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THE DELAWARE NATION ELDER ASSISTANCE PROGRAM (Delaware Nation)

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1
THE DELAWARE NATION
ELDER ASSISTANCE PROGRAM
APPLICATION INFORMATION SHEET
The Delaware Nation Tribal Assistance Program (Formerly 10% Program) will be
assisting eligible Enrolled Delaware Nation Elders.
ELIGIBLITY REQUIREMENTS:
Enrolled Delaware Nation tribal citizen
60 years of age or older upon submission of application
ASSISTANCE AVAILABLE:
Major Dental:
o Extractions; root canals; crowns; and denture repair up to $500 once a
year
Glasses
o Up to $400 every two (2) years
Dentures; Bridges; and Partials
o Up to $3,000 every five (5) years
Hearing Aid
o Up to $3,000 every five (5) years
REQUIRED DOCUMENTATION:
Invoice from doctor and/or clinic (No Reimbursements will be made)
PLEASE KEEP THIS PAGE FOR YOUR INFORMATION
SUBMIT THE APPLICATION (PG.2) WITH YOUR INVOICE
2
THE DELAWARE NATION
ELDER ASSISTANCE PROGRAM
APPLICATION
PLEASE PRINT
Name
Enrollment#
Address
State
Zip
Birth date
Social Security #
Home Phone
Cell Phone
CHOOSE ONLY ONE BELOW
Major Dental Work up to $500 (once a year)
Glasses up to $400 (every 2 years)
Dentures up to $3,000 (every 5 years)
Hearing Aids up to $3,000 (every 5 years)
Please attach an invoice to this application
My signature below will indicate that I have agreed to the conditions listed on page one
of this application to receive funding from this program. Applications without an invoice
will be pending until one is submitted to Social Services.
APPLICANT SIGNATURE
DATE
SOCIAL SERVICES
You can mail for fax to:
Delaware Nation
Social Services Department
PO Box 825
Anadarko OK 73005
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THE DELAWARE NATION ELDER ASSISTANCE PROGRAM (Delaware Nation)

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Completed 20 July 2020

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