH, Black=BL, Asian=AS, Native Hawaiian or Pacific Islander=PI
Expedited Food Stamps Eligibility
Answer these questions to see if you can get food stamps within seven days:
Do you have more than $100 in the bank?
Yes No
Is your household monthly gross income (income before deductions less than $150?)
Yes No
Are your costs for rent/mortgage/utilities more than your monthly gross income, cash and money in the bank? Yes No
Household Income
Includes ALL income received this month or that will be received next month from all jobs and all household
members. This includes but is not limited to tips, self-employment, contract income, vacation pay, etc.
Household Member
(First Name, MI,
Last Initial)
Employer
Full-time=FT,
Part-time=PT,
or Seasonal=S
Hrs/Wk
Hrly Wage
or
Mo.Salary
Amount
Paid
this
Month
Amount
paid
next
Month
How Often
(Weekly,
Bi-Weekly,
Monthly)
Has anyone in your household had a job end in the last 60 days Yes No
If yes, who?
No
Do you or anyone who lives with you receive funds from any other source that is not work related income?
(i.e., TANF, Food Stamps, SSI, Unemployment, Pension/Retirement, Bingo/Pulltab Winnings, PFD, Scholarships, etc.)
If so, please list all that apply to you. Use additional paper if necessary.
Who receives money
Type of Resource (i.e., TANF, SSI, etc.)
Amount this
month
Amount
next month
How
often
Household Assets
List funds your household has in cash and in bank/credit union (CU) accounts.
Cash
Bank/CU
Name on Acct.
Bank/CU Name
Acct Number
Acct Type
$
$
$
$
$
$
List all property of all persons in your household including but limited to houses, land, mobile home, condo, etc.
Who Owns the Property
Type of Property
Estimated Value
Amount Owed
List all vehicles owned by anybody in the household including but limited to cars, trucks, motorcycles, boats,
snowmobiles, recreational vehicles, all-terrain vehicles, etc.
Vehicle Owner
Vehicle Type, Model, and
Year
How is the vehicle used?
Estimated Value
Amount Owed
$
$
$
$
$
$
$
$
List all other assets (i.e., things of monetary value) that are owned by persons in your household including but not
limited to land, fishing permits, stocks, bonds, etc.
Owner
Type of Asset
Value/Amt. of Shares
$
$
$
$
Yes
Yes
No
Household Questions: Check Yes or No and If yes Answer the questions below
Have you or anyone in your household received ATAP or TANF? If yes, when and from what Office:
When: Where:
Have you or anyone in your household received ATAP or TANF in the last month?
If yes, how much?
Has anyone in your household had ATAP or TANF benefits reduced due to penalties?
If yes, please explain:
Have you been terminated from ATAP or TANF?
If yes, Date of Termination
Have you been determined ineligible for ATAP or TANF?
If yes, please explain
Have you been denied ATAP or TANF?
Reason:
Are you eligible to reapply for ATAP or TANF?
Date able to reapply:
Are you requesting assistance for anyone in your household who is pregnant:
If yes, who: When is the baby due:
Have you or anyone living in your household been convicted of a felony?
If yes, who, when, and where:
Probation Officer name and phone number:
Is any adult in your household fleeing from prosecution, custody or confinement for a Felony or Class A
Misdemeanor from any State?
If yes, who:
Is anyone in your household attending college or university?
If yes, who:
Do you have a valid driver’s license?
If yes, License Number: Expiration:
If you are male between the ages of 18-25, have you registered with the Selective Service?
If yes, Registration Number: Date Verified:
Are you a Veteran of the Armed Services?
If yes, Enlistment Date: Branch:
Do you have a physical or mental disability?
If yes, Explain:
Is it a service related disability?
If yes, VA Disability Rating:
Education
Highest Grade Completed: (Circle One)
6
7
8
9
10
11
12
13
14
15
16+
High School:
High School Graduate:
GED
Vocational Training:
Enrolled in Vocational Training:
Vocational Training Graduate:
College:
Enrolled in College:
College Graduate:
School Name:
School Name:
School Name:
Date Completed
GPA:
Type of Degree:
Type of Degree:
Community of Origin:
Date Completed
GPA
Date Completed:
GPA:
Monthly Expenses
Rent/Mortgage/Space Rent
Car Insurance
Transportation
Electricity
Garbage
Gas
Oil/Fuel
Water/Sewer
Other:
Telephone
Groceries
Other:
CERTIFICATIO
N AND AGREEMENT
I (we) certify to the best of my (our) knowledge that the information and
documentation contained in this application is accurate and true. I (we)
also understand that additional information may be requested to verify
what has been submitted.
I (we) underst
and that my (our) application is subject to verification, and
that falsification of information shall be grounds for immediate
termination from the program and will subject me to Federal
prosecution under 18 U.S.C. §1001, which carries a fine of not more
than $10,000 or federal imprisonment for not more than 5 years, or
both. I (we) also understand that if I (we)
receive services as a result of falsified information, I (we) will have to repay
the Tribe for those services.
I (we) understa
nd that there is an Appeal Procedure by which I (we) can
challenge a decision with regard to this application. I (we) certify that I (we)
have received a copy of this Appeal Procedure, have read it, understand it
and will abide by it.
Applicant Signature
Date
Applicant Signature
Date
Parent/Guardian Signature (if applicable)
Date
Central Council
Tlingit & Haida Indian Tribes of Alaska
320 W. Willoughby Ave., Suite 300
Juneau, Alaska 99801
800-586-1432 • 586-1432 • FAX 907-885-0052
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Applicant/Client Appeal Procedure
A client who is denied or received a reduction of services or benefits has the right to file a written
appeal by following these procedures. Determination of client services or benefits are made based on
a review of program policies, procedures and the required official documentation.
