List all household members (Name & Date of Birth)

Include all household members. Use the + button to add another person; additional rows are available for households with more than eight members.

I certify that the information provided on this application is complete and accurate to the best of my knowledge. I understand that providing false information may result in denial of assistance, repayment of funds, and/or criminal prosecution.

I agree to submit all required receipts to the Social Services Department within thirty (30) days of receiving assistance. I understand that no additional vouchers will be issued until all required receipts have been received and verified.

I further understand that if more than two (2) vouchers are requested, I may be required to participate in financial literacy classes prior to receiving additional assistance, contingent upon program funding and availability.

I authorize the Social Services Department to verify information with other Tribal programs as necessary.