Fillable Tribal COViD-19 DisasTer assisTanCe aPPliCaTiOn (Cheyenne and Arapaho Tribes)

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Tribal COViD-19 DisasTer assisTanCe aPPliCaTiOn (Cheyenne and Arapaho Tribes)

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CA Tribes | Tribal COVID-19 Disaster Assistance | 6-1-2020
FOR OFFICE USE ONLY – PLEASE DO NOT WRITE IN THIS SPACE
Date Application Received _______________ #Adults Approved _________ Amount ________________
Caseworker Initials _____________________ #Children Approved ________ Amount ________________
Tribal COViD-19 DisasTer assisTanCe aPPliCaTiOn
Cheyenne and Arapaho Tribes • HOPE Program • P.O. Box 167 • Concho, OK 73022 •Phone: (405) 422-7580
Fax: (405) 422-8246 • Email: HOPE@cheyenneandarapaho-nsn.gov
Every adult tribal member is eligible for this assistance and eligibility is not based on household size. DEADLINE TO SUBMIT APPLICATION IS
AUGUST 3, 2020. Checks will be mailed—no exceptions.
INCOMPLETE APPLICATIONS MAY BE DELAYED UP TO TWO (2) WEEKS OR LONGER. PLEASE COMPLETE APPLICATION IN ITS ENTIRETY.
Name ______________________________________________________________ Date of Birth ______________
Please check one of the following:
□ Cheyenne and Arapaho Tribal Member Roll # __________________
□ Non-Tribal Custodial Parent of Tribally-Enrolled Child(ren)
Phone _____________________ Alternate Phone _____________________ SS # (last four digits) ____________
Mailing Address _______________________________________________________________________________
City___________________________________________ State ___________________ Zip ___________________
Please check all that apply. WHAT IS YOUR COVID-19 RELATED NEED?
□ Housing—Rent/Mortgage □ Car Payment □ Utilities □ Medication
□ Medical Equipment □ Food □ Household Items □ Firewood
□ Child Care □ Education □ Purchase of PPE □ Unemployed
□ Other (please be specific) __________________________________________________________________________________
CHEYENNE AND ARAPAHO ENROLLED TRIBAL CHILDREN LIVING IN THE HOME
Children must have been born before June 1, 2020 and must have turned 18 on June 1, 2020 to be considered an adult. Parents of newborns must start the
tribal enrollment process as soon as possible. DO NOT INCLUDE NAMES OF CHILDREN SUBMITTED ON ANOTHER APPLICATION IN ORDER TO PREVENT
DUPLICATION OF SERVICES.
FULL NAME OF CHILD
(as it appears on the Cheyenne and Arapaho Tribal Roll)
AGE
Must provide DOB if tribal roll # is not known
VERIFICATION OF
ENROLLMENT
(OFFICE USE ONLY)
DOB TRIBAL ENROLLMENT #
□
YES
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NO
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YES
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NO
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YES
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NO
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YES
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NO
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YES
□
NO
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YES
□
NO
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YES
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NO
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YES
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NO
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YES
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NO
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YES
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NO
By my signature below, I attest that the information provided above is true and correct and that the children listed are enrolled in the Cheyenne and Arapaho
Tribes and are in my sole custody. I understand that if I purposely falsify this document in order to receive funds, I will jeopardize future services with the
Cheyenne and Arapaho Tribes and/or the HOPE Program.
___________________________________________________________________
Signature Date
TOTAL APPROVED HOUSEHOLD
PAYMENT AMOUNT
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Tribal COViD-19 DisasTer assisTanCe aPPliCaTiOn (Cheyenne and Arapaho Tribes)

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Completed 20 July 2020

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