General Assistance Application

List of Required Documents

Complete GA Application
Application needs to be signed and dated by applicant and CTC
Complete Individual Self Sufficiency Plan (ISP)
Eligibility Review Form

Copies of the Following:

Proof of current bills for deductions and Residency
Tribal ID or Certification of Indian Blood
Photo ID
Social Security Cart if SSN is not listed on application
Bank Statement for the month that the application was submitted
Proof of ALL income for the month the application is submitted
- Examples
  - Employment Wages
  - Child Support
  - Unemployment Income
  - Self-Employment Income
  - Tax Returns

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Cheesh’na Tribal Council

HC01 Box 217

Gakona, AK 99586

907-822-3503

Applicant Information
Name
First Middle Last
Date of Birth
Date Format: MM slash DD slash YYYY
Maiden name or other names used
Regional Corporation
Mailing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Physical Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Email Address
Marital Status
List ALL MEMBERS of the Household
Check the box at the left of the name for each person NOT INCLUDED in the General Assistance Application Budget.
Person 1
Check this box only if Person 1 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 1 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Person 2
Check this box only if Person 2 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 2 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Person 3
Check this box only if Person 3 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 3 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Person 4
Check this box only if Person 4 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 4 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Person 5
Check this box only if Person 5 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 5 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Person 6
Check this box only if Person 6 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 6 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Person 7
Check this box only if Person 7 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 7 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Person 8
Check this box only if Person 8 is NOT INCLUDED in your General Assistance budget
- NOT included in budget
Person 8 Full Name
Relationship to Head
Date of Birth
Date Format: MM slash DD slash YYYY
Sex
Social Security #
Tribal Enrollment #
Monthly Income
Members of Household with Physical or Mental Handicaps
Person 1 Full Name
Nature of Handicap
Temporary or Permanent?
Minor or Major
Verified?
Person 2 Full Name
Nature of Handicap
Temporary or Permanent?
Minor or Major
Verified?
How many ADULTS live in the home?
How many CHILDREN live in the home?
Type of Services applying for:
*Emergency is for home burnout, flooding, etc., NOT for eviction/shutoff notices, medical travel, funeral travel, etc. Per 25 CFP Part 20
Where do you live now?
If you selected OTHER, please explain
Are you or any member of your household a shareholder in a Native Corporation?
If yes, list the NAME of the household member, the CORPORATIONS, and the SHARES OWNED here.
Have you received ATAP or TNAF in the last month?
If yes, how much?
Has your ATAP or TANF been reduced due to penalties?
Reason
Have you been terminated from ATAP/TANF?
Date of Termination
Date Format: MM slash DD slash YYYY
Have you been determined ineligible for ATAP/TANF?
Reason
Have you been denied ATAP/TANF?
Reason
Are you eligible to reapply for ATAP/TANF?
Reason
Which TANF office did you receive assistance from?
Explain FULLY, how you have supported yourself during the past three (3) months and what has changed in your situation to cause you to apply for assistance.
Failure to complete this section will render this application incomplete and therefore will not be processed.
Record of Income and Resources
You are required to report income received from the following.
Does anyone in your household have income from any source?
- Yes
- No
If yes, list the name of household member(s), source of income, and amounts below.
Salary #1: Applicant's Income/Salary
Name of Household Member
Salary #2: Spouce's Income/Salary
Name of Household Member
Tips or Gratuities
Name of Household Member
ATAP-TANF-ASAP (State Assistance)
Name of Household Member
Child Support and Alimony
Name of Household Member
Foster Care Payments
Name of Household Member
Adult Public Assistance (APA)
Name of Household Member
Social Security
Name of Household Member
Supplemental Security Income (SSI)
Name of Household Member
Disability Insurance
Name of Household Member
Alaska State Permanent Fund (PFD)
Name of Household Member
Cash Out of Retirement or Pension Plan
Name of Household Member
State Longevity
Name of Household Member
Veteran's Benefits
Name of Household Member
Unemployment Insurance Benefits
Name of Household Member
Worker's Compensation
Name of Household Member
Food Stamps
Name of Household Member
Medicare/Medicaid
Name of Household Member
Native Corporation Dividends
Name of Household Member
Checking Account Balance
Name of Household Member
Savings Account Balance
Name of Household Member
Student Loans/Grants/Scholarships
Name of Household Member
Bingo or Pull Tab Winnings
Name of Household Member
Other Income
Name of Household Member
TOTAL MONTHLY INCOME
Name of Household Member
Monthly Shelter Costs
Provide all expenses for the current month.
Rent
Telephone
Space Rent
Water
Mortgage Payment
Sewer
Electricity
Household Oil/Fuel/Wood
Heating
Other
Other
Other
READ BEFORE SIGNING
I/We apply for financial assistance/services for the listed members of my (our) household who are in need. I/We have received a copy of and have had explained to us and understand the provisions of Federal Law governing fraud.
Applicants or recipients who knowingly and willfully provide false or fraudulent information are subject to prosecution under 18 U.S.C. 1001, the Federal Law concerning fraud which carried a fine of not more than $10,000 or imprisonment of not more than fives years or both.
- I agree/understand
Initials of Applicant
I/We agree to supply information regarding resources and income and to notify the agency of any changes in my (our) situation. Release of Information: Human Services is authorized to obtain/exchange information necessary to establish eligibility for assistance. I (we) have read, or had explained to me/us, the provision of our protection under the Paperwork Reduction Act and Privacy Act.
- I agree/understand.
Initials of Applicant
Applicant E-Signature
E-Signature of Other Adult Household Member
Today's Date
Date Format: MM slash DD slash YYYY

General Assistance Application

List of Required Documents

Copies of the Following:

Applicant Information

List ALL MEMBERS of the Household

Members of Household with Physical or Mental Handicaps

Record of Income and Resources

Monthly Shelter Costs

READ BEFORE SIGNING