Form BIA 5-6601 BIA 5-6601 Social Services Application Form

OMB NO. 1076-0017

EXP: 9/30/08

BIA 5.6601

U.S. DEPARTMENT OF THE INTERIOR

BUREAU OF INDIAN AFFAIRS

Social Services

Application for Assistance/Services

NAME: (LAST) (FIRST) (MIDDLE) PHONE NUMBER: Address and Location:
FAMILY PROFILE
A. MEMBERS OF HOUSEHOLD	BIRTH DATE MO. DAY YEAR				SEX	RELATION TO HEAD OF HOUSEHOLD	SOCIAL SECURITY NUMBER	TRIBE ENROLL #
1.
2.
3.
4.
5.
6.
7.
8.
RECORD OF INCOME AND ASSETS				TYPES OF ASSISTANCE
Monthly Earned Income:____________________ Monthly Unearned Income: _________________ Monthly Liquid Assets Available: _____________ Total ______________________________ _______________________________________ Total Monthly Income ____________________ State Monthly Standard: __________________ Monthly Amount Needed: _________________				G eneral Assistance Burial _____ Child Welfare Disaster _______ Service Only Emergency ______ Decision Application: ☐ Approved ☐ Disapproved Date: __________ (Review Dates: __________/__________/_________) Caseworker: Date:

Statement of Cooperation

I (We) apply for financial assistance for 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.

I (We) agree to supply information regarding resources and income and to notify the agency of any changes in my (our) situation. Social Services is authorized to obtain information necessary to establish eligibility for assistance.

I (We) have read, or had explained to us, the provision of our protection under the Paperwork Reduction Act and the Privacy Act.

Client Terminated from TANF past 90 days? ☐ Yes ☐No Are you eligible to reapply for TANF? ☐ Yes ☐ No

DATE SIGNATURE OF APPLICANT DATE

B NO. 1076-0017

EXP: 9/30/08

BIA 5.6601

(a) Enter asterisk (*) at left of name of each person not included in general assistance payment

(b) When a member leaves the household group, draw line through the name and enter date.

(c) When name of member is added, enter date by name and include appropriate information.

FAMILY PROFILE (CONTINUED)

C. MEMBERS OF HOUSEHOLD WITH PHYSICAL OR MENTAL HANDICAP
NAME	NATURE OF PROBLEM					TEMPORARY PERMANENT		MINOR MAJOR	VERIFIED
1.
2.
3.
D. NAMES OF CHILDREN NOT IN HOME	RELATION	D.O.B.		MARI. STAT.		NO. DE-PENDENTS	ADDRESS
1.
2.
3.
4.
5.
6.
E. OTHER KEY RELATIVES	CASE NO.		NUMBER RELATED TO		DEGREE RELATED		ADDRESS
1.
2.
3.
4.
5.
6.
7.
F. CROSS REFERENCES: (1) TANF (2) OR SSI
1. CASE NO. 3. CASE NO.
2. CASE NO. 4. CASE NO.

(1) Temporary Assistance for Needy Families (TANF)

(2) Supplemental Security Income (SSI)

OMB NO. 1076-0017

EXP: 9/30/08 BIA 5.6601

Bureau of Indian Affairs

Application for Assistance/Services

Any individual or family may apply for Bureau of Indian Affairs Social Services financial assistance or services by supplying the needed information to the case worker who will complete the form and request the client to review the form and sign at the bottom.

Application Instructions

1. Under Name and Address/Location/Phone Number complete the name of the client and address and location of the client, and telephone number. Enter (*) at left of name of each person not included in general assistance payment.

2. Under Family Profile complete the names of the total members of the household starting with applicant, then spouse and then children in descending order of age. For each member list the birth date, sex, relation to head of household, social security number, and tribal enrollment number.

3. Under Record of Income and Assets complete the monthly income of the client and family members for earned, unearned income and liquid assets consistent with 25 CFR 20.307-20.309 and then total them under total. Under the listing of type of service - General Assistance, Child Welfare, Service Only, Burial, Disaster, and Emergency, check the types of service requested.

