SERVICES-AT-LARGE ELDERLY ENERGY PROGRAM
ASSISTANCE APPLICATION
First name:
Middle name:
Last name:
Suffix:
Mailing address:
City:
State:
ZIP:
Physical address:
Home phone:
Cell phone:
Message phone:
Social Security number:
Birth date:
Email:
HOUSEHOLD INFORMATION:
PLEASE LIST EVERYONE WHO LIVES IN THE HOUSE
Name
First, middle, last, suffix
Veteran
Veteran Verification Documents:
DD214 or NGB22
State issued driver’s license with veteran logo
Retired Military Identification card
VA (Veterans Affairs) Identification card
VA benefits letter or other documents
I declare that the information I have given in this application is true and correct, and that I will cooperate with the
Chickasaw Nation should my application become part of a quality control/audit review. I hereby authorize the Chickasaw
Nation to make any necessary investigations to other social services agencies of my household verification or other
information regarding my eligibility. If my request for assistance is denied despite meeting the eligibility requirement, I
have the right to appeal this decision and will request this in writing to the area office where my application was processed
within 30 days of the date of denial, or waive my rights to a hearing.
Signature of applicant Date
Resource specialist Date
The Chickasaw Nation Social Services Division and the applicant agree to strictly maintain the confidentiality of all information disclosed hereunder, or any amendments
thereto. The parties agree that the information contained in said application will be considered “Confidential Information” and will not be disclosed to third persons, except
upon written consent of the applicant or as otherwise required by law.
Page 2 of 2 Form no. 04748SAL CS-SS Rev. 12/2017
