Fillable POKAGON BAND OF POTAWATOMI INDIANS (Pokagon Band of Potawatomi Indians)

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POKAGON BAND OF POTAWATOMI INDIANS (Pokagon Band of Potawatomi Indians)

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The POKAGON BAND OF POTAWATOMI INDIANS (Pokagon Band of Potawatomi Indians) form is 2 pages long and contains:

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  • 33 check-boxes
  • 56 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Pokagon Band of Potawatomi Indians

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If application is approved, the vendor will be contacted with a pledge or
payment.
POKAGON BAND OF POTAWATOMI INDIANS
P.O. Box 180 ●
58620 Sink Road
● Dowagiac, MI 49047 ● Phone: 269-782-4300 ● Fax 269-782-4295
Email: social.services@pokagonband-nsn.gov
Supplemental Heating Program
2020-2021
Application must be complete. Include ALL household residents, Tribal ID’s, provide all
household income (check stubs, Trust payment, SSI/RSDI/Pension, proof of child support, etc.), and
current utility bill from the main heating source. The application process will NOT begin without all
verifications.
1. _______________________________ _______________ _______ ____________________
Applicants Name Date of Birth Age Social Security #
______________________________________________ _________________________ _______________
Street Address City/State Zip Code
______________________ __________________________ _________________________________________
County Telephone # Email Address
Are you a Pokagon Band Citizen? Yes No Tribal ID #_________
List all other household residents Age Date of Birth Tribal ID # Social Security
#
2. _____________________________ _____ ______________ ________ _________________
3. _____________________________ _____ ______________ ________ _________________
4. _____________________________ _____ ______________ ________ _________________
5. _____________________________ _____ ______________ ________ _________________
6. _____________________________ _____ ______________ ________ _________________
7. _____________________________ _____ ______________ ________ _________________
*
Are any household residents receiving:
Child Support? Yes No
Per Capita? Yes No
Elder Stipend? Yes No
Supplemental Assistance? Yes No
SSI/RSDI/Pension? Yes No
Do you have a child support order? Yes No
Per Capita from another Tribe? Yes No
Assistance from the State you live in? Yes No
Check all that apply: Utility Assistance Cash Assistance
Food Stamps Medicare Medicaid
* Are any household residents:
Currently employed? Yes No
Employed in the past 12 months? Yes No
Received Adult Trust Fund payment in the past 12 months? Yes No
Cultural Activity Pay? Yes No
Notes:________________________________________________
_____________________________________________________
Is address with enrollment current?____
If not must update with enrollment
2020-2021
What is the main heating source to heat the home? (Circle Utility)
Oil Natural Gas Electric Wood Pellets Propane % in tank:_______ Other:___________________
(Note: If propane is your main heating source, you will need to provide a propane statement from the vendor)
Disconnect Notice? Yes No If yes, what is the disconnect date?____________________________________
Name on bill/account:______________________________ Last four
digits of Social Security #____________
Vendor’s Name:___________________________________ Account #_____________________________
1. I hereby certify that all information in this application is true, correct, and complete to the best of my knowledge.
2. I understand t
hat giving false or incomplete information can result in referral to the prosecuting attorney for fraud and/or
recovery of funds paid on my behalf.
3. I understand that failure to provide all necessary information and documentation can result in denial of my application.
4. I hereby authorize the release of information by the appropriate agencies of the Pokagon Band of Potawatomi or community
agencies/individuals for the purposes of verifying information needed to establish eligibility for the program.
5. I understand that a decision will be made concerning my application within 10 working days of receiving application and all
required documentation.
6. I understand that I may be required to complete a year end survey to assess completion and continued need of the program.
7. I understand that I have the right to appeal any decision made on this application at any time.
_________________________________________________________ ____________________________
Applicant’s Signature Date
FOR OFFICIAL USE ONLY – DO NOT WRITE BELOW THIS LINE
Name Income Total Income:____________________
______________________________________________________ Income Limit:____________________
______________________________________________________
______________________________________________________ Approved:_______ Denied:_______
______________________________________________________
______________________________________________________
Vendor:_______________________________ LIHEAP Eligible:___________________________
Amount Approved:_______________________ Fuel Quanitity:________________________
Outreach Worker Signature:_________________________________________ Date :_______________
Notes:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
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POKAGON BAND OF POTAWATOMI INDIANS (Pokagon Band of Potawatomi Indians)

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Completed 27 January 2021

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