Page 4 of 4 Revised 1/2015 ss
DISCL
OSURE
FAIR HEARINGS STATEMENT:
TRIBAL BURIAL: Once the Social Services Office is in receipt of an application, it will be considered pending until all documentation required is
received or up to 30 days, whichever comes first. After 30 days, the application will be denied. All required documentation must be received in order for
eligibility to be determined. If the applicant feels the decision of the Social Services staff is in error, he/she may file a written appeal, within 10 days
from the date on the letter of denial, to the director of the Social Services Department. The Social Services director will forward the appeal letter to the
Appeals Team for review and a decision will be made within 10 days from receiving the appeal letter. All decisions will be based according to tribal and
federal law, and the programs policies and procedures to ensure the integrity of the department.
PRIVACY ACT STATEMENT:
The MCN Social Services Department cannot give out applicant’s information. However, Social Services can share the information with other Federal,
State, Tribal offices, programs and/or businesses who have some responsibility with the services for which the applicant is applying. For any other
person or program wanting information from the applicant’s case file, the applicant must first give his/her consent by signing the release of information
section below.
FRAUD STATEMENT:
All information pertinent to services requested is subject to verification. This includes, but is not limited to, landlords, mortgage companies, utility
companies, employer, funeral homes, schools, etc. Falsification of this information shall be grounds for 1) denial of application, 2) not eligible to receive
assistance for six (6) months up to a year, 3) all parties, agencies, tribes, etc. will be notified, and 4) may be forwarded to the MCN Attorney General’s
Office if further action is needed.
RELEASE OF INFORMATION:
Should you choose a friend or family member to receive or give information to our staff in regards to the application, please list their name, relation,
and
of their social security number for identification purposes:
Name: Relation: SSN: XXX-XX-
Name: Relation: SSN: XXX-XX-
Name: Relation: SSN: XXX-XX-
This Release of Information will remain in effect for one (1) year from date of signature or until you request to rescind authorization. Should you
choose a family member or friend to obtain information, you must check the box below authorizing it. Should you fail to check either
box and/or sign, your application will be considered incomplete and will be sent back to you.
I a
uthorize the Social Services Department to obtain and/or exchange information with the person(s) listed above.
I d
o not wish to list any person(s).
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.
Responsible Party Name (printed): Date:
Responsible Party Signature:
**********************************************OFFICE USE ONLY*********************************************
Staff Member Name: Date Completed:
Food:
Voucher Received? Yes No Reimbursement? Yes No
BIA Burial:
BIA Eligible? Yes No BIA Applications attached? Yes No