4. Under Record of Income and Assets, the caseworker will complete the total monthly income, state monthly standard, and monthly amount needed. Under total monthly income, record the total from the box above minus applicable deductions and prorate in accordance with 25 CFR 20.310-20.312. Under application approved or disapproved check whether the application is approved or disapproved and date decision is effective. This will be done when all information is reviewed. Under review dates the caseworker provides the dates when the case is reviewed for continued eligibility. Under caseworker, the caseworker will list their name and provide the date the application was taken.

5. Under the Statement of Cooperation the applicant is asked the following: request application for assistance, understand the provision of the Federal Law governing fraud, agree to supply information regarding resources and income and to notify the agency of any change in their situation, and understand protection under the Paperwork Reduction Act and the Privacy Act. The caseworker will ask the applicant to read and review [Application for Assistance/Services] or read the statement to the applicant and will ask him/her to sign and date the statement. In addition, the applicant will check yes or no in the appropriate box under client terminated from TANF past 90 days. He/she will also check the appropriate box as to whether he/she is eligible to reapply for TANF.

OMB NO. 1076-0017

EXP: 9/30/08

Definitions with Examples

Earned Income includes: wages, salary, commissions, or profit by an employee or self- employed individual This includes one-time payments for ongoing activities such as sale of crops or sale of art-work. Self-employed individuals must report profits from business enterprises (gross receipts minus business expenses included in the production of goods or services). Business expenses do not include depreciation, personal transportation costs, capital equipment purchases or principal payments on loans for capital assets or durable goods.

Unearned Income includes: interest, royalties, gaming income or other per capita distribution not excluded by federal statute, rental property, cash contributions such as child support and alimony, gaming winnings, retirement benefits, annuities, veteran's disability, unemployment benefits, and tax refunds. Other types of unearned income include financial assistance from government agencies, income from sale of trust land or other real or personal property set aside for investment in trust land that has not been reinvested in trust land or a sale of a primary residence that has not been reinvested in a primary residence at the end of one year from the date the income was received, and in- kind contributions providing free shelter up to the 25% of the amount for shelter included in the state standard.

Liquid Assets includes: properties in the form of cash or other financial instruments which can be connected to cash, such as savings or checking accounts, promissory notes, mortgages and similar properties and retirement annuities.

Privacy Act Statement

25 CFR Part 20 and 25 U.S.C. 13 authorize the collection of this information. The information is confidential and is never disclosed without written clearance and consent of the applicant. The primary use of this information is to determine eligibility for financial assistance and services from the Bureau of Indian Affairs (BIA) Child Welfare, Burial, and Disaster programs. Additional disclosures of the information may be to other BIA or tribal officials in the conduct of their official duties pertaining to the application for financial assistance or services, or in the conduct of program review and to the Office of the Inspector General or the General Accounting Office when conducting an audit of BIA programs, or local law enforcement agency when the Agency becomes aware of violation or possible violation of civil or criminal law, and to the General Services Administration in connection with its responsibility for records management. This information will be entered into the BIA, Social Services system of records which can be obtained upon request from Chief, Division of Social Services, 1849 C Street, NW, MS-4603-MIB, Washington, DC 20240. No record contained therein may be disclosed by any means of communication to any person, or to another agency, except pursuant to a written request by, or with prior written consent of the individual to whom the record pertains. Executive Order 9397 authorizes the collection of your Social Security number. Furnishing the information is voluntary but failure to do so may result in disapproval of your application. If the BIA uses the information furnished on this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes.

PAPERWORK REDUCTION ACT STATEMENT

The information is being collected to determine applicant eligibility for financial assistance and services and to provide Bureau of Indian Affairs (BIA) managers with information for program planning, reporting and utilization. Response to this collection is required to obtain a benefit(s) required in 25 CFR 20. A Federal Agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Public reporting for this form is estimated to average 15 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing the form. Direct comments regarding the burden estimate or any other aspect of this form to: Bureau of Indian Affairs, Information Collection Clearance Officer, 625 Herndon Parkway; Herndon, VA 20170.