PUBLIC DISCLOSURE OF POTENTIAL CONFLICT OF INTEREST
Per 24 CFR 1000.30 (b) and (c), applicants apply for Housing/NAHASDA program are required to provide the
following:
Are you and/or any immediate family members an employee of the Muscogee (Creek) Nation or any entity under the Nation?
☐ Yes ☐ No
Name: ________________________________________ Relation: _____________________________________
Name: ________________________________________ Relation: _____________________________________
This release of information will remain in effect for one year or until authorization is rescinded. Should you choose a representative to
receive or give information to our staff, you must enter their name in the box below.
☐ I authorize Social Services Department to obtain and/or exchange information with the person(s) listed below
NAME: ______________________________________________________________________________
☐ I do not wish to list any person(s)
Fair Hearing Statement:
Once the Social Service Office receives your application, it is pending until all documentation is received. After 30 days, pending
applications will be denied. All requested documentation must be received to determine eligibility. If you dispute an action taken by the
Social Service Office you may file a written appeal within twenty calendar days from your denial letter date. The Social Services Director
will forward the appeal letter to the Appeals team for review. All decisions are determined by tribal and federal law, along with the
programs’ policies and procedures. A written decision will be mailed to you within ten business days.
Privacy Act Statement:
The Muscogee (Creek) Nation Social Services Office may share information with other Federal, State, and Tribal programs. Social Services
may also contact employers, landlords, utility vendors, businesses, etc., to verify the information provided to our office. Social Services will
not share your information other than as described here unless you tell us writing. You may use the release of information statement
provided to allow others access to your case information.
Federal Law Governing Fraud:
Whoever, in any matter within the jurisdiction of any department or agency of the United States, knowingly and willfully falsifies, conceals,
or covers up by any trick, scheme, or devise a material fact, or makes or uses any false writing or documents, knowing the same to
contain any false, fictitious or fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than five years
or both. Muscogee (Creek) Nation Social Services has the right to verify all information provided to our office. Falsification of this
information may result in the following actions (1) denial of application, (2) ineligibility of services for up to one year, (3) notice of fraud
sent to affected parties.
General Assistance:
In accordance to Subpart C-Direct Assistance Eligibility for Direct Assistance at 25 CFR §20.300-§20.319, applicants/recipients must:
1. Actively seek employment and accept local and seasonal employment.
2. Report any changes which may affect eligibility. These changes include, but are not limited to, residence, employment,
income/resources (earned and unearned), and household members.
3. Provide information to aid in the development of the Individual Self-Sufficiency Plan (ISP) and sign the document.
4. Perform all tasks defined in the ISP.
5. Participate successfully in treatment and counseling services identified in the ISP
6. Participate in evaluation of job readiness and/or other testing required for employment purposes. If the applicant/recipients do
not comply with the ISP, an ineligibility period of 60-90 days will be imposed.
BIA Funds:
Muscogee (Creek) Nation Social Services BIA programs are subject to Congressional appropriations, pursuant to 25 C.F.R. § 20.102 (c).
Certification:
By signing below, I certify 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 also acknowledge I have read and understand the Fair Hearing Statement, Privacy Act Statement, Fraud
Statement, and the Release of Information Section.
Responsibility Party Name (printed):___________________________________
Responsibility Party Signature: _______________________________________ Date: ______________________
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