Fillable CTTPTANFProgram NonRecurringShortTermBenefitEmergencyAssistanceProgram a. FullnameandBirthdatesoffamilymembersinthehousehold; NameBirthday (Susanville Indian Rancheria)

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CTTPTANFProgram NonRecurringShortTermBenefitEmergencyAssistanceProgram a. FullnameandBirthdatesoffamilymembersinthehousehold; NameBirthday (Susanville Indian Rancheria)

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U.S.A. forms for Susanville Indian Rancheria

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CTTPTANFProgram
Non‐RecurringShort‐TermBenefitEmergencyAssistanceProgram
1. NameofApplicant:_________________________________________________
a. FullnameandBirthdatesoffamilymembersinthehousehold;
NameBirthday
____________________________ ____________________
____________________________ ____________________
____________________________ ____________________
____________________________ ____________________
____________________________ ____________________
____________________________ ____________________
2. AddressofApplicant:_________________________________________________
___________________________________________________________________
Phone#:_____________________
ServiceAreaEligibilityVerified:
Y___
N___
ProofofResidency:
Y___
N___
3. TribalAffiliationofEligibleChild(ren):__________________________________
TribalAffiliationVerified:
Y___
N___
4. Income(300%)ofFPL)Lastmonth’sincome:$___________________________
IncomeVerified:
Y___
N___
5. AllEligibilityfactorsmet
Y___ Approval
N___ Denial
AmountofCheck:$_________________
AFFIDAVIT
CTTPNon‐RecurringShort‐TermBenefitforEmergencyServices
ApplicationInformation
Name
Address
DateofBirth SocialSecurityNumber
ACKNOWLEDGEANDAGREEMENT
InmakingthisapplicationforCTTPNon‐RecurringShort‐TermBenefitsforemergencyservices,I
certifyunderpenaltyofperjury:
1. ThatmyfamilyandIresideinanidentifiedserviceareforemergencyassistance.
2. ThataneligibleNativeAmerican/AlaskaChildresidesinmyhomeandatthelistedaddress.
3. ThatalltheinformationonthisdocumentandtheEmergencyAssistanceRequestforis
truthfulandaccurate.
4. IunderstandtheCTTPanditsagentsmayinvestigatetheaccuracyofmystatementsandwill
requiremetoprovidesupportingdocumentation,toincludebutnotlimitedtophoto
identification,birthcertificatessocialsecuritycard,tribalidentification,residencyand
incomeverification.
5. Iamwillingtoprovideanyandallsupportingdocumentsandanswerallapplicationrelated
inquiresinatimelymanner.
6. IamnotonaCountycashassistanceprogram(includingCalworksand/orFosterCare)
____________________________________________ ____________________
ApplicantSignatureDate
____________________________________________ ____________________
WitnessSignatureDate
Stateof_____________
Countyof____________
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CTTPTANFProgram NonRecurringShortTermBenefitEmergencyAssistanceProgram a. FullnameandBirthdatesoffamilymembersinthehousehold; NameBirthday (Susanville Indian Rancheria)

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Completed 20 July 2020

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