Step 1 – Client
• A client has ten (10) working days from the date of receipt of a decision to submit a written appeal
to the Program Supervisor or his/her designee.
• A client outside of Juneau must have their written appeal postmarked within ten (10) working
days from the date of receipt of a decision.
• A client may request another person to be present at meetings or interviews. The client must
notify the Program Manager or designee who this person is, contact information, and their role.
2
Step 2 – Program Director/Manager
• The Program Director/Manager or his/her designee, in consultation with subordinate staff, will
make every effort to review documentation and make a decision in the shortest amount of time
possible and not to exceed five (5) working days from the date of receipt of the appeal.
• A client not satisfied with the department or program’s decision may submit a written request
within five (5) working days from the date of receipt of the decision to the Program Compliance
Manager or his/her designee to have their appeal reviewed by the Appeals Committee.
Step 3 - Appeals Committee
• A client must complete Step 1 before the Program Compliance Manager will consider a
referral to the Appeals Committee.
• The Appeals Committee will review appeals within five (5) working days of receipt.
• The client will be notified of the Appeals Committee's decision within one (2) working days after
the date of its meeting.
• All decisions of the Appeals Committee are final.
Step 4 - Appeals WIA/WIOA Clients
• Only applies to clients applying for WIA/WIOA funds. Questions about our complaints alleging
a violation of the nondiscrimination provisions of WIA 181 may be directed or mailed directly to
the Director, Civil Rights Center, U.S. Department of Labor, Room N-4123, 200 Constitution
Avenue, NW, Washington, D.C. 20210 for processing.
Applicant Signature Date
Applicant Signature Date
Parent/Guardian Signature (if applicable) Date
Central Council
Tlingit & Haida Indian Tribes of Alaska
Employment and Training Department
320 W. Willoughby Ave., Suite 300
Juneau, Alaska 99801
800-586-1432 • 586-1432 • FAX 887-333-3449
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CENTRAL COUNCIL
Tlingit and Haida Indian Tribes of Alaska
Employment and Training Department
320 W. Willoughby Ave., Suite 300 Juneau, Alaska 99801
800-586-1432 • 586-1432 • FAX 887-333-3449
GENERAL
AUTHORIZATION
FOR RELEASE OF INFORMATION
I authorize the release of information requested by the Central Council
Tlingit & Haida Indian Tribes of Alaska program service office or its agents; hereunto referred to as (CCTHITA). The
requested information will only be used in the administration of CCTHITA programs, and will not be released to any
other person or agency outside of CCTHITA. This release of information will be in effect while I am an applicant or
recipient of CCTHITA program services, and for any later investigations of my eligibility and receipt of benefits.
Persons or organizations that may be contacted include, but are not limited to: the Department of Law, the Department
of Public Safety, the Department of Fish and Game, the Department of Labor, the Department of Military & Veterans
Affairs, the Department of Revenue, the Bureau of Citizenship and Immigration Services, Alaska Housing Finance
Corporation, Social Security Administration, local governments, public assistance program contractors and grantees,
tax assessors, financial institutions, Native corporations, stock brokerage firms, landlords, employers, school
authorities, and private individuals.
This release expires on .
A COPY OF THIS RELEASE IS AS VALID AS THE ORIGINAL
Your Signature (Head of household) Signature of Other Adult Household Member
Printed Name (Head of household) Printed Name of Other Adult Household Member
Social Security Number Social Security Number
Address Address
Phone Number Phone Number
Date Date
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Revised 7.23.15 FNC
Central Council
Tlingit & Haida Indian Tribes of Alaska
Finance Department
9097 Glacier Hwy
Juneau, Alaska 99801
Fax: 1-888-922-2520 Email: financerequests@ccthita.org
Request for Vendor Setup
(This form is used in lieu of the W9 form published by the Internal Revenue service)
All required forms must be completed and signed before payment is issued
☐ New ☐ Update
Legal Name (as shown on your tax return)
Social Security Number
Business Name (if different from above)
EIN (for businesses)
Mailing Address:______________________________________________
City: _____________________________ State: _________ Zip: ________
Telephone Number:
(____)_______________________________
Email Address:
____________________________________
VENDOR TYPE
Non Taxable
1099 Vendor (Taxable)
☐ Client
☐ Non-Profit
☐ Landlord
☐ Daycare Provider
☐ Employee
☐ Corporation
☐ Attorney
☐ Medical Provider
☐ Council Delegate
☐ Government
☐ Sole Proprietor/Partnership
☐ Other (Specify)
☐ Other (specify)
Certification:
Under penalties of perjury, I certify that:
1) The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to
me and
2) I am not subject to backup withholding because: (a) I am exempt from backup withholding; or (b) I have not been notified
by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of failure to report all interest or
dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding and
3) I am a US person (including a US Resident alien)
Certification instructions: You must cross out 2 above if you have been notified by the IRS that you are currently subject to
backup withholding because you have failed to report all interest and dividends on your tax return.
Signature _______________________________________________________ Date ___________________________
Penalties
Failure to furnish TIN: If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50.00 for each
such failure unless your failure is due to a reasonable cause and not to willful neglect.
Civil penalty for false information with respect to withholding: If you make a false statement with no reasonable basis that
results in no backup withholding, you are subject to a $500.00 penalty.
Criminal penalty for falsifying information: Willfully falsifying certifications or affirmations may subject you to criminal
penalties including fines and/or imprisonment.
Misuse of TINs: If the requester discloses or uses TINs in violation of Federal law, the requester may be subject to civil and
criminal penalties.
Finance Only
Debarment Certification:
Date
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Application for Services (Central Council Tlingit and Haida Indian Tribes of Alaska)

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Completed 18 November 2021

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