Social Service Form 001_Revised September 2020
Tribal Assistance Program
The Tribal Assistance Program application period begins October 1
st
and ends September
30
th
. This program operates on a first come first serve basis depending on availability of
funds. All checks for utilities, glasses, hearing aids and dentures are made to the vendor.
NO REIMBURSEMENTS will be made for purchases made prior to this application.
ASSISTANCE:
The following benefits are for all tribal citizens.
Food $100
Unapproved grocery purchases include: makeup, jewelry, perfume, hair products, tobacco and
alcohol products. Applicants are required to submit receipt for items purchased.
Utilities $150
Tribal citizen must be 18 years old or older to receive utility assistance and attach a utility bill in
the tribal citizen’s name. All cut off notices for utilities will take 7-10 business days before a
check will be issued to utility vendor. Delaware Nation is not responsible for late fees or
reconnect fees.
HEALTH:
Glasses up to $200 for tribal citizens (0-59)
ELDER HEALTH ASSISTANCE:
All applicants must be 60 years old or older at the time of request. An elder application
must be submitted for assistance.
Glasses up to $400 every 2 years
Major Dental up to $500 every year
Dentures up to $3,000 every 5 years
Hearing Aids up to $3,000 every 5 years
REQUIREMENTS:
All applications must have a bill or invoice if you apply for UTILITIES, DENTURES OR
GLASSES. If not your application will be placed on pending status.
Minors (under 18) cannot apply for utilities.
Our office cannot rush checks for utility cut off notices.
SERVICES AREA
NATIONWIDE
Tribal Assistance Program
P.O. Box 825
Anadarko, OK 73005
Toll Free 1-800-203-2121
Phone (405)247-2448
Fax (405)247-5942
Social Service Form 001_Revised September 2020
PLEASE PRINT
Name
Enrollment#
Male
Female
Address
City
State
Zip
Birth date
Age
Social Security #
Phone
PLEASE READ CAREFULLY: Minors (under 18) cannot apply for utilities. All cut off
notices for utilities will take 7-10 business days before a check will be issued to utility
vendor. NO REIMBURSEMENTS WILL BE MADE FOR PURCHASES PRIOR TO THIS
APPLICATION. Payment will be made to the vendor indicated on the utility bill or invoice.
CHOOSE ONE ITEM BELOW
FOOD ($100) RECEIPTS MUST BE SUBMITTED AFTER PURCHASE.
GLASSES ($200) An invoice must be attached with the application.
UTILITIES ($150) A utility bill in tribal citizen’s name must be attached with application.
I certify that the enclosed information is true to the best of my knowledge. In regards to
a minor child: I understand that if requested by the Delaware Nation Social Services to
submit supportive documentation stating proof of legal custody of said minor child, it
will be furnished and that if supportive documents are not submitted then I will not be
eligible for this program. It is further understood that this is not an entitlement
program. I also understand that receipts will be submitted for food assistance in order
for future eligibility.
OFFICE USE ONLY
PRINT NAME (Parent/Legal Guardian)
Signature (Parent/Legal Guardian)
Date
Social Services Department
Date
Approved
Denied
Amount
$
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signature
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