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

Application for Welfare Assistance

**Incomplete Applications Will NOT be Processed**

First Name

Middle Name

Last Name

Date of Birth

Maiden Name (or other names used)

Regional Corporations

Mailing Address

City

State

Zip

Physical Address

City

State

Zip

Home Phone

Message Phone

Cell Phone

Email Address

Marital Status

List ALL MEMBERS of the Household

Person 1

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Person 2

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Person 3

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Person 4

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Person 5

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Person 6

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Person 7

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Person 8

Full Name

Included in General Assistance Application Budget?

Relationship to Head of Household

Birthday

Social Security #

Sex

Tribal Enrollment #

Monthly Income

Members of Household with Physical or Mental Handicaps

Person 1

Name

Nature of Handicap

Temporary or Permanent?

Minor or Major?

Verified?

Person 2

Name

Nature of Handicap

Temporary or Permanent?

Minor or Major?

Verified?

Number of Adults in Living in the Home

Number of Children Living in the Home

Type of Services Applying for

General Assistance

Emergency (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

Are you or any members 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:
Please list and format accordingly: "Name, Native Corporation, Shares Owned" for each member.

Have you received ATAP or TNAF in the last month?

If yes, how much?

Has your ATAP or TNAF been reduced due to penalties?

Reason

Have you been terminated from ATAP/TANF?

Date of Termination

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 & therefore will not be processed.

Record of Income and Resources

Does anyone in your household have income from any source?
If yes, list the name of household member(s), source of income, and amounts below.

**You are required to report income received from the following**

Salary #1: Applicant's Income/Salary
$ Amount

Name of Household Member

Salary #2: Spouse's Income/Salary
$ Amount

Name of Household Member

Tips or Gratuities
$ Amount

Name of Household Member

ATAP-TANF - ASAP (State Assistance)
$ Amount

Name of Household Member

Child Support and Alimony
$ Amount

Name of Household Member

Foster Care Payments
$ Amount

Name of Household Member

Adult Public Assistance (APA)
$ Amount

Name of Household Member

Social Security (SSA)
$ Amount

Name of Household Member

Supplemental Security Income (SSI)
$ Amount

Name of Household Member

Disability Insurance
$ Amount

Name of Household Member

Alaska State Permanent Fund (PFD)
$ Amount

Name of Household Member

Cash Out of Retirement or Pension Plan
$ Amount

Name of Household Member

State Longevity
$ Amount

Name of Household Member

Vetrans Benifits
$ Amount

Name of Household Member

Unemployment Insurance Benefits
$ Amount

Name of Household Member

Workers Compensation
$ Amount

Name of Household Member

Food Stamps
$ Amount

Name of Household Member

Medicare/Medicaid
$ Amount

Name of Household Member

Native Corporation Dividends
$ Amount

Name of Household Member

Checking Account Balance
$ Amount

Name of Household Member

Savings Account Balance
$ Amount

Name of Household Member

Student Loans/Grants/Scholarships
$ Amount

Name of Household Member

Bingo or Pull Tab Winnings
$ Amount

Name of Household Member

Other Income
$ Amount

Name of Household Member

TOTAL MONTHLY INCOME
$ Amount

Name of Household Member

Monthly Shelter Costs

**Provide all expenses for the current month**

Rent
$ Amount

Telephone
$ Amount

Space Rent
$ Amount

Water
$ Amount

Mortgage Payment
$ Amount

Sewer
$ Amount

Electricity
$ Amount

Household Oil/Fuel/Wood
$ Amount

Heating
$ Amount

Other
$ Amount

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.
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.
Initials of Applicant

Applicant Signature

Signature of Other Adult Household Member

Date